October 2008

2008 MAGGIE AWARD WINNER

OFFICIAL PUBLICATION OF THE SAN DIEGO COUNTY MEDICAL SOCIETY OCTOBER 2008

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

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We proudly announce SCPIE and The Doctors Company have united.

Together, we set a higher standard.

We aggressively defend your name.

We protect good medicine. We reward doctors for their loyalty. We ensure members benefit from our combined strength. We are not just any insurer. We are now the largest insurer of physician and surgeon medical liability nationwide.

On June 30, 2008, The Doctors Company and SCPIE officially joined forces. With the addition of SCPIE, we have grown in numbers, talent, and perspectiveâ&#x20AC;&#x201D;strengthening our ability to relentlessly defend, protect, and reward our 43,000 members nationwide.

Endorsed by the San Diego County Medical Society since 2005, The Doctors Company remains committed to protecting your livelihood and reputation. To learn more about our professional liability program for SDCMS members, call (858) 452-2986, or visit us at www.thedoctors.com.

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Contents

VOL. 95 | NO. 10

[ON

[ F E A T U R E ]

18

THE

COVER]

Rendering of the new medical education building (breaking ground fall 2008), designed by Brian Mulder of Skidmore, Owings & Merrill LLP.

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

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:FEKI@9LKFIJ1 This Issue’s Contributing Writers

<;@KFIËJ :FCLDE1 Being a Culturally Competent Physician

J<D@E8IJ1 SDCMS Seminars and Events

:FDDLE@KP ?<8CK?:8I< :8C<E;8I 9I@<=CP EFK<;1 Ask Your Physician Advocate, SDCMS Member Spotlight, and More ...

8::<JJ KF :8I<1 How One Physicianrun Managed Care Company Is Different

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24 26 34 38 41 44

GL9C@: ?<8CK?1 Why Taking a Sexual History Matters

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

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Joseph Scherger, MD, MPH Kyle Lewis Ketty La Cruz

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MILLION (UMANA MEMBERS NEEDING A PHYSICIAN

(UMANA EMPLOYEES MAKING IT EASY FOR YOU TO TREAT THEM

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Editor’s Column

By Joseph E. Scherger, MD, MPH socioeconomic, and cultural backgrounds.

That is certainly a goal more than a destination. While I have taken the training in Culturally and Linguistically Appropriate Services (CLAS) she describes, I still consider myself a novice in cultural competence. The best way for me to know that I am doing some things right is that I have many patients of different cultures who keep coming back to me as their personal physician. Sophistication aside, I’d like to share some of my insights into being at least a little culturally competent.

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More than our differences, I am convinced that all of us are more alike than different as human beings. We all love, laugh, get upset, and generally like the same things, especially when we live together in America. As physicians, treating everyone with the same interest and respect goes a long way in having a healing relationship with people of different cultures. Use this sameness as the foundation of your interactions rather than any assumed differences, and I think your mistakes will be fewer. I continue to enjoy watching people very different from me have the same reaction to the world as I do.

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iving and working in San Diego County exposes us to many cultures from around the world. This rich diversity helps make San Diego such a great place to live. I grew up in a small town in Ohio that was 80 percent German Catholic. Most of the others were German Protestants. I went to a Midwest Catholic university with only a little more diversity.

Moving to California in 1971 to attend medical school began my journey of discovery of other peoples.

In this issue of San Diego Physician, Cathy Coleman gives us a rich collection of resources to help us be culturally competent, a continuous journey with no real destination. We always have much more to

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Everyone deserves respect as human beings, regardless of how they look, Taking a real interest in dif- talk, or dress. Prejudice comes from ferent people adds a spice to not respecting diflearn about other people. Taking a our work, and this interest, ferences and reactreal interest in difing against them. coupled with caring, autoferent people adds We all get annoyed matically puts us on the path or turned off by a spice to our work, and this interest, toward cultural competence. certain appearanccoupled with caring, es and behaviors. automatically puts Be conscious of us on the path toward cultural competence. that and strive to make sure that these are I love the definition of cultural competence not prejudices. she provides: Today I find that patients of middleeastern origin often have the toughest time Acquiring and integrating knowledge with in America. Islam, a very loving, peaceful awareness, attitude, and skills about culture religion for most, is especially suspect for and cultural differences that enables healthcare many Jewish and Christian physicians. professionals to provide optimal and expert These prejudices do not contribute to any care to patients from different racial, ethnic, good and do much harm to future peace

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and harmony in the world, let alone the doctor/patient relationship. Loving your neighbor does not have cultural or religious boundaries.

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Respect for any patient is at the core of professionalism in medicine. We all learned it and practiced it. In a land of diversity, respect remains at the core of successful healing and medical practice. Respecting peopleâ&#x20AC;&#x2122;s diďŹ&#x20AC;erences is a skill that requires continuous reinforcement. We all encounter people that we do not understand. We usually will not have enough time with them to gain any deep understanding, but treating them with respect often creates a magical connection.

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Empathy gets back to the common core of all humanity. Illness causes suďŹ&#x20AC;ering, and the experience of suďŹ&#x20AC;ering is universal. Saying things like, â&#x20AC;&#x153;I see that you are in pain,â&#x20AC;? â&#x20AC;&#x153;This must be very diďŹ&#x192;cult you,â&#x20AC;? â&#x20AC;&#x153;I know that you are suďŹ&#x20AC;ering,â&#x20AC;? are healing words. Everyone responds to empathy, and cultural diďŹ&#x20AC;erences take a back seat when suďŹ&#x20AC;ering evokes a concern for the human condition.

So do not be intimidated by the vast knowledge required for cultural competence among the many cultures living in San Diego County. These simple rules have worked for me. Competence as a physician requires a combination of medical and relationship abilities. Cultural competence is mostly about the relationship. Doing well with other people is a lifelong process. If you strive to keep doing it better, you will be going in the right direction. Take an interest in and celebrate cultural diversity. San Diego County looks so much better if you do.

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:

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Seminars 2008 SDCMS Seminars and Events OCTOBER

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

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

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

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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 DEVELOPMENT: Janet Lockett at (858) 300-2778 or at JLockett@SDCMS.org DIRECTOR OF MEMBERSHIP OPERATIONS AND PHYSICIAN ADVOCATE: Marisol Gonzalez at (858) 300-2783 or at MGonzalez@SDCMS.org OFFICE MANAGER ADVOCATE: Lauren Wendler at (858) 300-2782 or at LWendler@SDCMS.org

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DIRECTOR OF ENGAGEMENT: Jennipher Ohmstede at (858) 300-2781 or at JOhmstede@SDCMS.org SDCMS FOUNDATION INTERIM 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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Community Healthcare Calendar

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By Marisol Gonzalez

HZkZg^c\ V GZaVi^dch]^e L^i] V EVi^Zci Dji"d["cZildg` Egdk^YZg EVnbZcih JcZi]^XVa 8dcigVXidg 7Z]Vk^dg L<JK@FE1 @ Xd j\m\i`e^ X i\$ cXk`fej_`g n`k_ X gXk`\ek# Xe[ @ nXek kf Y\ XYc\ kf X[[ k_\ ZfekXZk `e]fidXk`fe ]fi k_\ JXe ;`\^f :flekp D\[`ZXc JfZ`\kp Xj X i\]\iiXc i\$ jfliZ\ `e dp c\kk\i kf k_\d% :Xe J;:DJ Xjj`jk k_\d `] k_\p n\i\ kf ZXcc6 8EJN<I1 Yes. For our members we do provide this as a service to their patients.

In addition to our phone number, you can also give them our website, www.SDCMS.org, where they will find a physician locator that will allow them to look up a physician by just about any parameter.

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methodology the plan uses.

The best practice is to inform your patients that you are not contracted with Blue Shield; however, the patient’s PPO benefit plan most likely permits him or her to obtain services from a non-network physician. The patient should be informed that he or she will probably incur a higher co-pay and/or deductible for seeing an out-of-network physician, and the office should have the patient sign a release of financial responsibility wherein the patient agrees to be responsible for any amounts not paid by his or her insurer.

L<JK@FE1 @] 9cl\ J_`\c[ gXpj d\ X Z\ikX`e Xdflek ]fi Xe f]ÔZ\ m`j`k Xj Xe `e$e\knfib gifm`[\i# `j `k i\hl`i\[ kf gXp Xk c\Xjk k_\ jXd\ Xdflek ]fi Xe flk$f]$e\knfib gifm`[\i6 8EJN<I1 No. Payers are not required to reimburse out-of-network providers at the same rate as in-network providers. Some payers pay more than the contracted rate — some pay less. If a non-contracted physician believes he or she has been underpaid, he or she can either appeal the claim, requesting additional payment, or bill the patient for the amount not paid by their insurer.

The scenario described would not be feasible in that the physician would not know what Blue Shield’s fee schedule is for non-contracted physicians. Because the physician is not contracted, the health plan is under no obligation to disclose their rates or the payment

L<JK@FE1 @ _X[ Xe \dgcfp\\ n_f nXj _`i\[ k_ifl^_ X Y`cc`e^ Zfd$ gXep kf [f Y`cc`e^ ]fi dp f]ÔZ\% @ Xcjf _`i\[ _\i fe X ZfekiXZk`e^ YXj`j kf Zfc$ c\Zk fe dp fc[ XZZflekj% @ ]fle[ flk k_Xk j_\ nXj Xck\i`e^ _\i _flij# gcXp`e^ Xifle[ n`k_ _fn j_\ ^fk gX`[# Xe[ Xck\i`e^ [Xk\j fe YXeb [\gfj`kj% J_\ ef cfe^\i nfibj ]fi d\% N_\i\ [f @ jkXik6 8EJN<I1 According to CMA, you have a few different options in handling this situation. First, once you determine the total amount that you believe your former employee misappropriated from you, you should make a business decision as to whether it is worthwhile pursing. You should consider the time, energy, and resources necessary to pursue criminal or civil remedies.

Second, if you determine that it is worthwhile pursuing, you can report the alleged theft/misappropriation to the police. The police will take the report and

Q

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likely refer the matter to the district attorney. The amount at issue will, however, likely affect whether or not the district attorney pursues criminal charges against the former employee, and will determine whether the charged offense(s) is a misdemeanor or felony. With some criminal charges, there is an opportunity for the victim of the crime to receive restitution (monetary or otherwise).

Finally, you may pursue civil remedies against your former employee and possibly the billing company that was her coemployer. Depending on the amount, you could file a complaint in small claims court (up to $5,000), in a limited civil action (up to $25,000), or in an unlimited civil action. You may have claims against the former employee and/or the billing company for embezzlement, conversion, misappropriation, interference, failure to supervise, etc. CMA suggests that you consult with an employment attorney to further explore your possible claims against the former employee and/ or billing company.

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.

ABOUT THE AUTHOR:

DOES YOUR OFFICE MANAGER HAVE A QUESTION TOO? CXli\e N\e[c\i# pfli J;:DJ f]ÔZ\ dXeX^\i X[mfZXk\# `j fe jkX]] Xe[ i\X[p kf _\cg pfli f]ÔZ\ dXeX^\i n`k_ Xep hl\jk`fej k_\p dXp _Xm\% =\\c ]i\\ kf ZfekXZk CXli\e Xk /,/ *''$)./) fi Xk CN\e[c\i7J;:DJ%fi^ ]fi _\cg%

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N<9J@K< JE8GJ?FK nnn%c\^`e]f%ZX%^fm efore you vote this election season, take the time to learn more about current California legislation. OfďŹ cial California legislative information can be found at www.leginfo. ca.gov, a website maintained by the Legislative Counsel of California. Visitors to the site are provided with updates on Assembly and Senate ďŹ&#x201A;oor items, full texts on bills, resolutions, and constitutional amendments, California law codes, and laws currently in effect. There is also detailed information on how a bill becomes law and an array of legislative publications for further political education, as well as a â&#x20AC;&#x153;know your legislatorâ&#x20AC;? tool that locates the legislative representative(s) in your district.

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SDCMS-CMA MEMBER PHYSICIANS If you are paying full, non-discounted dues and are with a medical group of 19 or fewer physicians, you will receive a 5% discount off of your 2009 SDCMS-CMA dues if you renew and pay in full before October 31, 2008.

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6 GZ[j\ZZ 8Vbe ^c i]Z =ZVgi d[ i]Z 8^in Médecins Sans Frontières / Doctors Without Borders Refugee Camp in the Heart of the City” is an 8,000-square-foot outdoor exhibit displaying actual materials Médecins Sans Frontières/Doctors Without Borders (MSF) uses in its medical humanitarian work, including a cholera treatment center, health clinic, and vaccination tent. Doctors, nurses, epidemiologists, and other professionals who have worked in the field with MSF

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will guide visitors through the exhibit, explaining how MSF provides healthcare in resource-limited settings. The exhibit is free and open to the public and will run from 9:00 a.m. to 5:30 p.m. daily.

From September to November, “A Refugee Camp in the Heart of the City” will tour eight cities across western Canada and California and will be in San Diego from Nov. 6 through Nov. 9, Presidents

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D\dY\i Jgfkc`^_k Adam Dorin, MD, Anesthesiologist and Author of the Recently Published Jihad and American Medicine: Thinking Like a Terrorist to Anticipate Attacks via Our Health System J8E ;@<>F G?PJ@:@8E1 ?8M< PFL 8CN8PJ N8EK$ <; KF 9< 8 G?PJ@:@8E6 ;I% 8;8D ;FI@E1 Yes. I always liked science,

and it seemed like the sort of thing that would keep my interest. I tend to like challenges and get bored when I donâ&#x20AC;&#x2122;t feel like Iâ&#x20AC;&#x2122;m being continually required to learn more, be better, and rise to the next level.

The idea of a profession that would combine the fascination of human physiology with the art of patient care appealed to me from a very young age.

J;G1 N?P ;F PFL K?@EB ;F:KFIJ J?FLC; 9<$ :FD< @EMFCM<; N@K? FI>8E@Q<; D<;@:@E<6 ;I% ;FI@E1 In the current political cli-

J;G1 N@K? N?8K K?FL>?KJ NFLC; PFL C@B< KF C<8M< LJ6 ;I% ;FI@E1 I challenge my colleagues to

mate, it is important for physicians to maintain that collective will and cooperation that will help eďŹ&#x20AC;ect meaningful change. There are many challenges ahead (initiatives to raise the â&#x20AC;&#x2DC;capâ&#x20AC;&#x2122; and amend MICRA, eďŹ&#x20AC;orts by non-physicians to expand their â&#x20AC;&#x2DC;scope of practice,â&#x20AC;&#x2122; and bills to decrease insurance reimbursement); working together, we can make things better.

start thinking critically about what they can do to make things better and safer within the healthcare system. For those of you who are not members, I encourage you to join SDCMS because it is a stellar example of a community-based organization that can make a diďŹ&#x20AC;erence for patients and the ďŹ eld of medicine in general on a state and national level.

J;G1 8I< PFL ;F@E> N?8K PFL N8EK<; KF ;F FI K?FL>?K PFL NFLC; 9< ;F@E> @E K?< ?<8CK?:8I< @E;LJKIP6 ;I% ;FI@E1 As an anesthesiologist, I can only

really take care of one person at a time. I feel a lot of satisfaction in being able to be a perfectionist for just one patient in this way; but, Iâ&#x20AC;&#x2122;m also very much interested in the bigger picture. I want to be able to help make a diďŹ&#x20AC;erence for people on a much larger scale. My biggest interest right now is safety within the healthcare system. By giving lectures and writing about this topic, I hope to make eďŹ&#x20AC;ective changes that will reach the masses.

J;G1 N?<E ;@; PFL AF@E J;:DJ$:D8 8E; N?P6 ;I% ;FI@E1 I joined SDCMS in 2002 be-

cause I saw this as a new opportunity to make a diďŹ&#x20AC;erence for physicians and the community. I love the fact that SDCMS doctors come together to share their ideas and expertise for the beneďŹ t of all of us!

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he Mediterranean diet and a low-carbohydrate diet were each more effective for modest long-term weight loss than a low-fat diet (level 1 [likely reliable] evidence), based on a randomized trial of 322 mostly male adults. Participants had type 2 diabetes, coronary artery disease, or were aged 40â&#x20AC;&#x201C;65 years with body mass index * 27 kg/m2 and were randomized to 1 of 3 diets for 2 years: Mediterranean diet, low-carbohydrate () 120 g/day) non-restricted-calorie diet, or American Heart Association low-fat diet. Mediterranean diet and low-fat diet groups were restricted to 1,500 kilocalories/day for women and 1,800 kilocalories/day for men. Mean weight loss at 2 years was 4.4 kg (9.7 pounds) with Mediterranean diet vs. 4.7 kg (10.3 pounds) with low-carbohydrate diet vs. 2.9 kg (6.4 pounds) with low-fat diet (p < 0.001 for low-fat diet vs. each other group) (N Engl J Med 2008 July 17;359(3):229).

For more information, see the Diets for weight loss topic in DynaMed.

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From DynaMedâ&#x20AC;&#x2122;s Mediterranean diet â&#x20AC;&#x201D; EďŹ&#x20AC;ects on Weight Loss â&#x20AC;&#x201C; Weight Loss: t .FEJUFSSBOFBO EJFU PS MPX DBSCPIZdrate diet is more eďŹ&#x20AC;ective for modest long-term weight loss than low-fat diet (level 1 [likely reliable] evidence) o based on randomized trial o 322 adult participants (86% male) with type 2 diabetes (any age or body mass index [BMI]), coronary artery disease (any age or BMI), or aged 40-65 years with BMI â&#x2030;Ľ 27 kg/m2 were randomized to 1 of 3 diets for 2 years o Mediterranean diet

o low-carbohydrate (â&#x2030;¤ 120 g/day) non-restricted-calorie diet o American Heart Association lowfat diet o Mediterranean diet and low-fat diet restricted to 1,500 kcal/day (women) or 1,800 kcal/day (men) o mean weight at baseline 91.4 kg (201.5 lbs) o 16% of participants lost to followup, intention-to-treat (ITT) analysis used last observation carried forward for 2-year outcome o mean weight loss at 2 years signiďŹ -

Mediterranean diet

Low-carbohydrate diet

Low-fat diet

Completed 2-year study

85.30%

78%

90.30%

Mean baseline weight

91.1 kg (200.8 lbs)

91.8 kg (202.4 lbs)

91.3 kg (201.3 lbs)

Mean weight change at 2 years (ITT)

-4.4 kg (-9.7 lbs)

-4.7 kg (-10.4 lbs)

-2.9 kg (-6.4 lbs)

Mean weight change in completers

4.6 kg (-10.1 lbs)

-5.5 kg (-12.1 lbs)

-3.3 kg (-7.3 lbs)

cant with either Mediterranean diet or low-carbohydrate diet vs. low-fat diet (p < 0.001) in ITT analysis o low-carbohydrate group had signiďŹ cantly increased HDL cholesterol, decreased total cholesterol/HDL ratio and decreased triglycerides compared to low-fat group o Reference - DIRECT trial (N Engl J Med 2008 Jul 17;359(3):229)

DynaMed is a point-of-care reference resource designed to provide doctors and medical researchers with the best available evidence to support clinical decision-making

ABOUT THE AUTHOR:

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Originally Published in the February 1948 San Diego Physician (Then Known as The Bulletin) ;<8I J@I1

I wish to inform you that my shattered ďŹ nancial condition, due to federal laws, state laws, county laws, city laws, corporation laws, liquor laws, road improvement laws, in-laws, and other laws, makes it almost impossible for me to send you a check this year.

Through these laws I am compelled to pay amusement tax, head tax, school tax, liquor tax, furniture tax, street improvement tax, and excise tax. I am required to get a professional license, car license, hunting and ďŹ shing license, not to mention marriage and dog license. I am also required to contribute to every society and organization that the genius of man is capable of bringing to life. ...

For my safety, I am compelled to carry life insurance, accident insurance, earthquake insurance, tornado insurance, malpractice insurance, unemployment insurance, old age, and ďŹ re insurance. My own practice is so governed that it is hard for me to know who runs it, but I do all the work. I am inspected, suspected, rejected, dejected, examined, re-examined, cross-examined, informed, required, summoned, ďŹ ned, commended, and compelled until I provide an inexhaustible supply of money for every known need of the human race. If I refuse to donate something or other, I am talked about, lied about, pushed about, and discriminated against until I am almost ruined.

Iâ&#x20AC;&#x2122;ll conclude by telling you honestly that except for a miracle that happened, I could not make you this promise. My little dog just had some puppies and when I sell them Iâ&#x20AC;&#x2122;ll send you a check.

I@JB K@G =FI F:KF9<I 9p K?< ;F:KFIJ :FDG8EP hanks to technology that has made procedures less expensive and invasive, an estimated 20â&#x20AC;&#x201C;25 percent of all surgeries are now performed in physician ofďŹ ces. Unfortunately, several liability claims underscore the potential hazards of ofďŹ ce-based procedures: t " ZFBS PME GFNBMF TVÄ&#x160;FSFE DBSEJBD arrest and subsequent death during ofďŹ ce anesthesia for breast augmentation.

Liability issues included lack of pre-op clearance for a patient with a history of chronic heart disease. t "MMFHFE BEWFSTF SFBDUJPO UP *7 BOFTUIFUics resulted in the death of a 63-year-old male. Multiple liability issues included incomplete chart documentation and

the inappropriate handling of the oďŹ&#x192;ce code blue. t "MMFHFE OFHMJHFOU VTF PG BOFTUIFUJD medications and failure to respond appropriately to an emergency resulted in the death of a ďŹ ve-year-old male.

Consider the following: Since most oďŹ&#x192;ce-based procedures are elective surgeries, the expectations for optimal results are very high. The informed consent process should be completed well in advance of the procedure.

The discussion should be documented in the patientâ&#x20AC;&#x2122;s chart and a consent form collected from the patient.

There are stringent federal and state requirements that hospitals must follow in maintaining their facilities, but very little regulation pertains speciďŹ cally to a physicianâ&#x20AC;&#x2122;s oďŹ&#x192;ce. To maintain patient safety, the oďŹ&#x192;ce must comply with 1) all applicable federal, state, and local laws; 2) codes and regulations relating to ďŹ re prevention, building construction, and occupancy; and 3) occupational safety and health statutes.

It is always possible that a patient emergency may arise and the oďŹ&#x192;ce must be prepared to handle any intraoperative complications. At a minimum, facilities should have a reliable source of oxygen, suction, resuscitation equipment and emergency drugs. Also, without a written emergency plan, a patient emergency could be devastating. StaďŹ&#x20AC; should be educated about the plan so that each person knows what is expected of him or her.

Physicians can minimize their liability and improve patient safety by recognizing and managing the potential risks associated with oďŹ&#x192;ce-based procedures.

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UCSD School of Medicine The University of California, San Diego School of Medicine CELEBRATES ITS 40TH ANNIVERSARY

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orty years ago, in September 1968, 44 adventurous students became the charter class of the brand new UCSD School of Medicine. The school itself was a bold new venture of the young UC San Diego campus, which was already receiving national attention for the quality of its faculty and the strength of its research programs. The success of that first class and of our subsequent classes mirrors the success of the School of Medicine.

“The last 40 years have proven that I made a wise choice,” says charter class member Dr. William Jessee, who today serves as president and chief executive officer of the Medical Group Management Association (MGMA), based in Denver.

“UCSD was something of an unknown

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quantity, but I think that’s why many of my classmates chose it. It was an opportunity to be on the ground floor. Today, by any ranking, UCSD has become one of the toptier medical schools, and, as I meet alumni from other classes, I am impressed with how many UCSD medical school graduates have distinguished themselves in their chosen careers.”

Dr. Cheryl Burian-Baldwin, a pediatrician with Kaiser Permanente in San Diego, entered the UCSD School of Medicine the following year, and, like Dr. Jessee, recalls the excitement of being part of the medical school’s launch.

“My class had 50 students, and only five women,” she says. “But that wasn’t unusual then. It was a very interesting time; there

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9p ;8M@; 9I<EE<I# D; were lots of new ideas about how to run a school that were very good. For example, we had a year-end exam on everything we had studied, instead of finals throughout the year. That was a good way to learn; in fact, during our second year, we took part in one of the national boards and got the highest score in the country.”

We just welcomed our newest entering class of 134 students, and over half of the matriculants are women. More than 60 members of the total class are earning MD/ PhD degrees. Of more than 3,800 graduates since the UCSD School of Medicine opened, nearly two-thirds are practicing in California today. In its “Best Graduate Schools” edition, U.S. News and World Report ranks the UCSD School of Medicine

ÈKf[Xp# Yp Xep iXeb`e^ L:J; _Xj Y\Zfd\ fe\ f] k_\ kfg k`\i d\[`ZXc jZ_ffcj# Xe[# Xj @ d\\k Xclde` ]ifd fk_\i ZcXjj\j# @ Xd `dgi\jj\[ n`k_ _fn dXep L:J; d\[`ZXc jZ_ffc ^iX[lXk\j _Xm\ [`jk`e^l`j_\[ k_\dj\cm\j `e k_\`i Z_fj\e ZXi\\ij%É as the fifth leading public medical school, and 14th ranked research school out of over 130 medical schools in the nation. The UCSD School of Medicine is also among the top schools in the country in garnering medical research support from the National Institutes of Health.

“The addition of medical students in San Diego has been a tremendous benefit,” said Dr. James Hay, past president of the San Diego County Medical Society (SDCMS) and a family practice specialist in North County.

“Having the school here has helped bring in more specialists, and more specialty physicians are trained here and stay. The school also brings in a number of physicians who bring an added level of expertise to our community; one of my patients, for example, recently needed lung cancer care, and the university has some of the best specialists in the country. The level of healthcare in San Diego has always been high, and the medical school has added another dimension.”

I first came to San Diego in 1985 as a resident at UCSD Medical Center and the VA Medical Center. I left to join the faculty at the University of North Carolina and then Columbia College of Physicians and Surgeons, and was very happy to return to UCSD in 2007 in my current role. As we prepare to celebrate our 40th anniversary, we are also launching a number of initiatives to build on our 40-year legacy.

One measure of our medical school’s growth has been the expansion of clinical programs to support the school’s clinical teaching needs. When the school first opened, our early plans to build a new hospital on the UCSD campus were put on hold due to budgetary constraints.

Instead, the university leased the former county hospital facility, transforming it into what was then known as “University Hospital” (the University of California purchased the facility in 1981), where I

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trained and where my son was born. The school also formed a close partnership with the Veterans Affairs Health System, which continues to this day.

Today, the UCSD Medical Center operates hospitals in Hillcrest and La Jolla, as well as the Moores UCSD Cancer Center, awarded “Comprehensive” status by the National Cancer Institute, the Shiley Eye Center, extensive primary and special care practices, and federally sponsored centers studying a full spectrum of diseases and conditions in order to fulfill the university’s clinical, teaching, and research missions. Also key to the success of our teaching programs is the extensive network of community partnerships that has evolved over the years.

A large number of community physicians act as preceptors and mentors for our students and trainees, which is critically important. We could never have enough faculty to teach our students what it’s like to be a practicing physician. Today we

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have partnerships throughout San Diego County, for example, with the Community Clinics, with Rady Children’s Hospital, and our Blood and Marrow Transplant program with Sharp.

Former SDCMS president Dr. Theodore Mazer, a San Diego otolaryngologist, agrees that “having a school of medicine means San Diego patients have access to cuttingedge services, from tertiary clinical care to investigational trials. In communities without a medical school, you may need to settle for routine care or have to travel some distance” for this level of care.

“This serves everyone well, both the patients and the referring physicians; and it is good for the whole climate of the city,” Dr. Mazer noted, with the research effort contributing to the region’s pharmaceutical and biotechnology strengths.

But Dr. Mazer notes that while “UCSD is becoming one of the nation’s leaders in advanced medical care, I would like to see better cooperation with the community so we have fewer hurdles sending our patients to UCSD. The university still has some work to do in its relationships with community physicians.”

Our dean for clinical affairs, Dr. Tom McAfee, is focusing on this issue. As he explains, “We are more committed than ever to providing great clinical care and service for our community partners. This has included electronic linkages for medical records in community clinics and other settings, as well as the use of technology to support our specialists’ ability to communicate back to referring doctors.”

Dr. McAfee, who serves on the SDCMS board of directors, adds that “our commitment to our community colleagues goes be)'

yond clinical practice. We are more engaged periences with them.” than ever in SDCMS and its role of advocaFour decades ago, these types of relationcy on behalf of all San Diego physicians and ships helped shape Dr. Bill Jessee’s career, patients, and to playing a leadership role in leading to his current role with MGMA. the San Diego healthcare delivery system.” Giving students and residents a chance to In fact, UCSD School of Medicine faculty learn from community colleagues is more physicians constitute the third-largest num- important than ever, he said. ber of SDCMS members, a change that has “I attribute a lot of what I wound up doing taken place over the past few years. in my career to my time as a medical student.

Dr. Hay makes the important point that I got involved in Student AMA. My interest working to forge closer partnerships is to everyone’s advantage.

“We all tend to act in silos, and we work better when we work together,” he said. “Any way that we can facilitate better communication throughout the county would be positive, and the university can play a big part in that. School of Medicine faculty are able to pay more attention to addressing some of the pressing issues that we L:J; J:?FFC F= D<;@:@E< :8DGLJ @E (0.. Ç D<;@:8C K<8:?@E> =8:@C@KP 9<@E> :FEJKIL:K$ all face as part of their ‘day jobs,’ such <; M8 D<;@:8C :<EK<I @E 98:B>IFLE; as quality of care, and other health and industry issues.” and involvement in policy and economics Drs. Hay and Mazer also note that ex- came from my medical school experiences,” panding upon relationships between com- said Dr. Jessee. “One of the big challenges munity physicians and students and train- today is helping physicians understand that ees is a “win-win.” We agree. the practice of medicine isn’t just the art and “The practice of medicine today is not science of medicine, but also how healthcare divided from politics and the economic is organized and financed, and how to manrealities of the real world,” said Dr. Mazer. age a successful practice. Students without “When I trained, we had no idea about the this exposure run the risk of being thrown economics of the industry, but today you to the wolves. In today’s complex economic can’t practice medicine in a vacuum. UCSD environment, that is more important than has a good relationship with SDCMS, and ever. It’s also important for residents to spend we have had an opportunity to see some of time in non-hospital settings. Many physithe future leaders in medicine. We’ve got cians today are practicing almost entirely in some fantastic medical students and resi- an ambulatory setting, while most medical dents working with SDCMS, some great schools still view the hospital as the center of representatives who bring us their problems the universe. It’s obviously important but no and concerns, and allow us to share our ex- longer where most patients receive care.”

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As part of our commitment to training the physicians of the future, UCSD School of Medicine is preparing to break ground on a new Medical Education Building, equipped with telemedicine technologies and state-of-the-art centers for medical and surgical simulation. The building will also contain classroom space and â&#x20AC;&#x153;learning communitiesâ&#x20AC;? where small groups of students will convene throughout their medical school career to socialize and learn in smaller groups. â&#x20AC;&#x153;Medicine is becoming increasingly complex with new scientiďŹ c discoveries occurring daily,â&#x20AC;? said Dr. Maria Savoia, vice dean for medical education at the School of Medicine, whose team is also leading a curriculum update that will introduce more clinical experience in to the ďŹ rst and second years. â&#x20AC;&#x153;The new Medical Education Building will be a place to learn the fundamentals and advanced skills, and it will be a home to students, residents, fellows, and practicing physicians as they progress on their journey of life-long learning.â&#x20AC;?

From my perspective, the future is bright. When I left UCSD 15 years ago for

the University of North Carolina, this was already an exciting place with outstanding faculty and staďŹ&#x20AC;, a robust research enterprise, and some of the brightest students, residents, and fellows I have ever worked with. One of the biggest and most positive changes since I have been gone has been the incredible surge in community engagement and support for the university, which has meant so much in our ability to expand and improve our programs, facilities, research, and training opportunities.

With the help of colleagues, community and industry leaders, there is absolutely no doubt that we can continue to provide San Diego with a premier academic medical center that is nationally recognized for clinical research and specialized services, and that attracts and prepares the best students and trainees to become the practitioners of tomorrow.

San Diegoâ&#x20AC;&#x2122;s vice chancellor for health sciences and dean of the School of Medicine in February 2007. He has oversight of over 900 faculty physicians, pharmacists, and scientists, 7,500 staďŹ&#x20AC;, over 600 medical and pharmacy students, and a health system that cares for approximately 135,000 patients annually.

AF@E LJ =FI FLI +'K? 8EE@M<IJ8IP :<C<9I8K@FE Join with colleagues and community members to celebrate the UCSD School of Medicineâ&#x20AC;&#x2122;s 40th anniversary on Friday, November 14, 2008, at the Hyatt Regency La Jolla at Aventine. The evening will include dinner, dancing to the band NRG, and comments

by Brian Druker, MD, SOM â&#x20AC;&#x2122;81, one of the developers of Gleevec.

For more information, visit www. somanniversary.ucsd.edu or call (858) 822-3455.

Dr. Brenner, a distinguished physician-scientist who specializes in diseases of the liver, became UC

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Access to Care

All Health Plans Are Cdi 8gZViZY :fjVa ?fn Fe\ G_pj`Z`Xe$ile DXeX^\[ :Xi\ :fdgXep @j ;`]]\i\ek 9p A% D8I@F DFC@E8# D;

any physicians realize that health plans are not alike, but what are the differences and how might they affect your interaction as a physician and your experience? Evaluating a health plan to partner with is difďŹ cult.

Surveys about health plans that often garner newspaper headlines can make it all the more confusing. While many of these surveys attempt to assess a health planâ&#x20AC;&#x2122;s overall quality, their treatment of health conditions, and brand awareness, there is one important dimension that has yet to be measured by a survey or a scorecard: Does the health plan understand your business?

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For physicians serving Californiaâ&#x20AC;&#x2122;s MediCal program, the stateâ&#x20AC;&#x2122;s long-lived budgetary woes come as no surprise, but they require physicians to adapt to a very challenging business environment. For example, earlier this year Californiaâ&#x20AC;&#x2122;s governor announced a 10 percent provider rate reduction. The proposed reduction had the potential to drop tens of thousands of children from the Medi-Cal program, restrict adult eligibility requirements hurting families, and reduce patientsâ&#x20AC;&#x2122; access to preventive care, thereby increasing the burden

on physicians and already overcrowded emergency rooms in the state.

Molina Healthcare, a health plan focused on serving patients that access healthcare through government programs, was one of the ďŹ rst health plans to develop and communicate a plan for mitigating the cuts to its physician partners. The plan called for Molina Healthcare to: t 1SPQPTF BOE JNQMFNFOU B NPEFTU percent reduction in capitation payments to its provider network (other health plans proposed to pass on the full equivalent reduction to their capitated provider network). t $PNNJU UP DPOUJOVF QBZJOH JUT DBQJtated providers whether the health plan received payments from the state or not during the budgetary crisis. t 3FEVDF JUT IFBMUI QMBO BENJOJTUSBUJWF costs by approximately 6 percent. t *NQMFNFOU B OVNCFS PG NFEJDBM NBOagement initiatives designed to better manage its medical care costs. t "TTFSUJWFMZ BEWPDBUF PO CFIBMG PG QBtients and physicians among California lawmakers and leaders to raise awareness regarding the impact of the budget cuts.

Because Molina Healthcare partnered

closely with its contracted providers to combat these budget cuts, the plan was commended by physician group members of the California Association of Physician Groups (CAPG) as transparent and a fair approach to the state budget cuts. All of these initiatives were rooted in Molinaâ&#x20AC;&#x2122;s understanding of physiciansâ&#x20AC;&#x2122; business needs, its experience in the market, which spans nearly 30 years, and the strong relationships it has forged with providers and government agencies during that time. :FDD@KD<EK KF D<;@:8@; 8E; GIFM@;<I IFFKJ

In the San Diego market, you may know Molina as the health plan that stayed. Starting in 2004 with the exit from San Diego Medi-Cal by Sharp and Universal Care

[This article is the ďŹ rst in a series of occasional articles from San Diego County healthcare stakeholders expressing their ďŹ rst-person viewpoints on healthcare today.] ))

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care to those most in need and least able to afford it. Molina Healthcare now delivers care to over 1.2 million members in 10 states. For the past 10 years, Molina Healthcare has been a member of the California Medical Association (CMA), and Molina continues to own and operate one of the largest medical groups in California with 17 medical group sites throughout the state. =8JK =FIN8I;

health plans, the exit of Blue Cross of California in 2007, and through various budgetary crises, Molina Healthcare has always been there for providers. So, when other health plans ask the question “if” they are going to stay in a market, Molina asks the question “how” will we stay in the market.

Staying and being successful in any market requires Molina to have the right focus on physician and hospital networks.

Many physicians want to serve this population, and Molina’s goal is to work in a collaborative manner with the physician community to make this happen in the most efficient manner. Partnering with physicians to overcome business challenges and making it all work, under one common umbrella of Medicaid, is Molina Healthcare.

Molina grew out of a healthcare environment not so unlike today where low income patients without primary care physicians seek medical care in hospital emergency departments. As an emergency room physician, Dr. C. David Molina saw this trend first-hand. He recognized that this type of care lacked a preventive component and was not the most appropriate use of healthcare resources.

As a result in 1980, Dr. Molina opened his first primary care office in Long Beach.

That office plus 17 others still exist today and continue to provide quality health-

organization that has a history in providing quality medical services. This is a claim that not all health plans can make. In fact, Molina Healthcare of California is one of only 60 Medicaid health plans in the nation to receive an “excellent” accreditation by the National Committee on Quality Assurance (NCQA). In addition, all of Molina’s eligible health plans were ranked “Among America’s Best Health Plans” by U.S. News and World Report in 2007.

And earlier this year, Molina Healthcare

However, what Dr. Molina faced =fi g_pj`Z`Xej j\im`e^ :Xc`]fie`XËj in dealing with managed care companies then and what physiD\[`$:Xc gif^iXd# k_\ jkXk\Ëj cfe^$c`m\[ cians experience when they conYl[^\kXip nf\j Zfd\ Xj ef jligi`j\# Ylk tract with Molina now is different.

Molina prides itself on being un- k_\p i\hl`i\ g_pj`Z`Xej kf X[Xgk kf X m\ip like other managed care organizaZ_Xcc\e^`e^ Ylj`e\jj \em`ifed\ek% tions. We don’t have commercial lines of business that generate internal competition for resource allocation. of California received the 2008 Bronze All of our resources are dedicated to meetQuality Award from the California Deing the needs of our members. Molina is a partment of Healthcare Services for Outphysician-run organization, so we understanding Performance for 2007 HEDIS stand the value of our provider network. measures for Medi-Cal Managed Care in And, because we strive to be prudent stewSan Diego County. Molina Healthcare ards of the public’s fund, we have achieved of California participates in annual HEnoteworthy levels of administrative effiDIS audits as part of California’s quality ciency that many other health plans find reporting and voluntary quality accreditadifficult to match. Not every health plan tion process with the independent, nonpossesses the experience or willingness to profit National Committee for Quality meet those challenges … and be unlike the Assurance (NCQA). HEDIS reporting is rest of the pack. recognized as the most widely used set of healthcare performance measures in the 8::LI8K< 8E; K@D<CP :C8@DJ GIF:<JJ@E> United States.

Molina is striving for operational excelWhen you survey the Medicaid manlence in the provider payment process. aged care environment, you have a choice This goal is so important that a new seto work with a variety of managed care nior position, vice president of provider companies. Is Molina Healthcare differpayment, was created to oversee claims ent? Yes. We communicate effectively with processing and provider payments. There you about matters important to you. We is constant scrutiny in analyzing the infrahave made it one of the top priorities in structure and step-by-step processes from our organization to pay claims accurately the time a contract is written until a check and timely. While we cannot claim victory is cut to maximize efficiency and accuracy. yet on the claims side, each and everyday To do so, Molina has committed not only we are making progress. We make quality resources and training but we are working care a priority. on systemic approaches to analyzing and As a physician, if you have to work with resolving issues. And although the health a managed care company, wouldn’t you plan has made great progress, there is still want to work with one that understands much to be done to improve the service to your business? Molina Healthcare is that physicians. company.

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In case the surveys and scorecards do matter, Molina excels in this area as well.

Quality is a priority for Molina. When you contract with Molina, you are joining an F : K F 9 < I ) ' ' / s

Dr. Molina is president and chief executive officer of Molina Healthcare, Inc.

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N_p KXb`e^ X J\olXc ?`jkfip DXkk\ij 9P <C8@E< G@<I:<# D;# DG? ne in four adolescent girls in the United States is infected with a sexually transmitted disease (STD).” Perhaps the only thing more startling than this statistic from the recent national population-based study was the fact that 20 percent of teen girls with a single lifetime partner were already infected. The vast majority of persons studied were asymptomatic and unaware of their infections.

STDs take an enormous toll on health here and around the world. Chlamydia and gonorrhea outnumber by far all other reportable diseases. Nationally, there are over one million cases of pelvic inflammatory disease (PID) annually. Twenty percent of these women will become infertile, with the risk of infertility doubling with each subsequent episode of PID. Another 18 percent will develop chronic pelvic pain, and 9 percent will have an ectopic pregnancy. These infections occur mainly in young women who are at the beginning of their reproductive years. Other consequences of these diseases include urethritis, epididymitis, proctitis, adult conjunctivitis, Fitz-Hugh-Curtis syndrome, Reiter’s syndrome, neonatal conjunctivitis, and pneumonia. STDs that cause inflammation (e.g., trichomonas and gonorrhea) and those that cause ulceration (e.g., herpes and syphilis) increase risk of both acquisition and transmission of HIV. Congenital syphilis can lead to spontaneous abortion and devastating malformations in newborns.

While any sexually active person may be affected, STDs disproportionately affect persons of color and those with fewer means to seek help. In San Diego County,

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Latinos and African Americans are more time and less than 35 percent inquired likely to be exposed to chlamydia and gonabout specific sexual risks. Male clinicians orrhea, even if they have few sexual partwere significantly less likely to explore ners. Persons of color are more likely than these areas than their female counterparts. whites to be diagnosed with HIV shortly Examples like these of missed opportunibefore developing AIDS. ties for detection abound.

The county is also experiencing rising Just like the general public, physicians rates of syphilis, primarily in gay men have a wide range of attitudes and beliefs. and other men who have sex with men Many are uncomfortable with discussions (MSM). HIV-positive persons who get about sexual practices and are apprehensive infected with syphilis are at risk for early neurosyphilis, JkXe[Xi[ [`[XZk`Z d\jjX^\j ljlXccp [f efk which can lead to permanent neurologic deficits, df[`]p Y\_Xm`fi# Ylk efeal[^d\ekXc# `e[`m`[l$ such as blindness or stroke. Xc`q\[ i`jb i\[lZk`fe ZfXZ_`e^ _Xj Y\\e j_fne A report from the New York City Public Health kf c\jj\e k_\ c`b\c`_ff[ f] ]lkli\ JK;j% Department showed that while 19 percent of white MSM failed to that patients will be upset if conversation reveal their status to their medical providabout sexual history is initiated; however, ers, 60 percent of African American men, studies have found that, far from being of48 percent of Latino men, and 47 percent fended, patients feel that they receive betof Asian men did not disclose their MSM ter care when their sexual health is assessed status. This reveals the cultural stigma and during medical evaluations. While teenagdiscrimination that continue to make ers rarely bring up sexual matters to their some patients reluctant to provide critiphysicians, most are willing to discuss their cal information without prompting. Furconcerns when asked. thermore, despite the 2006 CDC national The take-home message is that cliniguidelines, which call for HIV testing for cians need to do a better job of protecting all sexually active persons between 13 and their patients from diseases that may insid64, men who did not disclose their risks iously do damage to them, or, in the case were only half as likely to be tested for of women, their unborn children. ProvidHIV (36 percent vs. 63 percent). ers need to keep any personal opinions to In 2002, only 38 percent of American themselves and ask how they can best serve women seeking emergency contraception in a compassionate, effective manner those after unprotected sex were offered STD/ who depend on them.

HIV testing. A Canadian study found that Wondering how to begin the discusprimary care physicians and gynecologists sion? Here is a good introduction: “Now I discussed condom use with their sexually am going to take a few minutes to ask you active patients less than 50 percent of the some direct questions about your sexual

[For the complete version of this article with resources, please go to www.SDCMS.org.] )+

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health. These questions are very personal, but it is important for me to know so I can help you stay healthy. I ask these questions to all of my patients regardless of age, marital status, or sexual preference, and, like the rest of this visit, the information is conďŹ dential.â&#x20AC;? Alternatively, the ďŹ rst website listed below provides a patient-administered sexual history questionnaire that can be reviewed during the interview.

The taking of a sexual history matters because it will help you as the provider make three critical decisions: (% How often to screen the patient. )% What diseases to screen for. *% What body sites need to be screened.

The components of a sexual history are â&#x20AC;&#x153;the ďŹ ve Psâ&#x20AC;?: (% Partners a. Number (all sexually active women under 26 should be screened for chlamydia annually; persons with multiple partners or additional risks require more frequent STD screening). b. Gender (MSM who are not in a mutually monogamous relationship should be tested for syphilis, chlamydia, and gonorrhea every three to six months).

c. Risk factors (e.g., sex under the inďŹ&#x201A;uence of drugs or alcohol; anonymous partners). )% Pregnancy Prevention *% Protection From STDs (condom use) +% Practices (accurate diagnosis of chlamydia or gonorrhea requires specimen collection from each body site exposed; knowledge of sexual practices determines which patients are more likely to have occult primary syphilis ulcers and present with secondary syphilis). ,% Past history of STDs (recent history of chlamydia or gonorrhea increases current risk â&#x20AC;&#x201D; rescreening at three months post-diagnosis is recommended; persons with a history of syphilis need follow-up nontreponemal titers to determine whether treatment was successful).

Eliciting a frank sexual history creates an opportunity to discuss risk reduction, especially if a diagnosed STD provides a â&#x20AC;&#x153;teachable moment.â&#x20AC;? These conversations are not a â&#x20AC;&#x153;one size ďŹ ts allâ&#x20AC;? activity â&#x20AC;&#x201D; they should sound very diďŹ&#x20AC;erent with a man who has numerous anonymous partners, a middle-aged woman re-entering the dat-

ing scene after a divorce, or a teen who has recently become sexually active. Standard didactic messages usually do not modify behavior, but nonjudgmental, individualized risk reduction coaching has been shown to lessen the likelihood of future STDs. The key is to understand the patientâ&#x20AC;&#x2122;s starting point via the sexual history, and to encourage patients who engage in risky behavior to step down one or two levels from the current level of risk.

Despite requiring deeper introspection than most other aspects of oneâ&#x20AC;&#x2122;s job, the prevention and treatment of sexually transmitted infections can be a rewarding arena to truly practice the science â&#x20AC;&#x201D; and art â&#x20AC;&#x201D; of medicine. These resources provide a wealth of information to support your eďŹ&#x20AC;orts: t www.stdcheckup.org t www.cdc.gov/std t www.sfcityclinic.org/providers t www.ashastd.org

ABOUT THE AUTHOR: Dr. Pierce is the

STD controller for the County of San Diego, Public Health Services.

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here is growing concern about our nation’s lack of progress in reducing racial and ethnic disparities and the need to accommodate increasingly diverse patient populations, as evidenced by the 2007 National Healthcare Disparities and Quality Reports from the Agency for Healthcare Quality and Research (AHRQ).

In the AHRQ state snapshots for quality, California obtained a solid score of “average.” Another key finding: Being uninsured was the most important risk factor in six out of seven measures for poor quality healthcare. Other risk factors include poverty, race, ethnicity, gender, education, and geography. Language and literacy are also important determinants of cultural competency and effective communication. An estimated one in five in the United States speaks a language other

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than English in the home, according to the Medical Leadership Council. Thus, it is critical that fields for collecting race, ethnicity, language, and literacy data, as well as other pertinent cross-cultural information, be included in health records and other databases.

Citing data from the United Health Foundation, a recent report from the California Academy of Family Physicians (CAFP), Strong Medicine: Family Medicine’s Fix for California’s Fractured Health Care System, states in 2006 California ranked 23rd in the nation in health status.

The report also indicates that the current health status of Californians is not what it

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should be despite spending more than $170 billion annually, and almost one in five Californians lacks health insurance. While many factors influence quality and cross-cultural care, there are abundant resources available to change the status quo and improve care today and tomorrow. :LCKLI8CCP 8E; C@E>L@JK@:8CCP 8GGIFGI@8K< J<IM@:<J :C8J

During the past few years, it has been my privilege to consult with physicians and office managers throughout California to promote quality improvement and

cultural competency. Through a unique program from the U.S. Department of Health and Human Services Office of Minority Health (OMH), administered

by Lumetra, California’s Medicare Quality Improvement Organization, I have worked with California physicians who have shown exceptional dedication to high quality, culturally responsive care.

Understanding culturally and linguistically appropriate services (CLAS) is an important first step toward eliminating

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healthcare disparities. Each of the Physician Champions of Culturally Responsive Care recognized on the Lumetra website completed at least one theme of OMH’s free, selfpaced, online training, A Physician’s Practical Guide to Culturally Competent Care, which offers up to nine CMEs. The participating practices have one common characteristic: They truly care about their patients and their communities. However, many physician practices do not have ready access to or knowledge of the plethora of cross-cultural communication and education resources available to them at little or no cost.

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Lumetra offers a myriad of CLAS resources online at no cost. Our diabetes and Take 5 mammography campaigns resulted in an increased number of California Medicare beneficiaries receiving annual diabetes

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monitoring tests and biennial mammograms. Our diabetes education brochures using the stages of change or Transtheoretical Model (TTM) and multilingual Managing Your Medicines patient booklets are extremely popular for their visual appeal and clarity. You can also access our ¡Viva la Vida! Controle Su Diabetes (Live Your Life! Control Your Diabetes) bilingual diabetes patient education booklet on our website. Visit Lumetra’s Topics page for a complete listing of tools.

ducing health disparities by helping organizations and providers improve their ability to provide culturally responsive care through education, training, and organizational change. Numerous available tools include a short patient satisfaction survey, tracking spreadsheet, and hundreds of translated health materials.

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t Language Assessment Questions — Developed by Leah Karliner, MD, UCSF The following are two key questions to ask each patient in assessing a language barrier:

t Network for Multicultural Health, Center for Health Professions, University of California, San Francisco (UCSF) — This Network focuses on re-

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t The Provider’s Guide to Quality and Culture, The Manager’s Electronic Resource Center (ERC)

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JFD< 98J@: ;<=@E@K@FEJ 1. How well do you speak English? t Very Well t Well t Not Well t Not at All 2. In general, in what language do you prefer to receive your medical care?

t 5FSN .FEJDBM (MPTTBSJFT, The Cross Cultural Health Care Program t ICE Health Plan Identified Threshold Languages for the Department of Managed Health Care’s Language Assistance Regulations, Industry Collaboration Effort (ICE) — In 2003, the California Legislature passed Senate Bill 853, mandating that all California health plans provide language assistance services to their enrollees with limited English proficiency. The legislation stipulates that all vital documents must be translated into threshold languages and interpretation services made available to enrollees. The most common threshold languages are: o Chinese — traditional characters o Chinese — simplified characters o Korean o Spanish o Tagalog o Vietnamese t Language Access Database, The Medical Leadership Council (MLC) — The Language Access Database provides local, state, and national resources to assist in providing language access and culturally proficient healthcare.

The database is searchable by California county, specific language, and resource type.

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t Asian Pacific Health Center (APHC) — This nonprofit community clinic in eastern San Diego received the Asian Heritage Award in Health and Medicine offered by ASIA Media, Inc., and the

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Asian Heritage Society in May 2008.The APHC was founded in 2000 by a group of Vietnamese health professionals. Lowcost and family-centered health services are available to community members regardless of ethnic background. t The Behavioral Diabetes Institute (BDI) — Unique to San Diego is the world’s first organization dedicated to addressing the unmet psychological needs of people with diabetes. Prior to founding the nonprofit BDI, William H. Polonsky, PhD, CDE, assistant clinical professor in psychiatry, University of California, San Diego (UCSD), served as a behavioral consultant in multi-site clinical research trials, including the National Institutes for Health Diabetes Prevention Program. The BDI helps people overcome emotional and behavioral obstacles to master the unique challenges of diabetes, conducts behavioral research, and offers specialty behavioral training necessary for managing diabetes effectively. One popular DVD demonstrates Dr. Polonsky modeling motivational interviewing techniques with multicultural patients.

Another effective tool is a patient quiz to assess level of stress related to diabetes.

low-income and uninsured populations.

Call (619) 542-4300 or visit their website at www.ccc-sd.org. t Project Dulce, The Whittier Institute for Diabetes — Initiated in 1997, Project Dulce provides diabetes care and education to ethnically diverse populations

t Council of Community Clinics (CCC) — The CCC is composed of 17 community clinics and health center organizations operating more than 75 primary care sites throughout San Diego and Imperial counties. Their mission is to provide access to quality healthcare and related services for diverse communities with an emphasis on

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throughout San Diego County. Nurseled teams provide diabetes care in collaboration with primary care physicians, and peer educators provide diabetes self-management education that addresses each patient’s cultural and language needs. The program has managed thousands of ethnically diverse and low-income patients at community clinic and university health system sites. Patient education materials are available in eight languages: English, Spanish, Arabic, Chinese, Laotian, Somali, Tagalog, and Vietnamese.

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t American Cancer Society (ACS) — Find local support groups, programs, and services in San Diego County at (619) 299-4200, or visit the ACS website at www.cancer.org. t Every Woman Counts — Funded by the State of California Department of Public Health, Every Woman Counts offers free breast and cervical cancer screening for eligible women. Counselors are available in English, Spanish, Mandarin, Cantonese, Korean and Vietnamese. Call (800) 511-2300. t National Cancer Institute — Call (800) 422-6237 or (800) 4-CANCER, or visit its website at www.cancer.gov.

t Council on Multicultural Health (CMH), California Department of Public Health (CDPH) — The CMH mission is to advise the CDPH about improving access to quality healthcare and eliminating health disparities. The CMH is a conduit for exchange of information with racial and ethnic communities in California. t Intercultural Cancer Council (ICC) — The ICC promotes policies, partnerships, and research to eliminate the unequal burden of cancer among racial and ethnic minorities and medically underserved populations in the United States and associated territories. A local San Diegan, Susan Matsuko Shinagawa, co-

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founder and past chair, is a breast cancer survivor, advocate, and self-described “troublemaker” who serves on the ICC board. t Office of Minority Health Resource Center (OMHRC) — This is the nation’s largest repository of information and statistics for African Americans, American Indians/Alaska Natives, Asian Americans, Hispanics, and Native Hawaiians and other Pacific Islanders. For customized responses, call toll-free (800) 444-6472, or email info@omhrc.gov. Bilingual information specialists are available. t RecreationRx.org — Started in Chula Vista, the mission of RecreationRx.org is to promote health through work and play by facilitating partnerships between healthcare and recreation providers. The “recreation prescription” offers both physical and social activities that match the benefits of exercise with camaraderie and fun. There is dancing, walking, swimming, ball sports, yoga, or tai chi for every age and fitness level. This program also supports California Medical Foundation’s Obesity Prevention Project and the Network for a Healthy California. t San Diego County Medical Society t Susan G. Komen Race for the Cure — Seventy-five percent of net proceeds from

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Quality and Culture Quiz. The purpose is to stimulate your thinking and help you reflect on experiences, knowledge, and attitudes regarding diverse populations.

The Office of Minority Health seeks to improve the health equity of racial and ethnic minority populations. Take the first step to improve quality care for diverse populations by learning about cultural competence, language access services, and organizational supports.

OMH offers free, self-paced, online training to earn up to nine CMEs.

the Susan G. Komen Race for the Cure stays in San Diego to support uninsured and underinsured individuals with breast cancer in the areas of screening, diagnosis, treatment, and education. The remaining 25 percent supports national research. Participate on Sunday November 2, 2008, at Balboa Park in San Diego. t The California Endowment — The California Endowment awards grants to organizations that support its mission to expand access to affordable, quality healthcare for underserved individuals and communities, and to promote fundamental improvements in the health status of all Californians. t Asian and Pacific Islander American Health Forum — The Asian and Pacific Islander American Health Forum envisions a multicutural society where the Asian American, Native Hawaiian and other Pacific Islander communities are included and represented in all health, political, social, and economic arenas. Its mission is to promote improvement in the health status of all Asian Americans, Native Hawaiians, and other Pacific Islanders in the United States.

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t Creating Equity Reports: A Guide for Hospitals — One of the first action steps for any hospital to address potential inequalities in care is to assess its data. Equity reports serve a key role by helping individual institutions identify inequalities and monitor changes over time. Equity reports inform hospitals about where to focus their resources and efforts to reduce disparities, improve quality, and increase patient satisfaction. t Cultural Competency Videos, Fanlight Productions — Fanlight Productions is an independent film company

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We need to remain committed to community-based approaches that ensure our racial, ethnic, indigent, and other special populations experience high quality, culturally appropriate care. There are many resources to help busy physicians meet the changing needs of their growing and diverse practices. Probably the most important factor still remains the daily conversations between physicians and patients. If you have questions or need assistance related to culturally competent care, please contact me at Lumetra via email at ccoleman@caqio.sdps.org or by telephone at (415) 677-2089.

Ms. Coleman is a healthcare consultant with Lumetra, an independent, nonprofit healthcare consulting organization dedicated to improving the quality, safety, efficiency, and integrity of healthcare. Lumetra provides an array of professional consulting services, including healthcare process improvement, scientific analysis, healthcare review, and healthcare marketing and communications, to public and private entities across the country. Visit Lumetra online at www. lumetra.com.

ABOUT THE AUTHOR:

specializing in healthcare, cross cultural perspectives, professional ethics, and disabilities. Educational programs are emotionally and intellectually stimulating and up-to-date. Their four “trigger” video series, “Worlds Apart,” is effective in all settings to promote conversations about culturally responsive care.

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You can examine your own cultural competence by taking a quick, 10-minute

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9p ;8E B<8PJ# DJ# 8E; >FEQ8CF 98CCFE$C8E;8# D; bviously, Dr. Stewart got it wrong. Microbes have been confounding us with their adaptive abilities since the introduction of penicillin, and they’re not going to stop.

The flood of new classes of antibiotics introduced in the 1950s and 1960s has slowed to a trickle, even as the number of resistant strains encountered grows inexorably. Some authors have already begun to refer to the “post-antibiotic era.”

Several years ago, the San Diego County Medical Society (SDCMS) founded the Group to Eradicate Resistant Microbes (GERM). One of its mandates was to survey the level and trends of antimicrobial resistance within San Diego County and serve as a guide to the medical community as to appropriate actions to at least forestall the consequences of antibiotic use. This article is a summary of available antibiotic data over the last six years in our commu-

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eral large local hospitals that use the current CLSI antibiogram format.

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The traditional way of measuring the effect of an antibiotic against a species of bacteria is the preparation of an antibiogram. The number of times an organism is encountered in a laboratory is tabulated and the percentage of strains testing susceptible to usual therapeutic levels is recorded. It sounds simple enough, but a number of variations of how many times to count multiple isolates from a patient have lead to confusion. In 2002 the Clinical Laboratories Standardization Institute, or CLSI (formerly NCCLS), recommended a standard antibiogram preparation in which only the first isolate of a species of bacteria from a patient was counted and inpatient data was separated from outpatient data.

The data that follow were taken from sev-

Because of its pathogenicity and persistence, discussions of drug-resistant organisms usually start with methicillin-resistant Staphylococcus aureus. The term is a poor one, as not only methicillin is ineffective, but also all penicillins, cephalosporins, carbapenems, and monobactams. Additionally, though not affected by the same altered penicillin binding protein produced by the mecA gene, MRSAs are usually resistant to several other antibiotics, including fluoroquinolones and macrolides. This is especially true of hospital-associated strains.

Use of any of these drugs selects for MRSA and facilitates its colonization.

Table 1 shows the percentage of S. aureus strains isolated at several major San Diego hospitals since 2002 that are me-

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community-associated from healthcare-associated ER patients. Data are also limited by the decision of a physician to submit a culture on what now has become a rather commonly recognized presentation. Nevertheless, the data are instructive.

K89C< (% Percentage of S. aureus isolates from hospitalized patients in San Diego County that were methicillin resistant.

MSSA = Methicillin Susceptible S. aureus; MRSA = Methicillin Resistant S. aureus K89C< )% Percentage of S. aureus isolates from out-patients (mainly emergency room) in San Diego County that were methicillin resistant.

thicillin resistant. Clearly there has been a steady increase in the percentage of resistant strains, with less than half now susceptible.

Before 2000, MRSA was limited to infections associated with the healthcare setting. A new strain of Staphylococcus has emerged, however, that has acquired not only altered penicillin binding proteins but an enhanced virulence factor known as the Panton-Valentine leukocidin (PVL).

PVL is a modiďŹ ed delta-hemolysin that enables the organism to destroy neutrophils.

While most commonly seen in dermatologic infections, they are particularly invasive in pulmonary and bone infections.

This new strain has spread with amazing rapidity around the world.

Table 2 shows the percentage of S. aureus from San Diego outpatients (mostly emergency room) since 2001 that are methicillin resistant. From the labâ&#x20AC;&#x2122;s perspective, it is impossible to clearly categorize

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The increased use of vancomycin for the treatment of MRSA infections has no doubt driven the emergence of vancomycin-resistant Enterococcus (VRE). Table 3 illustrates the trend of emergence of VRE at several San Diego hospitals over the last six years. Most strains are Enterococcus faecium. Vancomycin-resistant E. faecalis are still rare.

K89C< *% Percentage of vancomycin-resistant Enterococcus isolates from hospitalized patients in San Diego County.

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To date, no vancomycin-resistant Staphylococcus has been isolated in San Diego.

A few strains have been isolated in the United States in the past few years, but the organism has not yet ďŹ gured out how to incorporate the vanA gene complex from Enterococcus into its chromosome. The minimum inhibitory concentrations of Staphylococcus to vancomycin have been increasing, however, and while MICs of 0.5 mcg/ml used to be the norm, many strains now require 1.0 or even 2.0 mcg/ ml for inhibition. In a recent study, 55 of 883 (6 percent) of MRSA strains isolated from San Diego hospitals had vancomycin MIC of 2 mcg/ml. Both anecdotal evidence from infectious disease specialists as well as published reports have raised concern over the limited eďŹ&#x20AC;ectiveness of using vancomycin alone in treating MRSA bacteremia when the MIC is over 1 mcg/ ml [Soriano, A. et al. InďŹ&#x201A;uence of vancomycin minimum inhibitory concentration on the treatment of MRSA bacteremia.

Clinical Infectious Diseases, 15 Jan, 2008, 46:2, 193-200]. =CLFIFHL@EFCFE<J

Upon their introduction for clinical use in the mid-1990s, virtually all members of the Enterobacteriaceae were susceptible to ďŹ&#x201A;uoroquinolones. Table 4 illustrates the trend in the susceptibility in hospitalisolated strains of E. coli in San Diego over the last six years, with over 30 percent of strains now resistant. While tested separately, all ďŹ&#x201A;uoroquinolones (ciproďŹ&#x201A;oxacin, levoďŹ&#x201A;oxacin, gatiďŹ&#x201A;oxacin, and moxiďŹ&#x201A;oxacin) show the same susceptibility pattern.

Proteus mirabilis shows a resistance pattern similar to E. coli. Klebsiella, Enterobacter, and other Enterobacteriaceae remain susceptible at or slightly above 90 percent.

Table 5 shows the trend in ďŹ&#x201A;uoroquinolone resistant from outpatient strains of E. coli. While not as profound as hospital strains, the trend is nonetheless the same.

While growing in numbers internationally, Streptococcus pneumoniae resistant to levoďŹ&#x201A;oxacin is still rare in San Diego; only a few strains have been isolated.

While not considered an adequate treat-

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ment option for Staph. aureus, the heavy use of ďŹ&#x201A;uoroquinolones for other organisms has been considered a major driving force behind the emergence of MRSA, as most strains are resistant, and their use creates an ecological niche for colonization.

K89C< +% Percentage of E. coli isolates from hospitalized patients in San Diego County that were resistant to ďŹ&#x201A;uoroquinolones.

there. While not yet at the level of some other multi-drug resistant organisms, ESBL activity in San Diego has undoubtedly been increasing, as shown in Table 6.

The data refer to cefotaxime, but all thirdgeneration cephalosporins show similar susceptibility patterns.

K89C< -% Percentage of E. coli isolates from hospitalized patients in San Diego County that were susceptible to cefotaxime.

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K89C< ,% Percentage of E. coli isolates from outpatients (mainly emergency room) in San Diego County that were ďŹ&#x201A;uoroquinolone resistant.

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From the selective data presented here, it is obvious that the general trend within San Diego, as in the rest of the world, is toward a more drug-resistant bacterial population.

Newer antimicrobials such as linezolid, daptomycin, and tigecycline will be helpful, but pharmaceutical pipelines are reportedly sparse. Judicious use of antibiotics remains the main weapon to at least slow the antimicrobial resistance trend.

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Resistance of Gram-negative organisms to third generation cephalosporins can be due to the organismsâ&#x20AC;&#x2122; acquisition of any one of a number of complex enzymes known as extended spectrum beta-lactamases (ESBLs). Because of their parenteral administration, use of these drugs is usually conďŹ ned to the healthcare setting, and most isolates of resistant strains originate

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Mr. Keays is a clinical microbiologist with Scripps Health. Dr. Ballon-Landa, who specializes in infectious disease and internal medicine, is chair of SDCMSâ&#x20AC;&#x2122; Germ (Group to Eradicate Resistant Micro-organisms) Commission.

ABOUT THE AUTHORS:

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REGISTRY

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PLACEMENT

FIRM

Physicians Nurse Practitioners Physician Assistants

Locum Tenens Permanent Placement V oi ce : 8 0 0 -91 9 - 9 1 4 1 o r 8 0 5 - 6 4 1 - 9 1 4 1 FAX : 8 0 5 - 6 4 1 - 9 1 4 3

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

The

Pulse

NO 43

D<JJ8>< =IFD K?< GI<J@;<EK Dear Friends: As the seasons come and go, it is never without change. Change is happening at the Foundation, too. The Foundation has been working in tandem with the San Diego County Medical Society to launch a new website this fall. This new website will deliver even more information about our core initiatives and be a resource for all of our programs. Please visit our new website later this fall at www.SDCMSF.org and let us know what you think!

In addition to updating our website, we will be modifying the Foundation’s logo to create a look and feel to accompany our growing Foundation into the future. With all of our funded programs, we are spend-

Save

ing more time in the public, and we want to identify ourselves to physicians, patients, and our community partners with the new image. We believe it will portray our continued commitment to our mission of addressing the unmet healthcare needs of all patients and physicians in San Diego through service, education, and innovation.

The Foundation has other exciting news on the horizon as well. Project Access San Diego (PASD) has partnered with Kaiser Permanente to offer the first “Super Saturday Surgery Day” for PASD patients! This exciting and groundbreaking event will provide low-risk surgeries, free of charge, to patients who have been selected through our program. With 14 volunteer surgeons and many

t e dates the

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surgical and administrative staff volunteers, this day will be a life-changing event for patients, physicians, and the medical staff. Stay tuned for more announcements regarding other community participants in programs like this to benefit our community.

Without your help, none of this would be possible. Your Foundation will continue to work in furthering our mission.

Thank you for all that you do for the patients in San Diego!

Sincerely,

CAROL L. YOUNG, MD, PRESIDENT OF THE BOARD

Showcasing a Foundation Inititative Super Saturday Surgery Days

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The Foundation, through its Project Access San Diego initiative, is in the final planning stages to launch its first “Super Saturday Surgery Day.” Project Access is currently partnering with Kaiser Permanente San Diego and is in discussions with other area hospitals to provide low-risk, minor surgeries for patients in San Diego.

Patients who are served in this project are uninsured, meet income eligibility requirements, and meet certain medical criteria to participate.

staffing for the surgery day. In addition, they will provide any labs and/or imaging needed to support the surgeon. All medications the patient needs between the surgery and post-op appointment and all supplies needed for the actual surgery day are also provided.

Super Saturday Surgery Days are a tremendous community effort and benefit.

Generally, 10 to 20 surgeries are performed in a half-day with a value to the community in the neighborhood of $70,000. The value to the patients is life long!

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For surgery days, PASD will work with San Diego County Community Health Centers and Free Clinics (Clinics) to identify low-risk, healthy patients who are uninsured for whom an outpatient surgery would have tremendous value to their quality of life, e.g., getting back to work, living pain-free. PASD works with the clinics to care coordinate these patients to and screen them for eligibility.

Volunteer surgeons are responsible for making the final patient candidacy determination. Participating surgeons donate one pre-op appointment, the actual surgery, one post-op appointment, and work with the primary care physician (medical home) for any follow-up plans that need to be developed.

Partner hospitals donate the OR space, equipment needed to perform surgeries, and the medicines patients will need post-op. Participating hospitals designate a committee to help with the implementation. PASD works with that committee to recruit volunteers, including physicians, surgical staff, environmental services, and administration staff to provide the

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Surgery days will consist of general surgery that can be done on an outpatient basis. Surgeries must be outpatient and elective. Availability of procedures depends on volunteer surgeon availability.

Common procedure types (others may be available) include: Hernia repair Cyst excision Ear, nose, and throat procedures Ophthalmology procedures Orthopedic procedures Urology procedures Biopsies Other low-risk, outpatient procedures (as selected by surgeon) For more information about “Super Saturday Surgery Days” or how to get involved in Project Access San Diego, please contact Tana Lorah [TLorah@ SDCMS.org or (858) 300-2779]. There are numerous ways to volunteer with your Foundation — call us to find out how!

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SDCMS Members BE SURE TO TAKE ADVANTAGE OF THE FOLLOWING MEMBERSONLY BENEFITS FROM SDCMS’ ENDORSED PARTNERS!

AKT, LLP

AKT has provided audit, tax preparation and planning, accounting assistance, and business consulting to San Diego County clients for more than 50 years. AKT understands physician practices, and their personal, local, and global services can help you achieve success. SDCMS members receive a 15% discount on standard rates for professional services, with an unconditional satisfaction guarantee: Disappointed clients pay only what they thought the work was worth. Call Ron Mitchell (760) 268-0212 or email him at rmitchell@aktcpa.com.

ALLIANT INSURANCE SERVICES

As California’s largest premier specialty insurance broker, and ranking among the 13th largest in the nation, Alliant Insurance delivers a comprehensive portfolio of insurance products and services. SDCMS members receive a savings of 5–10% or more off of the cost of insurance, or cash rebates related to practice size, a savings of 7–12% on long-term disability income protection, and no-cost human resources consulting. Contact Mark Allan at (800) 654-4609 or at mallan@alliantinsurance.com, call Alliant Insurance Services at (888) 849-1337, or visit www.alliantinsurance.com.

SDCMS members receive a free consultation, a discount on hourly rates, and a package price on services for contract negotiations. Contact Kim Fenton at (949) 481-9066, at kimf@healthcareconsultant.org, or visit www.healthcareconsultant.org for more information. For consultation scheduling, contact Marisol Gonzalez, your physician advocate, at (858) 300-2782 or at MGonzalez@SDCMS.org.

PRACTICE PERFORMANCE GROUP (PPG)

Practice Performance Group provides high performance medical practice management services for physicians, including consulting, expert witness, workshops, speaking, and a monthly newsletter. SDCMS members receive discounted management consulting on productivity and patient flow, personnel, governance and management, market strategy and tactics and practice acquisitions, sales and mergers, and a free one-year subscription to their newsletter, UnCommon Sense ®. PPG also conducts free half-day seminars for members and their employees at SDCMS (watch your faxes and emails). Contact Jeffrey Denning or Judy Bee at (858) 459-7878 or at Jeff@PPGConsulting.com, or visit www.PPGConsulting.com.

ALLSCRIPTS

Allscripts offers substantial discounts to SDCMS members on its award-winning practice management and electronic health records.

Allscripts’ solutions provide improved patient care, complete workflow management, P4P and P4Q clinical and financial reporting, e-prescribing with builtin formularies, built-in claims scrubbing, and complete revenue cycle management for your practice. SDCMS members receive special preferred early-adopter pricing and discounts on HealthMatics EHR and practice management solutions. For more information, call Jamie Smolin at (619) 665-6139, call Allscripts at (888) 672-3282, or visit www.allscripts.com/ healthmatics.

THE DOCTORS COMPANY (TDC)

TDC enjoys a reputation as the industry vanguard for low California rates, aggressive claims defense, expert patient safety programs, superior customer service, and exemplary member benefits. Everyday, The Doctors Company relentlessly strives to reduce unreasonable legal liability, improve the environment in which all healthcare professionals practice, lead legislative and judicial reform, and enhance patient safety for the benefit of its members. Most SDCMS members are eligible for a 5% discount on insurance premiums, and a 7.5% dividend credit. To learn more, contact Janet Lockett at (858) 300-2778 or at JLockett@SDCMS.org.

AMERICAN SECURITY RX

American Security Rx (ASRX) is a California Department of Justice and California Board of Pharmacy approved security printer (SP-9) to provide tamper-resistant California security prescription forms for controlled medications. SDCMS members receive discounts on tamper-resistant prescription forms. Call American Security Rx at (877) 290-4262, email them at info@americansecurityrx.com, or visit ww.americansecurityrx.com.

CHMB SOLUTIONS

CHMB provides outsourced medical billing, revenue cycle management services, information technology support, and hardware solutions to physician practices, clinics, and multi-specialty organizations. SDCMS members receive a 50% discount on startup fees, a $33 per physician per month services credit, and a free coding hotline. Contact Ron Anderson (CHMB Solutions) at (760) 520-1340 or at randerson@chmbsolutions.com.

Email your coding question(s) to SDCMS at Coding@SDCMS.org.

COASTAL HEALTHCARE CONSULTING GROUP, INC.

Coastal Healthcare Consulting Group, Inc., is a specialty consulting firm that assists clients with managed care contracting, contract negotiations, credentialing, revenue enhancement and strategic planning.

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TORREY PINES BANK

Torrey Pines Bank is familiar with the business challenges facing medical professionals. Their goal is to be a “low maintenance” bank, meeting business owners’ high expectations, with the absolute minimum time and effort required of them. They offer a full array of banking services.

Approved SDCMS members receive no-fee lines of credit, $1,000 fee discounts on commercial real estate loans, waived monthly maintenance fees on personal accounts for practice partners and employees up to $10/month, free first order of standard checks for personal accounts, increased deposit interest rates, waived monthly maintenance fee for business online banking and bill pay services, ATM fees waived up to $15/month, and free courier service or remote deposit service. Contact Benjamin Pimentel at (858) 259-5317 or at bpimentel@torreypinesbank.com.

TSC ACCOUNTS RECEIVABLE SOLUTIONS

TSC Accounts Receivable Solutions has provided personalized, innovative collection and total accounts management services since 1992. This local San Diego family-owned business management team has a combined experience of more than fifty years in the healthcare billing and collection field. SDCMS members receive a 10% discount on monthly charges. Contact Catherine Sherman at (888) 687-4240, ext. 14, at csherman@tscarsolutions.com, or visit www.tscarsolutions.com.

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Practice of Medicine M@<NGF@EK

?fg\ ow does a doctor sustain hope? I we wonâ&#x20AC;&#x2122;t use the money to care for a pahave wrestled with this through- tient with no insurance. It seems to me that out my 30-year career in medi- deliberate use of treatments the physician cine. When I was trained in internal medi- thinks will be ineďŹ&#x20AC;ective, or have very small cine and hematology/oncology in the early chances of being eďŹ&#x20AC;ective, are equivalent to â&#x20AC;&#x2122;70s, I was taught that offering treatment of prescribing a placebo. I also know that, as a the disease, even if it wasnâ&#x20AC;&#x2122;t likely to work, profession, we gave up the use of placebos sustained hope. In contrast, when I began in the 1960s as unethical because they unworking as a hospice physician in 1978, I dermine the public trust in physicians.

It also seems to me that prescribing was shocked to learn how little the hospice patients understood about their illnesses therapies with no expected beneďŹ t puts the and how they felt misled by the false â&#x20AC;&#x153;hopeâ&#x20AC;? patient at risk. If there is no expectation of their physicians had maintained about the beneďŹ t, then any risk is excessive, including effectiveness of therapy. In other words, the risks of adverse reactions. Even a one-inwhat I learned to do in my training wasnâ&#x20AC;&#x2122;t a-million chance of a side eďŹ&#x20AC;ect is too high a risk for something with no chance of benthe right thing at all.

When I went into the private practice of eďŹ t. Even the beneďŹ t of maintaining hope internal medicine and oncology in 1980, I is not acceptable because it is false hope needed to resolve the conďŹ&#x201A;ict by trying a â&#x20AC;&#x201D; when the patient learns the truth, the patient feels duped, lied diďŹ&#x20AC;erent approach. At the to, and deceived. This is ďŹ rst visit, I told every new patient referred to me that N_Xk @ c\Xie\[ kf [f what the hospice patients taught me in 1978, and it I would always tell them the truth. If they were not `e dp kiX`e`e^ nXjeĂ&#x2039;k hurts me to hear it today doing well, if the disease k_\ i`^_k k_`e^ Xk Xcc% too. That is an adverse eďŹ&#x20AC;ect of oďŹ&#x20AC;ering an inefwas getting worse or the fective treatment just to treatment not working, I would tell them. I also said this meant that â&#x20AC;&#x153;maintain hope.â&#x20AC;?

Most medical treatments help some paif I told them everything was ďŹ ne, then they were doing well and things were as tients â&#x20AC;&#x201D; not all of them or none of them. expected. In other words, they could really Consequently, the therapeutic concept believe me. Interestingly, recent research has of â&#x20AC;&#x153;number needed to treatâ&#x20AC;? is becoming conďŹ rmed that this approach sustains more widespread for a way that the community physician can evaluate a treatment. Simply hopefulness in patients.

In my current role as the chief physician put, the number needed to treat is the numfor a large hospice, I think a lot about hope. ber of patients a physician may treat before Many patients are referred for hospice care one patient receives beneďŹ t from the treatwith recommendations for treatments that, ment. So, for example, a treatment with a as one referring physician said, â&#x20AC;&#x153;Wonâ&#x20AC;&#x2122;t hurt, 33 percent response rate is associated with a number needed to treat of three. A treatmight help, and will sustain hope.â&#x20AC;?

What are the ethics of recommending ment that helps 1 percent is associated with ineďŹ&#x20AC;ective therapies related to principles of a number needed to treat of 100.

It strikes me that we should also be calcudistributive justice? For example, if I decide that we can treat a patient with total par- lating the number needed to harm as a way enteral nutrition, I am also deciding that to assess the risk/beneďŹ t ratio. I would argue

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9p C8LI<C ? ?<I9JK# D; that spending money on useless treatment is harmful because other patients will not get access to care. So, for example, a cancer treatment that costs $100,000 per patient, and has a number needed to treat of 20, must be balanced against the $2 million that is not available for the care of other patients.

The recent research on hope is fascinating. We have learned that the quality of hopefulness can be sustained without childlike promises that all will be well. The practical implications of this research for all physicians are these: t "TL XIBU UIF QBUJFOU JT IPQJOH GPS -JTten for a range of things, not just life or death. For many patients there are things worse than death. t 6TF iXJTIw TUBUFNFOUT UP SFTQPOE UP unrealistic hopes. â&#x20AC;&#x153;I wish that were possible.â&#x20AC;? t "TTFTT UIF QBUJFOU T HPBMT PG DBSF ɨFZ may be diďŹ&#x20AC;erent from your goals for them. t 0Ä&#x160;FS DPVOTFMJOH TVQQPSU TZNQUPN management, and spiritual and practical care. t $POTJEFS UJNF MJNJUFE USJBMT GPS UIFSBQZ of uncertain beneďŹ t. â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;ll try this for a month and see if it helps you get closer to your goals.â&#x20AC;? t 5SVTU QBUJFOUT UP NBLF EFDJTJPOT GPS themselves after they know what medicine can and cannot do. t )POPS UIF QBUJFOU T EJHOJUZ BOE FTUFFN by keeping timely appointments, addressing by appropriate name and title, and recognizing the trust the patient has placed in the healthcare system.

Dr. Herbst is vice president for medical affairs at San Diego Hospice and the Institute for Palliative Medicine.

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