March 2009

official publication of the san diego county medical society • March 2009

Physician Volunteerism

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

> SDCMS Seminars Viewable Online now P.9 > Implementing a Family Violence Screening Tool P.16 > Chinese Healthcare P.18

We reward loyalty. We applaud dedication. We believe doctors deserve more than a little gratitude. We do what no other insurer does. We proudly present the Tribute® Plan. We honor years spent practicing good medicine. We salute a great career. We give a standing ovation. We are your biggest fans.

We are The Doctors Company.

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

You deserve more than a little gratitude for a career spent practicing good medicine. That’s why The Doctors Company created the Tribute Plan. This one-of-a-kind benefit provides our long-term members with a significant financial reward when they leave medicine. How significant? Think “new car.” Or maybe “vacation home.”

Now that’s a fitting tribute. To learn more about our medical professional liability program for SDCMS members, including the Tribute Plan, call (858) 452-2986 or visit www.thedoctors.com/tribute.

Endorsed by

VITAS is about life, some of the most important moments of life.

My aunt, father’s older sister, had no other family. She’d always been carefree and independent.

But when her lungs started to give out, she said she wanted to stay with us. And we wanted to honor her wish. But it was hard. On all of us.

After another in countless trips to the ER, a nurse said maybe a hospice called VITAS could help.

And VITAS was there. Right away.

When my aunt would have one of her breathing spells, VITAS was there.

At all hours.

VITAS calls it Telecare. We call it VITAS … the hospice that never sleeps.

My aunt did die at home. Peacefully. We couldn’t have done it without VITAS.

Serving the San Diego area since 1995 Innovative Hospice Care

For information, please call 1.800.93.VITAS www.VITAS.com

Contents VOL. 96 | NO. 3

[ f e a t u r e s ]

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Physician Volunteerism

• A New Year Brings a New Way to Manage Your Volunteer Care • Voluntary Liability • Adventures in the South Pacific • Cambodia, Thailand, and Uganda • The Purple Palace • The Mercy Outreach Surgical Team (M.O.S.T.)

[ D e p a r t m e n t s ]

4 6 8 10 12 2

16 18 42 44

Contributors

This Issue’s Contributing Writers

Editor’s Column

San Diego Physicians Are Generous

SDCMS’ 2009 Seminars and Events Community Healthcare Calendar Ask Your Physician Advocate

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Public Health

I mplementing a Family Violence Screening Tool

First-person perspective Chinese Healthcare

Physician Marketplace Classifieds

creative writing CMA HOD Invocation

Service and Value MIEC takes pride in both. For 34 years, MIEC has been steadfast in our protection of California physicians. With responsible Underwriting, excellent Claims management and hands-on Loss Prevention services, we’ve partnered with our policyholders to keep premiums low.

Added value: At MIEC we have a history of dividend distributions.

Because we are a zero-profit carrier with low overhead, MIEC has been able to return dividends to our California policyholders 16 of the last 19 years with an average savings on premiums of 25 %.

For more information or to apply: Contact Karen Tuttle by phone: 800.227.4527 email: karent@miec.com You can also go to www.miec.com or call 800.227.4527, and a helpful receptionist (not an automated phone tree) will connect you to one of our knowledgeable underwriting staff. * (On premiums at $1/3 million limits. Future dividends cannot be guaranteed.)

MIEC 6250 Claremont Avenue, Oakland, California 94618 800-227-4527 • www.miec.com SanDiegoMedSoc_ad_02.18.09

MIEC Owned by the policyholders we protect.

Contributors Kitty Bailey Ms. Bailey is the executive director of the San Diego

Dewan-Syed Adnan Majid Ms. Majid is a first-year medical student

County Medical Society Foundation (SDCMSF).

at the UCSD School of Medicine.

Michael Goldman After 35 years of employment at CMA, Mr. Gold-

Steven Ngai Mr. Ngai is a third-year medical student at the UCSD

man retired from his position as senior vice president. Currently, he serves as a chaplain associated with San Francisco General Hospital’s Sojourn Multi-faith Chaplaincy, as well as in the San Francisco County jail hospital’s medical/surgical and psychiatric units.

School of Medicine.

Marisol Gonzalez Ms. Gonzalez is your SDCMS physician advocate.

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

James Santiago Grisolía, MD Dr. Grisolía is a neurologist in solo practice at Scripps Mercy Hospital San Diego. A former District I trustee to CMA, he has also served as SDCMS communications chair and San Diego Physician editor.

James T. Hay, MD Dr. Hay is a family physician in full-time private practice in Encinitas. He founded North Coast Family Medical Group in 1978 and North County Physicians’ Medical Group (an IPA) in 1990. He is past president of SDCMS, past president of the SDCMS Foundation, current “Champion” of the Foundation’s Project Access San Diego (PASD), and current speaker of CMA’s House of Delegates.

Lance Hendricks, MD Dr. Hendricks, SDCMS member since 1977, is a member of Anesthesia Service Medical Group, Division of Anesthesiology, Green Hospital of Scripps Clinic.

Linda Lake, RN, PHN, MSN Ms. Lake is the chief of public health nursing for the County of San Diego, HHSA, Public Health Services. She has been a public health nurse at HHSA for 13 years and in her current role as chief for the past one and a half years. She oversees PHN standards of practice, professional integrity, and strategic and operational planning for PHN staff.

James W. Ochi, MD Dr. Ochi is a pediatric ENT doctor in solo private practice. His website is ENT4MyKids.com, and his office telephone is (858) 792-4800.

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

Carla Stayboldt, MD Dr. Stayboldt is a pathologist at Scripps Mercy Hospital San Diego and Scripps Mercy Hospital Chula Vista, as well as president of San Diego Pathologists Medical Group. She is a past chief of the medical staff at Scripps Mercy Hospital Chula Vista and served on the San Diego County delegation to CMA for many years.

Thomas Vecchione, MD Dr. Vecchione is one of the founding physicians of Mercy Outreach Surgical Team (M.O.S.T.) in 1988. He has practiced plastic surgery in San Diego County for 35 years. Dr. Vecchione describes M.O.S.T. as the best thing he does with his life, “It is an honor and a privilege.”

Tyler Youngkin, MD, and Connie Youngkin Dr. Tyler Youngkin, a pathologist at Scripps Mercy Hospital San Diego, and Connie Youngkin, a registered nurse, lived in Poway where they raised their three children: John, Mariah, and Jessica. They now also have five grandchildren. Tyler and Connie learned Spanish in Costa Rica and also worked in an orphanage there for two years. For the past eight years they have been helping abused children to get out of Tijuana’s red light district.

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

East County Director Hillcrest Director Kearny Mesa Director EDITOR MANAGING EDITOR

Joseph Scherger, MD, MPH Kyle Lewis

La Jolla Director North County Director

editorial board

MARKETING & PRODUCTION manager Sales Director PROJECT DESIGNER COPY EDITOR

Van Cheng, MD Adam Dorin, MD Robert Peters, PhD, MD David Priver, MD Roderick Rapier, MD Joseph Scherger, MD, MPH

Jennifer Rohr Dari Pebdani Lisa Williams Adam Elder

South Bay Director At-large Director

Young Physician Director Resident physician director Retired Physician director MEDICAL Student Director

William Tseng, MD Woody Zeidman, MD Roneet Lev, MD Thomas McAfee, MD Adam Dorin, MD Sherry Franklin, MD Steven Poceta, MD Wayne Sun, MD James Schultz, MD Douglas Fenton, MD Arthur Blain, MD Vimal Nanavati, MD Anna Seydel, MD Jeffrey Leach, MD Robert Peters, PhD, MD David Priver, MD Wayne Iverson, MD Paul Kater, MD John Allen, MD Kevin Malone, MD Mihir Parikh, MD Kimberly Lovett, MD Glenn Kellogg, MD Geraldine Kang

SDCMS EXECUTIVE COMMITTEE PRESIDENT president-elect past president secretary treasurer COMM. CHAIR DELEGATION CHAIR Board REP. Board REP. LEGIslative chair executive director SDCMS cma trustees

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

OTHER cma trustees

Catherine Moore, MD Diana Shiba, MD

ama delegates alternate delegate

Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org. All advertising inquiries can be sent to cpinfo@sandiegomag.com. San Diego Physician is published monthly on the first of the month.

Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

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

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

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Mark Avilla 760.431.4223 mavilla@breb.com

Matty Sundberg 760.431.4232 msundberg@breb.com

Information contained herein has been obtained from sources we deem reliable. We have no reason to doubt its accuracy, but we do not guarantee it.

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Editor’s Column

By Joseph E. Scherger, MD, MPH

San Diego Physicians Are

Generous a focus on volunteerism

T

his issue of San Diego Physician focuses on volunteerism among San Diego County physicians.

Every year, numerous San Diego County physicians travel to less-fortunate parts of the world and provide medical services.

The generosity of these physicians is truly remarkable considering all the challenges of maintaining a medical practice. Many volunteers care right here in San Diego County with the UCSD Student-Run Free Clinic Project, in the church-based clinics like St. Leo’s and Father Joe’s, the VIM clinic, and in their own offices.

Through the efforts of the San Diego County Medical Society Foundation (SDCMSF), physician volunteerism is expanding right here in San Diego Coun-

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ty through Project Access San Diego (PASD), which has been in development for several years. PASD is a communitybased program that coordinates donated medical care and services provided by physicians, hospitals, pharmacies, and others for uninsured, low-income San Diego County residents. In PASD, both primary care physicians and specialists make a commitment to see one or more uninsured patients each month or even each year and at no charge. Patients enrolled in PASD are given access to needed medical services that would not otherwise be available to them. For more information about PASD, read “A New Year Brings a New Way to Manage Your Volunteer Care” on page 22 of this issue.

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Recently, PASD, in conjunction with Kaiser-Permanente, held a day of no-cost surgery procedures for the uninsured.

Nineteen procedures were performed — a truly remarkable accomplishment. Daniel (Stoney) Anderson from Kaiser and Tana Lorah from SDCMSF deserve special recognition for their amazing efforts in coordinating this event.

SDCMSF recently hired a new executive director, Kitty Bailey, relocated here from Denver. Kitty has extensive experience running nonprofit organizations and working on issues related to the medically underserved and increasing access to care.

A part-time medical director for PASD has been hired as well to provide clinical leadership. Together the SDCMSF staff will expand and enhance Project Access San Diego.

Hopefully, the number of people without access to mainstream healthcare will recede with new legislation, making basic healthcare a right and a privilege for all Americans. The new administration in Washington, DC, has an opportunity equivalent to 1965 when Medicare and Medicaid were enacted to fundamentally change the financing of healthcare in America. However, with or without reform, it is likely that physician volunteerism will continue to play an important role in the U.S. healthcare system.

It is often said that difficult economic times bring out the best in us. Certainly, many San Diego County physicians are taking the high road and keeping the needs of patients first in their professionalism. Being a member of the San Diego County Medical Society connects physicians with the work of PASD and other volunteerism projects being coordinated

by SDCMSF, which calls its volunteer physicians “Doctors with Heart.”

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

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SDCMS Members-only Benefits

2009

Seminars and Events

March

May

25 Wednesday 6:30PM–8:30PM Human Resources Seminar/Webinar

6 Wednesday 4:00PM-8:00PM EMR Road Show

26 Thursday 11:30AM–1:00PM Human Resources Seminar/ Webinar (Office Managers Forum)

April 15 Wednesday 5:00PM–9:00PM Practice Management Seminar/Webinar 16 Thursday 9:00AM–1:00PM Practice Management Seminar/Webinar (Office Managers Forum) 18 Saturday 8:45AM–4:30PM Resident and New Physician Seminar: “Preparing to Practice: What You Need to Know BEFORE You Begin Your Practice” 22 Wednesday 6:30PM–8:00PM Risk Management Seminar/Webinar: “How to Handle Legal Notices (Summons, NOI, Subpoenas)” 23 Thursday 11:30AM–1:00PM Risk Management Seminar/Webinar: “How to Handle Legal Notices (Summons, NOI, Subpoenas)”

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7 Thursday 9:00AM–12:30PM EMR Road Show (Office Managers Forum) 20 Wednesday 11:30AM–1:00PM Billing Seminar/Webinar (Office Managers Forum)

June 17 Wednesday 6:30PM–8:30PM Legal Seminar/Webinar 18 Thursday 11:30AM–1:00PM Legal Seminar/Webinar (Office Managers Forum) 24 Wednesday 2:00PM–6:00PM CMA Contracting Seminar/Webinar: “Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiations — A Focus on Payor Contracting” 25 Thursday 9:00AM–2:00PM CMA Reimbursement Seminar/ Webinar (Office Managers Forum): “Back to Basics: A Step-by-Step Guide to Maximizing Your Cash Flow”

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Free to Member Physicians and Their Office Staff!

SDCMS strives to build a robust schedule of free seminars and events for our member physicians and their office staff. All SDCMS member physicians and their office staff attend SDCMS seminars free of charge (including Office Managers Forums). Our seminars cover a broad range of practice management topics, including legal issues, HIPAA, risk management issues, contract negotiations, and more. For further information about any of these seminars and events, watch your emails and faxes, visit SDCMS’ website at www.SDCMS.org, or contact Lauren Wendler at (858) 300-2782 or at LWendler@SDCMS.org.

Watch Previous SDCMS Seminars Online Now! Available at SDCMS.org

The following seminars, webinars, and presentations are available for viewing by SDCMS member physicians and their staffs at SDCMS.org.

To locate any of these seminars, simply do a search in the search field on the homepage. For assistance in locating a seminar or in logging into SDCMS’ website, please contact Kyle Lewis at (858) 300-2784 or at KLewis@SDCMS.org. All SDCMS seminars are made available for viewing online within 24 hours of their date of occurrence. Thank you for your membership!

• Coding Seminar: Optimize Compliance and Reimbursement (filmed February 18, 2009) •C ontract Negotiations Seminar: Health Plan Contracting Savvy for Physicians (filmed February 11, 2009) • Marketing Seminar: How to Attract and Keep the Best Patients (filmed January 28, 2009) • E-prescribing for Dummies (filmed January 20, 2009) • Top 10 Collections Procedures (filmed January 1, 2009) • Electronic Medical Records (filmed November 20, 2008) • Sexual Harassment (filmed October 15, 2008) • E-prescribing: Facts and Myths (filmed October 9, 2008) • Medicare Transition to Palmetto Seminar (August 21, 2008) • Hospital Medical Staff Leadership Seminar (filmed August 15, 2008)

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• Best Practices for Disciplinary Procedures and Terminations (filmed May 22, 2008) • Preparing to Practice (filmed April 19, 2008) • Contract Negotiations (filmed April 17, 2008) • Maximize Your Reimbursements With Effective Collections (filmed March 20, 2008) • Best Practices in Revenue Cycle Management (filmed February 21, 2008) •O SHA for Dummies (filmed January 29, 2008) •F rightening Times, Risky Conversations: Handling Disclosure (filmed January 23, 2008) •J oe Dunn Hospital Hop (filmed March 23, 2007)

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Community Healthcare Calendar

TOPICS AND ADVANCES IN INTERNAL MEDICINE Topics include neoplastic diseases, rheumatology, geriatrics, infectious diseases, and hospital medicine, among others. March 5–11 at the Hilton San Diego Resort. Visit http:// cme.ucsd.edu/internalmed/index2.html.

PERCUTANEOUS CATHETER ABLATION OF ATRIAL FIBRILLATION Directed at those interested in incorporating percutaneous catheter ablation into their clinical management of patients with atrial fibrillation. March 7 at the Hilton La Jolla Torrey Pines. Contact (858) 652-5400 or med.edu@scrippshealth.org.

2009 Radiology at Alta and snowbird Covering the applications of imaging techniques in the diagnosis of diseases of the brain, spine, musculoskeletal system, and body. March 8–12 at the Cliff Lodge, Snowbird, Utah. Visit http://cme.ucsd.edu/radiology.

14th Annual Primary Care in Paradise Assess current trends in preventive healthcare with an emphasis on endocrinology, orthopedics, obesity, migraines, COPD, melanoma, and sleep apnea. Summarize recent developments and changes in the treatment of disease processes likely to be seen in the primary care office setting. Identify and treat problems commonly encountered in primary care clinical practice. March 17 at the Hapuna Beach Prince Hotel, Big Island, Hawaii. Contact med.edu@scrippshealth.org or (858) 652-5400.

ADVANCES IN THE NEUROPSYCHOLOGICAL ASSESMENT AND TREATMENT OF SCHOOL-AGED CHILDREN WITH COGNITIVE DEFICITS Presentation of the latest findings on the assessment and remediation of cognitive and behavioral impairments in school-age children. April 2–9 at the Hilton San Diego Resort. Visit http://cme.ucsd.edu/neuro.

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14th Annual Primary Care in Paradise Will assess current trends in preventive healthcare with an emphasis on endocrinology, orthopedics, obesity, migraines, COPD, melanoma, and sleep apnea; summarize recent developments and changes in the treatment of disease processes likely to be seen in the primary care office setting; and identify and treat problems commonly encountered in primary care clinical practice. April 6–9 at the Hapuna Beach Prince Hotel, Big Island, Hawaii. Contact (858) 652-5400 or med.edu@scrippshealth.org.

Fresh Start’s Surgery Weekend A team of dedicated medical volunteers donates their time and expertise to provide disadvantaged children with the highest quality medical services and ongoing care.

April 18–19, June 13–14, July 25–26, September 12–13, and November 7–8 at the Center for Surgery of Encinitas. Contact (760) 4482021 or mimi@freshstart.org, or visit www. freshstart.org.

2ND ANNUAL SUDDEN CARDIAC ARREST April 25–26 at the Hilton San Diego Resort.

Visit www.scripps.org/health-education.

AMERICAN OCCUPATIONAL HEALTH CONFERENCE 2009 Topics include occupational medicine/ research, infectious disease, toxicology, workers’ compensation, ergonomics, and environmental pollution. April 26–29 at the Manchester Hyatt Hotel in San Diego. Visit www.acoem.org.

ESSENTIAL TOPICS IN PEDIATRICS 2009 May 14-15 at the Catamaran Resort Hotel.

Visit http://cme.ucsd.edu/events.cfm.

Integrative Holistic Nursing Conference: Bringing Healing to You and Your Patients May 15–16 at the Paradise Point Resort, San Diego. Contact (858) 652-5400 or med.edu@scrippshealth.org or visit www. scrippsintegrativemedicine.org.

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2009 American Thoracic Society International Conference Educational program for clinicians and researchers in adult and pediatric pulmonary, critical care, and sleep medicine. Sample a broad spectrum of topics or concentrate on critical care, sleep, allergy/immunology or other specialty related to respiratory medicine. May 15–20. Visit www.thoracic.org.

ALZHEIMER’S DISEASE: UPDATE ON RESEARCH, TREATMENT, AND CARE May 21–22 at the Omni San Diego Hotel. Visit http://cme.ucsd.edu/events.cfm.

Riverside County Medical Association: 5th Annual “Cruisin’ Thru CME” (Eastern Mediterranean) July 6–17. Call (800) 745-7545.

20TH ANNUAL CORONARY INTERVENTIONS October 28–30 at the Hilton La Jolla Torrey Pines. Visit www.scripps.org/health-education.

XVII World Congress of Psychiatric Genetics Offers a forum for exchange of the latest scientific data and education for the interested clinician. November 4–8 at the Manchester Grand Hyatt. Contact (858) 534-3940 or ocme@ucsd.edu.

To submit a community healthcare event for possible publication, email KLewis@SDCMS.org.

All events should be physician-focused and should take place in San Diego County.

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Noted

now allow implementation of these CDC recommendations?

ANSWER: Yes. The major revisions from previously published guidelines are as follows:

Ask Your

Physician Advocate

By Marisol Gonzalez

Language Assistance Programs • IPA-insured Patients • HIV Testing

Your Physician Advocate Has the Answers!

Q

UESTION: The effective date for the establishment and implementation of a Language Assistance Program (LAP) for a DMHC regulated plan is January 1, 2009. DOIregulated plans must have an LAP in place by April 1, 2009. How do these regulations impact physicians?

ANSWER: Health plans now have an obligation to offer qualified interpreter services to limited English proficient (LEP) enrollees, at no cost to the enrollee, at “all points of contact” (a “point of contact” is where the enrollee accesses the covered services, including administrative and clinical services, and telephonic and in-person contacts). If a patient refuses the language interpreter services, physicians are obligated to document this in the medical record where applicable. The medical record should also contain any submission of physician language capability disclosure forms and attestations as well.

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Q

UESTION: My group and I take nonemergency calls at a local hospital. We sometimes assist patients who are insured through IPAs that we are not contracted with. Can they pay us whatever they want to?

ANSWER: Yes and no. IPAs should be paying physicians at their usual and customary rate (UCR). By the way, the Department of Managed Health Care (DMHC) opined that Medicare rates should not be used as a benchmark. If you are not being paid your UCR, then CMA recommends that physicians file an appeal with the IPA. If after an appeal has been filed, and the IPA does not pay a sufficient amount, then you can file a complaint with the DMHC as this is an unfair payment practice. For more information on how to appeal and filing a complaint with the DMHC, members can obtain CMA On-Call document #1051, “Physician Complaints About Managed Care Plans” from the San Diego County Medical Society.

Q

UESTION: Over a year ago, the CDC came out with recommendations regarding HIV testing. Has California law changed to

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For patients in all healthcare settings ...

• HIV screening is recommended for patients in all healthcare settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening).

• Persons at high risk for HIV infection should be screened for HIV at least annually.

• Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing.

• Prevention counseling should not be required with HIV diagnostic testing or as part of HIV screening programs in healthcare settings.

For pregnant women ...

• HIV screening should be included in the routine panel of prenatal screening tests for all pregnant women.

• HIV screening is recommended after the patient is notified that testing will be performed unless the patient declines (opt-out screening).

• Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing.

• Repeat screening in the third trimester is recommended in certain jurisdictions with elevated rates of HIV infection among pregnant women.

CMA On-Call document #0414, “Consent for HIV Test”, discusses the most up-to-date California law regarding HIV screening for patients in all healthcare settings as well as HIV screening for pregnant women. Members can obtain this document from the San Diego County Medical Society.

A b o u t t h e A u t h o r : 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.

Top

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Body Worlds and the Brain — Our Three-pound Gem

Publications of 2008

From the California HealthCare Foundation

By the California HealthCare Foundation In 2008, the California HealthCare Foundation (CHCF) published research on these and other topics. Below are the 10 publications from 2008 that drew the most interest from CHCF’s readers; to access these and other CHCF publications, visit www.chcf.org.

1. Snapshot:

Healthcare Costs 101, 2008 Edition and Quick Guide 2. The Wisdom of Patients: Healthcare Meets Online Social Media 3. Scope of Practice Laws in Healthcare: Rethinking the Role of Nurse Practitioners 4. Guide to Health Programs (English and Spanish)

5. O pen-source EHR Systems for Ambulatory Care: A Market Assessment 6. Whose Data Is It Anyway? Expanding Consumer Control Over Personal Health Information 7. G auging the Progress of the National Health Information Technology Initiative 8. California Employer Health Benefits Survey 9. Helping Patients Plug In: Lessons in the Adoption of Online Consumer Tools 10. Promoting Effective Self-management to Improve Chronic Disease Care: Lessons Learned.

A b o u t t h e A u t h o r : CHCF is an independent philanthropy committed to improving the way healthcare is delivered and financed in California.

Assemblywoman Mary Salas California State Assembly

P.O. Box 942849 Sacramento, CA 94249-0079 Birthday: March 17

Physicians: Get Noticed Wish Your Legislators a Happy Birthday!

Let your legislators know that you’re watching and that you vote — send them a birthday card this month!

Senator Denise Ducheny California State Senate

P.O. Box 942848 Sacramento, CA 94248-0040 Birthday: March 21 Assemblyman Martin Garrick California State Assembly

P.O. Box 942849 Sacramento, CA 94249-0074 Birthday: March 24

The Original Exhibition of Real Human Bodies

The first Southern California showing of “Gunther von Hagens’ Body Worlds and the Brain: Our Three-pound Gem” — a unique and educational exhibition about human anatomy, physiology, and health — will open at the San Diego Natural History Museum on March 5, 2009, and will run for a limited engagement. The exhibition will feature more than 200 real human body specimens, including more than 20 whole bodies and healthy and unhealthy organs, all preserved through a process called plastination, invented by anatomist Dr. Gunther von Hagens. Since 1983, more than 8,900 donors, including 175 from California, have bequeathed their bodies to serve educational purposes after death through plastination.

“Body Worlds and the Brain: Our Three-pound Gem” includes a special feature on the wonders of the brain — inspired by findings in neuroscience on brain development, function, disease, disorders, and brain performance and improvement. The exhibition at the San Diego Natural History Museum will be accompanied with programming created by a panel of experts in the local medical community. For further information, visit www.sdnhm.org.

Does Your Office Manager Have a Question Too? Lauren Wendler, your SDCMS office manager advocate, is on staff and ready to help your office manager with any questions he or she may have. Feel free to contact Lauren at (858) 300-2782 or at LWendler@SDCMS.org for help.

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Noted Franz John Kopp, MD Orthopedic Surgery (619) 299-1948

Please Welcome

SDCMS’

New and Rejoining Members “Physicians United for a Healthy San Diego” Welcome New SDCMS Members!

William Stuart Anapoell, MD Internal Medicine (619) 260-7125 John Michael Baker, MD Emergency Medicine (760) 806-5400 Jeffrey Ross Belanoff, MD Internal Medicine

Bret Robert Gerber, MD Pediatrics Alissa Jean Gilles, MD Internal Medicine (619) 278-3340 Asim Guha Roy, MD Internal Medicine (619) 937-6375 Alma Harb, MD Internal Medicine

P. Bertil Weldon Smith, MD Orthopedic Surgery

Erik Olaf Gilbertson, MD Dermatology (619) 675-5400

Saima Fatima Lodhi, MD Internal Medicine (619) 278-3300

Victor Laurindo Souza, MD Internal Medicine (760) 633-2320

James Norman Groth, MD Family Medicine (760) 901-5060

Ramona Master, MD Internal Medicine (760) 901-5100

Kuangkai Tai, MD Pediatrics (858) 487-8333

David Charles Herz, MD Pediatrics (760) 631-3186

Loren K. Mell, MD Radiation Oncology (858) 822-5036

Diane Vu, DO Family Medicine

Kevin S. Hirsch, MD Internal Medicine (619) 278-3300

David Jun-Hom Liu, MD Internal Medicine (619) 278-3300

Alex Mendivil, MD Internal Medicine Elizabeth Serrell Menkin, MD Geriatric Medicine Jason Madison Miller, MD Anesthesiology (760) 753-1104

Julie Ann Berry, MD Otolaryngology (760) 726-2440

John Terrel Hippen, MD Internal Medicine (858) 499-2705

Emily Suzanne Churchill, MD Internal Medicine

Chris Holt, MD Internal Medicine (619) 278-3300

Belinda T. Clanor, DO Family Medicine (760) 806-5800

Elizabeth Ann Hourihan, MD Family Medicine (619) 472-1000

Jennifer Ann Neff, MD Family Medicine (760) 806-5400

Brian Robert Huizar, MD Family Medicine

John Kellogg Parsons, MD Urology (858) 822-6187

Cheryl Lynn Jennett, MD Pediatrics (619) 278-3300

Juan Carlos Deza, MD Critical Care Medicine (760) 806-1123

Tanaz Kahen-Biton, MD Obstetrics and Gynecology (619) 260-7125

Stephen Anthony Dunphy, MD Emergency Medicine (760) 739-3300

Julie Anne Keeler, DO Family Medicine (619) 502-7486

Arman Faravardeh, MD Internal Medicine

Brian Sanghoon Kim, MD Radiation Oncology (760) 827-7230

Jeffrey Martin Ferber, MD Family Medicine (760) 806-5600 Franklin Galef, MD Internal Medicine (760) 806-5820

Joyce Moran Havranek, MD Internal Medicine

Simona Cornelia Deaciuc, MD Psychiatry (619) 281-1932

Trieva Karin Scanlan, MD Pediatrics

Catalina G. Escobar, MD Family Medicine (619) 422-6158

Stacy Jean Schlocker, MD Internal Medicine (619) 260-7220

Dania Judith Lindenberg, MD Pediatrics (619) 502-7491

Mihaela Beloiu, MD Family Medicine (760) 806-5500

Arnold Eusebio Cuenca, DO Family Medicine

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Sivathilaka Sadasivam Ganesh, MD Pediatrics

Joshua David Lawson, MD Radiation Oncology (858) 822-6046

Amardeep Singh Sahota, MD Internal Medicine (760) 633-6720

Gabriela Kathryn Mogrovejo, MD Family Medicine Maria Patricia Murillo, MD Obstetrics and Gynecology (760) 758-1220

Raj J. Patel, MD Emergency Medicine (760) 739-3300 Patricia Pisinger, MD Family Medicine Nena Magdalena Rocha, MD Family Medicine (619) 502-7484 Sharon Shahrzad Sadeghinia, MD Internal Medicine and Cardiovascular Disease

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Michael Patrick Waters, MD Emergency Medicine (619) 482-5800

Errol R. Korn, MD Gastroenterology (619) 425-5544

Frederick Dow Wu, MD Internal Medicine (619) 260-7125

Gene Ma, MD Emergency Medicine (760) 439-1963

Henry Clay Yeager, MD Internal Medicine (619) 278-3300

Eliot Keith Miller, MD Family Medicine (760) 901-5074

Welcome Rejoining SDCMS Members!

Shantu B. Patel, MD Internal Medicine (760) 806-5820

Ralph Ascher, MD Geriatric Medicine (760) 806-5500 Kaveh Bagheri, MD Critical Care Medicine (619) 589-2535 Harry Randolph Boffman, MD Orthopedic Surgery (619) 267-3020 Denise Andrews Brownlee, MD Pediatrics (619) 278-3350

Donald Joseph Ponec, MD Vascular and Interventional Radiology (760) 940-4055 Fred W. Schnepper, MD Obstetrics and Gynecology (619) 427-8892 Gerald David Weintraub, MD Pediatrics (760) 726-6310 David Todd Wine, MD Internal Medicine (760) 726-2180

David William Brunsting, MD Internal Medicine (619) 472-1000

Ronald William Woerpel, MD Pediatrics (760) 758-7971

Michael Charles Devereaux, MD Internal Medicine

Marcia H. Yee, MD Geriatric Medicine

If your medical license or privileges are on the line…

Get in Touch

Rosenberg, Shpall & Associates, APLC A P R O F E S S I O N A L L A W C O R P O R AT I O N

Your SDCMS Support Team Is Here to Help!

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

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

Wells Fargo Bank Plaza

CEO/Executive Director: Tom Gehring at (858) 565-8597 or at Gehring@SDCMS.org

401 “B” Street, Suite 2209 San Diego, California 92101 Telephone: (619) 232-1826

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 Director of Engagement: Jennipher Ohmstede at (858) 300-2781 or at JOhmstede@SDCMS.org

Facsimile: (619) 232- 1859 Email: RSALAW@yahoo.com

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

sdcms foundation executive director: Kitty Bailey at (858) 3002780or at KBailey@SDCMS.org sdcms foundation associate 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 Specialty society advocate: Karen Dotsonat (858) 300-2787 or at KDotson@SDCMS.org Letters to the Editor: Editor@SDCMS.org General Suggestions: SuggestionBox@SDCMS.org

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From the County Public Health Officer

By Linda Lake, RN, PHN, MSN

Family Violence Implementing a Screening Tool

A

ccording to Reuters, March 14, 2008, the Centers for Disease Control and Prevention (CDC) states 23.6 percent of women and 11.5 percent of men reported being a victim of family violence at some time during their lives. In San Diego County in 2007, there were 18,839 reports of domestic violence incidents. Family violence is a major public health problem that affects the health and well-being of women, men, youth, and children. During pregnancy, family violence has been associated with poor outcomes for mother and infant. Poor maternal outcomes include minimal or no prenatal care, low weight gain, low self-esteem, depression, substance abuse, and Post Traumatic Stress Disorder (PTSD). Poor outcomes for the infant include premature delivery and low birth weight. In addition to being a public health issue, family violence is a medical issue, and, as physicians, cases may be identified in your practice settings. Hopefully, the experiences outlined below will help

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you to implement a screening tool in your own settings.

Children exposed to family violence during childhood have negative socialemotional and physical health problems.

These include depression, anxiety, poor self-esteem, aggression, poor peer relations, poor school performance, physical health symptoms, under-immunization, and youth risk behaviors.

San Diego County Health and Human Services Agency (HHSA) nursing staff interact with multiple clients on a daily basis during home visits and in clinic settings.

Given the number of clients that San Diego County nurses interact with presents an opportunity to identify family violence situations that some of our clients may be experiencing. Public health nurses (PHNs) in San Diego County make an average of 35,000 home visits per year. Home visiting historically has been an essential component of public health nursing practice. The Nurse-Family Partnership (NFP) Program is an evidence-based PHN home visiting

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model, which has many positive outcomes for families — one being a reduction in child abuse and neglect. The County of San Diego has 12 NFP PHNs, which visit 300 first-time, low-income pregnant women per year. After delivery, the PHN continues to visit the mother through the infant’s second year of life.

In August 2007, a family violence workgroup was formed to identify a universal screening tool for family violence, develop a protocol for the use of this tool, and plan training in order to assist nursing and ancillary staff to develop a deeper understanding of family violence and the effects of violence on families. The workgroup consisted of all levels of public health nursing staff representing each of the six Regions in HHSA, the Sexually Transmitted Disease (STD) Clinic, and staff from the Office of Violence Prevention (OVP).

Studies have shown reliance on selfdisclosure or selective screening to identify family violence may result in missed opportunities for identification, interven-

tion, and potential prevention of further incidents. In addition, disclosure rates increase by 60 percent if women understand the legal implications of disclosing, confidentiality issues, and state-mandated reporting requirements. The objectives for choosing a universal family violence screening tool are to increase identification of family violence; increase resources, support, and education to families; increase safety for families; and decrease morbidity.

In order to identify an appropriate screening tool for PHNs to use, various domestic violence screening and assessment tools used in clinical settings, emergency departments, and other types of settings were examined. Items reviewed for every tool included the domain (basic or full screenings/assessments); age and stage of client when administered (adult/teen/

In addition to being a public health issue, family violence is a medical issue, and, as physicians, cases may be identified in your practice settings. Hopefully, the experiences outlined below will help you to implement a screening tool in your own settings. pregnant); administered by self, professional, or both; family violence experience/ training needed by professional administering the tool; languages in which the tool is available; validity/reliability of tool; and length of time to complete the tool.

In February 2008, the workgroup identified the Abuse Assessment Screening Tool (AAS) as the universal tool to be used by field PHNs and nurses in the STD clinic. The AAS is a valid and reliable fivequestion screening tool, proven to be as effective as longer tools in identifying victims of violence. The tool is used in a nurse interview assessment style rather than as a self-report tool. The tool may be used on adults, teenagers and pregnant women.

If any of the five questions on the AAS

is answered with a “yes,” then the tool is considered positive for identifying family violence. The PHN will then administer the Danger Assessment (DA) Tool, which is a more in-depth assessment tool.

The DA Tool was developed by Jacquelyn C. Campbell, PhD, RN, with the Johns Hopkins University School of Nursing.

Dr. Campbell is considered a national expert in the field of family violence. The DA Tool was developed to assist women to come to the realization that they are in a very dangerous relationship. This tool was chosen by the San Diego County HHSA family violence workgroup as a more indepth assessment tool to further assist clients involved in family violence.

In addition to identifying a universal family violence screening tool and developing a protocol for the use of the tool, the workgroup provided a training in partnership with the Laying a Foundation for a Safe Start Conference held in March 2008.

This was a two-day training in which one full day focused on the basics of family violence, mandated reporting, childhood effects of family violence, and the protocol for the universal screening tool. For this particular day of training, 320 people attended, representing PHN and nursing staff from HHSA, community based organizations, criminal justice, mental health agencies, schools, and hospitals.

Field PHN staff began using the AAS as a universal screening tool in April 2008.

Since that time, 180 newly identified cases of family violence have been identified.

Possibly the PHN experience with universal screening for family violence will encourage some readers to implement screening in their own practice settings.

Both of the screening tools discussed in this article are freely available in the public domain (though the DA Tool requires training).

For more information about the universal screening tool and/or a bibliography contact Linda Lake at Linda.Lake@sdcounty.ca.gov or at (619) 515-4207.

Ms. Lake is the chief of public health nursing for the County of San Diego, HHSA, Public Health Services. She has been a public

About the Author:

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health nurse at HHSA for 13 years and in her current role as chief for the past one and a half years. She oversees PHN standards of practice, professional integrity, and strategic and operational planning for PHN staff.

San Diego County Health Statistics • During FY 2006–07, there were more than 5,200 calls to the San Diego countywide DV hotline [1 (888) DV LINKS] with more than 30 percent of those calls including requests for shelter and/or safety planning (Source: County of San Diego, HHSA, Office of Violence and Prevention, 2007).

• In 2007, a sample of 222 San Diego domestic violence victims completed the Danger Assessment Tool during the intake process for DV advocacy services.

More than 44 percent reported their partner had threatened to kill them and 47 percent said their partner had attempted to strangle her/him (Source: County of San Diego, HHSA, Office of Violence and Prevention, Domestic Violence Services for Families Program, 2007).

To request additional health statistics describing health behaviors, diseases and injuries for specific populations, health trends and comparisons to national targets, please call the County’s Community Health Statistics Unit at (619) 285-6479. To access the latest data and data links, including the Regional Community Profiles document, go to www.sdhealthstatistics.com.

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First-person Perspective

Chinese

Healthcare

By the Mercy of God’s People

By James Santiago Grisolía, MD, and Carla Stayboldt, MD

O

n a roller coaster, you reach a pause, way up at the top, frozen in a slow instant of sensuous dread, just before that awful plunge down into the unknown. This past fall, we were privileged to explore China at that scary moment, its economy just faltering at the peak, with only a faint groan of rails, a slight creak of beams presaging the rollercoaster plunge that is now unfolding.

Here in San Diego, Point Loma Community Presbyterian Church recruited us as the only physicians on a mission trip who emphasized more than a century of relationship between American Presbyterians and Chinese Christians. With our leaders from the Outreach Foundation

18

(Rev. Jefferson Ritchie and Rev. Peter Lim) and members from five other congregations across the county, we surveyed the current state of faith in China and its impact on health, senior care, and other aspects of the caring society. Our trip included Shanghai, Suzhou, Nanjing, Jinan, Weifang, Xi’an, Beijing, and some adjoining cities and rural areas.

The crest of China’s boom staggered our imaginations: miles and miles of freshbuilt, hulking condo complexes devour everything from ancient redbrick neighborhoods to open farmland. Industrial parks and entire university cities, each housing multiple university campuses, doubled or tripled a city’s footprint almost overnight.

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The sleek immensity of highways, airports, and surreal neon skylines must be experienced to be understood.

Yet a curious ethical void lies at the heart of the Chinese miracle. The torrent of consumer goods from China includes a disturbing trickle of highly toxic production shortcuts: cheap “filler” in heparin that has killed patients across the U.S. and Europe, benzene in toothpaste, lead paint on children’s toys, ethylene glycol in cold remedies, toxic melamine substituted for more expensive protein in a host of foods — including baby formula that has killed at least six and sickened some 300,000 Chinese infants. And an ever-present gray fog of pollution blankets the entire nation, spreading out as far as the Middle East.

Communism strove hard to obliterate the “four olds” — old ideas, old culture, old customs, and old habits. Millennia of Chinese culture, including Confucianism, Taoism, and Buddhism burned on the Maoist bonfire. This spawned a new “postcommunist” generation of Chinese entrepreneurs with no roots or moral compass.

For the rest of the world, the meteoric rise of China, and its incipient downfall, holds both promise and peril.

In the ’80s and ’90s, China provided fairly comprehensive access to inexpensive, non-Western healthcare, both in urban and rural areas. Non-MD practitioners called “barefoot doctors” provided most frontline treatment, following precepts of traditional Chinese medicine (TCM). In major city hospitals, the mixture of Western medicine and TCM would depend on the institution’s history and affiliations.

Not uncommonly, herbs and acupuncture would anchor the treatment plan, even as the relevant MRI films would be stored under the thin mattress of each patient’s hospital bed.

By the early ’90s, increasing privatization ended government subsidies for healthcare, especially impacting rural areas. The increasingly affluent Chinese middle class also demanded “real” Western medicine.

The Communist attempt at authentically Chinese, cradle-to-grave health coverage was abandoned by consumers as ineffective and by technocrats as inefficient. In recent years, the poor and disabled have

been largely thrown to their own devices, a by-product of privatization, which would be unthinkable to Chairman Mao and his fellow ideologosaurians who once roamed Beijing.

As subsidies have evaporated, hospitals and doctors must earn their living from the fees they can charge. Patients complain of price gouging by hospitals and physicians, and widely accuse doctors of receiving kickbacks to prescribe new, expensive medicines. The Chinese patient has little defense against entrepreneurial price hikes.

We confirmed with local workers that they receive a fixed healthcare allotment annually, regardless of health condition.

We confirmed with local workers that they receive a fixed healthcare allotment annually, regardless of health condition. When the allotment is used up, workers and their families must use personal funds, challenging when the average daily wage approaches $10.

Even among our own local contacts, some had “gone through” their limited insurance benefit for this past year and put off orthopedic surgery and other nonemergent healthcare. Hospitals typically

insist on up-front payments by the patient of 100 percent of projected fees, with subsequent reimbursement by health insurance to the patient of 30–40 percent of total payments.

Western media report some dramatic cases of medical hardship. For example, a young farmer with a septic arm was moved from a rural clinic to an urban hospital, then immediately blamed for not coming sooner. He got an emergency amputation, but when he didn’t have enough cash to finish the hospital stay, he was sent to a hospice environment, still with active gangrene, essentially to die.

Too many private and public hospitals seem geared to the affluent Chinese, or perhaps a Saudi or Thai patient who arrives for major surgery that is much cheaper than in their own homeland. The sources of transplant organ donors are still in question, since courageous sleuthing showed that, at least in the past, the organs largely came from a “kill-to-order” program among prisoners in the Chinese gulag system.

No clear plan exists for treatment of the flocks of poorer patients whose needs may be much simpler. This huge gap in healthcare delivery affects no one more than the rural poor. Christian groups have been among the earliest and most effective providers to fill important gaps in service to impoverished

groups abandoned by the new economy.

These institutions serve all comers, regardless of faith.

Gaoli Church is a small rural church, lying amid modest brick and tile homes and farm fields, close to Weifang. Though poor, church leaders prepared local produce for us and fine, hot green tea in substantial ceramic mugs, welcome in the bone-cold country church. We learned about the social costs of the New China, including a problem that is utterly foreign to the Chinese family: As younger people leave the rural areas for jobs in the big city, their aging parents can’t move with their busy children. Overnight, economic displacement unraveled the cultural tapestry of millennia, as the tradition of caring for one’s parents withers with the dry, autumn fields. Instead, a strange, new harvest of senior housing facilities has sprouted in rural areas. Now, as factories close all over China, it remains to be seen how many of the prodigal sons return to their rural families.

The Gaoli Church opened its first senior residence in 2002, now expanded to hold some 400 residents. The elders had small, neat rooms, which they generally kept up without much help. Those with hemiparesis or other disabilities were helped by the

Left: Nursing unit, Linqu Hospital. Above: Our tour group with Linqu Hospital staff. right: Couple in their room at the Gaoli Senior Center

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By Shannon Brownlee and Ezekiel Emanuel

Outpatient IV therapy, Linqu Hospital

staff and by other elders. Both self-feeding and dependent adults ate in small dining rooms with attached kitchens, each for a dozen or so. The quarters were simple but seemingly well-ordered, and the active seniors were very engaging, miming frantically and posing for pictures with the meiguoren (us).

In 1992, the Gaoli Church opened the Zhen Suo rural clinic. Its small staff of paid practitioners provides reduced-fee, outpatient medical and dental services, now seeing some 30–40 patients daily. Zhou Fu Yuan, the clinic’s X-ray tech, proudly showed us recent equipment supplied by outside donors. In addition to simple Xray equipment, they have ultrasound and basic hematology and chemistry testing equipment. American and Chinese Christians replaced their slow, belt-driven dental drills with two high-speed, air-powered models, improving patient satisfaction and throughput. Major donation partners have included the Amity Foundation of China, the local Christian Councils, and Peachtree Presbyterian Church of Atlanta [the largest mission-oriented church in PC (USA) and the largest delegation in our group].

In contrast, the Linqu County Christian Amity Hospital began in 1985, with Dr. Zhao Bingchang, a retired doctor and director of the local church in Linqu. He was inspired to bring together other physicians retired from the national service corps into small “house clinics” that serviced the first patients. The initial buildings were ragtag, but by 2001, a six-floor medical building contained all active clinical programs, including some 30 inpatient beds. The poor, widows, and orphans receive free or reduced-fee services.

In 2007, the hospital moved from the

20

rural outskirts into the city center of Linqu. Although the inpatient beds are still restricted to 30, inpatient plus outpatient volume more than doubled since the move.

On entering the lobby, prices for each procedure are clearly posted in yuan. It’s not clear whether all discounts are posted on the “menu.” The dental, ophthalmology, and colorectal surgery programs are particularly busy and well regarded. The Christian Blindness Mission, an international association, partners with Linqu to provide cataract surgery for poor patients.

Despite the small inpatient size, according to our guides, the colorectal service performs major as well as minor surgeries.

Other services offered include ENT, general surgery, internal medicine, traditional Chinese medicine, gynecology, and pediatrics. We saw an outpatient intravenous therapy area, a small OR suite and recovery area, a well-appointed outpatient ophthalmology area, lab and X-ray facilities, and inpatient beds.

Like the Zhen Suo clinic in rural Gaoli, the Linqu Amity Hospital attempts to fill the needs of predominantly low-income and rural people, and others left behind by the New China. While young urban professionals, enjoying larger incomes and better food, education, and lifestyle, can afford a largely cash-based health system for minor problems, it is precisely the lowincome “left-behinds” of the new economy who cannot access care, who cannot afford care once accessed, and whose marginal lifestyles often result in more expensive, serious illnesses. Expect these numbers to grow as economics tighten.

In response to similar concerns, the Chinese government released a new health policy just days prior to our arrival, which

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specifically cites the unavailability and unaffordability of healthcare for most Chinese.

The government proposes direct, although unspecified, intervention. A standard formulary of medicines would be available at low cost. Fees at public hospitals will be brought under government control. Government will invest more in health infrastructure to reach the grassroots level.

We asked about the new national policy to doctors and administrators connected with Linqu, who doubted the new policies would offer anything relevant, either to Linqu Hospital directly or to the public hospitals in the same area. Only later did we learn the common parody of “The East is Red,” an old Communist anthem: “The government is like the sun because it shines everywhere; but government policy is like the moon, because every 28 days it changes.”

Most Chinese are not holding their breath, waiting for major government intervention to close the critical gaps in healthcare. As tens of thousands of factories already shutter their doors across China, we can only guess how the coming economic storm will worsen unmet health needs. Even in boom times, economically marginalized Chinese have been coming to Christ in record numbers — so many that most churches share a pastor or are entirely run by lay volunteers. With an economic downturn, even greater numbers will doubtless come to Christ. As the storm clouds gather, Christian missions continue to bridge gaps in healthcare and, through seminaries and lay training centers, help fill the ethical void left by Communism. t h e A u t h o r s : Dr. Grisolía is a neurologist in solo practice at Scripps Mercy Hospital San Diego. A former District I trustee to CMA, he has also served as SDCMS communications chair and San Diego Physician editor. Dr. Stayboldt is a pathologist at Scripps Mercy Hospital San Diego and Scripps Mercy Hospital Chula Vista, as well as president of San Diego Pathologists Medical Group.

She is a past chief of the medical staff at Scripps Mercy Hospital Chula Vista and served on the San Diego County delegation to CMA for many years.

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• Located at 10672 Wexford Street, off the I-15 at Scripps Poway Parkway (92131) • Strategic Scripps Ranch/Poway location perfectly situated off the I-15 to serve the North County Communities of Scripps Ranch, Rancho Bernardo, Poway, Mira Mesa and Carmel Valley • Minutes from SR-52 and SR56 for easy access to the coastal communities

For more information, please call Ed Muna at 619-702-5655 or e-mail ed@lankfordsd.com. • www.PinnacleMedicalPlaza.com

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volunteerism

Physician

A

New Year Brings a new way to manage your volunteer Care

Project Access San Diego

By K itty Bailey

photos courtesy of Maura Leonard Photography

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I

f there were a way to improve how you provide volunteer care, why wouldn’t you take advantage of it? Hundreds of millions of dollars of healthcare are given away for free in San Diego County. And the pressure on you and the whole medical community to care for the medically underserved grows each year. This problem is best handled in collaboration. That is why your San Diego County Medical Society Foundation (SDCMSF) offers Project Access San Diego (PASD), a proven, easy, efficient, and reliable way to coordinate your volunteer services, and, in turn, improve the health of our community.

Collaboration, regardless of the subject matter, produces something better than what we can achieve independently. It results in greater efficiencies, improved outcomes, and reflects a set of diverse inputs.

Consider the music world. As a group, The Beatles took America by storm and changed how we thought of music forever. Paul McCartney alone could not have achieved such success. And Mick Jagger without the other Rolling Stones just isn’t the same. Sports fans also know that the winning Super Bowl team is only as great as the sum of its parts.

No quarterback alone can win that coveted title.

There are also countless examples of how collaboration and cooperation have improved the medical community and the health of our communities. One such example is Project Access San Diego (PASD).

PASD is a countywide collaboration of healthcare partners — including hospitals, ancillary services providers, funders, and physicians — all with the shared goal of providing coordinated and efficient volunteer care to the neediest among us.

Simplify and Maximize Your Volunteer Efforts Think of Project Access San Diego as an extension of your staff, people dedicated to coordinating your volunteer services. Different from other referral efforts of the past, this pro-

gram is based on a case-management model. Project Access San Diego manages the patient care from beginning to end. We do this through: Enrolling Patients Based on Need:

We verify financial status so that you can be assured that your volunteer service is reaching those who are most in need.

Making Appropriate Referrals: We use referral guidelines that ensure that when a PASD patient comes to your office, he or she can take full advantage of the visit.

Providing Enabling Services: We provide services such as transportation and translation so that you don’t have to wonder if a patient is going to miss an appointment or if there will be a language barrier.

Providing Case Management Services:

We work with each patient one-onone to coordinate follow-through on all medical needs.

Providing

All

Needed

Services:

Through our partnerships, we ensure that a full scope of services is available to all of our patients, from office visits to hospital services, even including a defined pharmacy benefit.

Working with Project Access San Diego, you will know that your volunteer efforts are maximized to the

James T. Hay, MD, of North Coast Family Medical Group, says this about why he wanted Project Access San Diego (PASD) to help manage his volunteer care:

“

When my partners and I volunteered to provide medical homes for PASD patients, we knew we would be backed up by a system that would help us to help them.

”

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fullest. As a PASD physician, you volunteer your time at whatever level is comfortable for you — that could be two patients per month or two patients per year.

What We Are Not Project Access San Diego is not designed to take over any part of safety-net care in San Diego County. Our purpose is to augment, accentuate, and complement the work of our community partners. Project Access San Diego enhances access to care for the medically underserved by providing case management and care coordination.

Limiting Risk Project Access San Diego is conscious of your professional liability insurance concerns. When you provide this care for our patients in your own office, your own policy would be in effect, as long as you inform your insurance carrier. We also ensure that each patient you agree to see has a “medical home” where their care is being routinely managed, which also reduces liability.

Measurable Results Project Access San Diego tracks and quantifies the amount of free healthcare provided. This data helps to relieve some of the pressure on you

“

by educating lawmakers, healthcare organizations, the media, and the community about your contributions.

Don’t Wait Another Day Begin your new year with a new approach to volunteering. Let you can sign Project Access San Diego streamline up on our website, SDCMSF.org, or for and simplify your assistance, please contact Kitty Bailey at gift of helping others (858) 300-2780 or at KBailey@SDCMS.org in need. We know you have a heart for or Tana Lorah at (858) 300-2779 or healthcare, and we at TLorah@SDCMS.org. want to work with you to make it a better experience overall.

The next time you consider donatThere Are Many Reasons ing your time or hospital services, to Participate in Project do it through Project Access San Access San Diego: Diego.

• You want to help To get started, you can sign up • It’s easy to sign up at SDCMSF.org on our website, SDCMSF.org, or • Saves staff time and money for assistance, please contact Kitty • Convenience Bailey at (858) 300-2780 or at • Greater efficiency KBailey@SDCMS.org or Tana Lo• Lower risk rah at (858) 300-2779 or at TLo• Coordinates medical services properly rah@SDCMS.org.

• Limits the burden on you or your hospital About the Author: Ms. Bailey is the executive director of the San Diego County Medical Society Foundation (SDCMSF).

To get started,

The best thing about giving of ourselves is that what we get is always better than what we give. The reaction is greater than the action.

”

— Orison Swett Marden (1850–1924) American Author, Founder of Success magazine

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V

oluntary Liability Lowering the Bar for Volunteerism

By James T. Hay, MD

Problem Physicians volunteer their care to the medically underserved every day, in their offices, in free clinics, in ERs and hospitals.

The San Diego County Medical Society Foundation’s (SDCMSF) Project Access San Diego (PASD) is actively recruiting “Doctors with Heart” to do just that and, with the help of PASD, to coordinate their care. One frequently raised concern is the professional liability that may be encountered by the provision of volunteer care.

Perception Much of the concern is unfounded, however, since physicians with coverage by most of the liability carriers in California are already covered for the care they provide in any setting. Clinics designated as Federally Qualified Health Centers are covered under the Federal Tort Claims Act, as long as the care provided is within the health center’s federally approved “scope.”

And our UCSD Student-Run Free Clinics protect volunteer doctors under university policies covering those physicians who all supervise students as voluntary faculty.

But retired physicians without a malpractice policy, physicians in some selfinsured groups, and hospitals themselves may have a disincentive to volunteer care for fear of their liability risk.

Many states (43 out of 50) have adopted legislation to protect doctors who provide

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Dr. Ellen Beck and I have worked with SDCMSF staff to develop a network of allies and to learn what it will take to pass Florida-like legislation in our state. free care to the medically underserved.

California has considered such legislation in the past, and SDCMSF and CMA are actively working to see that we adopt protections in our state in the near future.

History in California California Assemblyman Alan Nakanishi, an ophthalmologist, has introduced several bills to address this issue over the past few years. One early attempt would have provided immunity from liability similar to “good Samaritan” laws, but was not adopted. AB 367 was signed into law, and it provides a waiver of the medical license fee for retired physicians who no longer earn any income from a medical practice but still wish to provide pro-bono care.

AB 367 did not address the liability issue.

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More recently, AB 2342 was enacted asking that the Medical Board of California, together with the Health Professions Education Foundation, study the issue of providing medical malpractice insurance for physicians who provide voluntary, unpaid services to indigent patients in medically underserved or critical-need population areas of the state. AB 2342 originally was written to provide for that state-financed liability coverage but was amended to a study bill after opposition from trial attorneys. The legislation required the report to be presented to the Legislature by January 1, 2008. The report has just been released to the Legislature and will be reviewed by the Medical Board at its quarterly meeting January 29–30, 2009. It addresses what must be included in a legislative solution to this problem for California and suggests several ways to pay for the costs incurred by the state to administer it. These include increasing the biannual licensing fee for physicians, charging a fee to the entities ultimately protected, seeking grant funding such as from the California Endowment, or by funding from the state’s general fund (which is the way almost all the other states pay for their programs).

History in Other States and Federally As noted above, almost all states have some form of legislative protection for doctors who volunteer care. Florida and Georgia, for example, have laws declaring that a physician providing volunteer care, and

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who has signed up with the program, is, at that moment, an “agent” of the state and thus covered by state liability protection, not immune from, but governmentdefended as if an employee of the state.

Wyoming Senator Enzi introduced a bill in the last Congress to give similar federal protection and cited as rationale the Florida experience that has documented more than $1 billion in charity care over its 16 years of existence in return for state infrastructure costs of $900,000 a year (Modern Physician Alert 7/29/08). Needless to say, much of that charity care would have ended up as state expense through ER and hospital care, hence they have found it to be cost-effective and have documented a significant ROI for the state’s investment.

The Enzi bill did not pass.

Obstacles Many things stand in the way of passing this type of legislation in California: 1. Any new costs to the state, regardless of the long-term benefit and ROI, are unthinkable during the current budget crisis. California already charges one of the highest licensing fees in the nation, and physicians will likely resist any increase to fund such a program.

2. Much confusion exists in the public’s mind and therefore also with legislators about the request for state provision of liability coverage (which still allows for recovery by harmed patients, and, incidentally, also for their lawyers) as opposed to immunity from prosecution, which would take the lawyers and courts out of the picture.

3. States vary also on the definition of what is “medically underserved.” That is, who qualifies for the receipt of the care for which the physician receives state liability protection and who decides. Does a physician have the ability during an individual patient encounter to make that determination, for example? The federal government’s Health Resources and Services Administration (HRSA) defines

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medically underserved populations to include “groups of persons who face economic, cultural, or linguistic barriers to healthcare.” Any individual who is not eligible to participate in existing public or private healthcare programs due to program restrictions, health plan exclusions, and/or preexisting health conditions can therefore only be served through safety-net providers.

4. Clarity is needed in defining whether state coverage applies to the individual encounter (such as a single patient seen in the office during an otherwise normal schedule of paying patients) or only to the site of care such as in existing free clinics.

5. A s occurs when the state provides health insurance that might otherwise have been supplied by an employer, “crowd out” could affect this coverage as well.

Our goal is to help them and to make it easier to recruit others to volunteer care to an unfortunately ever-increasing population of medically underserved.

Liability carriers might well decide they is to help them and to make it easier to no longer need to provide for volunteer recruit others to volunteer care to an unAKT_SDP_08:Layout 1 8/22/08 3:52 population PM Page of 1 doctors, thereby reducing their risk and fortunately ever-increasing allowing that coverage to be assumed medically underserved. Legislation that by the public. provides state liability protection to vol6. Any program organized to provide volunteer doctors will help us achieve that unteer services, such as Project Access goal.

San Diego itself, may incur liability risk as an entity, and if the program uses a A b o u t t h e A u t h o r : Dr. Hay “medical director,” that physician may have liability outside his or her usual liability coverage. We have heard from Richard Anderson, CEO of The Doctors Company, who has offered to make a discounted plan available to PASD.

is a family physician in full-time private practice in Encinitas. He founded North Coast Family Medical Group in 1978 and North County Physicians’ Medical Group (an IPA) in 1990. He is past president of SDCMS, past president of the SDCMS Foundation, current “Champion” of the Foundation’s Project Access San Diego (PASD), and current speaker of CMA’s House of Delegates.

(For an extensive review of the obstacles, see “Overcoming Barriers to Physician Volunteerism,” Paul A. Hattis, The University of Illinois Law Review 1/12/05.)

Next Steps Dr. Ellen Beck and I have worked with SDCMSF staff to develop a network of allies and to learn what it will take to pass Florida-like legislation in our state. We have met and stayed in touch with the UCI attorney who wrote the AB 2342 report for the Medical Board. We believe we have pro-bono legal assistance available when the time is right to introduce such legislation. During the several years we have been discussing this problem, at least one major doctor-owned liability company in California has clarified that it, like the others, does cover its insured regardless of where they provide their care, including in clinics outside of their own practices.

CMA’s legislative staff is helping us to decide when and how we should begin the legislative process, aided, we hope, by the AB 2342 report’s findings and recommendations. We hope to also enlist the support of the Medical Board, which is likely to be allied with us in the desire for such legislation.

Conclusion SDCMSF’s “Doctors with Heart” will continue to provide the care to those in need just as they always have. Our goal

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A

dventures in the South Pacific

Providing Both Clinical and Academic Help

By L ance H endricks , M D

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Our “Adventures in the South Pacific” originated with surfing on Tavarua Island, Fiji, starting in 1985. During the initial annual visits we would care for the Fijian workers on the island, then during later visits go to their villages on the “mainland,” as they call their largest island, Viti Levu. Then we began bringing Fijian adults and children to San Diego for medical care. The care included congenital cataract removal, cleft lip and palate repair, and chronic cardiac problems, among others. As more people in need appeared, I decided to ask the Ministry of Health if we could bring a surgical team to Fiji to care for the cleft lips and palates, burn scar revision and grafting, and (limited) congenital deformity patients coming to us during our visits. The Ministry staff were most gracious and helpful.

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We organized our first Scripps Health surgery team in 2001 with the help of International Relief Teams of San Diego. We went to a 40-bed subdivisional hospital in a smaller village on the main island. We performed 40 surgeries there in five working days. We returned in 2003 to Lambasa Hospital (a 125-bed hospital) on Vanua Levu, the second largest (but much less populated) island. In 2006 the team went to Lakemba Hospital and in 2007 to Vanuambalavu Hospital at the request of the Ministry.

These two islands are in the southern and northern ends of the easternmost isolated Fijian islands. In order to have our equipment and supplies there, we had to ship everything three months before our arrival.

The Ministry then shipped the materials to each of the islands on the once-a-month supply boat to arrive before the team did.

The team took the overnight flight from LAX to Nadi, Fiji, transferred by van to the capital of Suva, and the following day, took the once-a-week flight (if the weather is good) in a 16-passenger DeHaviland Otter type plane (Chinese made!), which lands on a grass landing strip in the jungle if there is not too much water on the runway.

The hospital on each island was a 12-bed hospital. We used one of the four-bed wards as our operating theatre, as they are called there. My anesthesia machine consisted of small oxygen bottles, a hand help breathing bag, a sevoflurane vaporizer, a monitor with EKG, blood pressure, and oximetry. We used dental-type sterilizers between cases and a small bovie unit. The 240-volt hospital generator was run during the day for us. Air conditioning consisted of a breeze blowing in off the bay (at about 88 or 90 degrees!). We performed 45 surgeries in Lakemba and 60 in Vanuambalavu. There were no hotels or restaurants on these islands, so we were strictly on the local diet of fish, crab, chicken, goat, taro, cassava, sweet potato, local vegetables, seaweed, and occasional pudding for dessert. We were the first team to ever visit these areas and were able to help many people.

At the time we started the surgery team visits, the American owners of a resort on one of the outer islands asked through International Relief Teams for a cataract surgery team to come to their island to care for

the many cataract patients there who could not get to the main island for care. In 2001 and 2002, we took a cataract team to Lalati Resort on Benqa Island and performed cataract surgeries in the utility room of the resort. Thirty surgeries were performed in 2001 and 25 in 2002. Some patients had not been able to see for 12 years. Needless to say, they were thrilled beyond words.

As a result of the interaction with the owners of this resort and several of their guests who wished to provide further help to Fiji, we set up the Loloma Foundation (www.lolomafoundation.org), a 501 (c) 3 U.S. nonprofit corporation. It is dedicated to providing medical and educational support to Pacific island countries. Since organization of the foundation, we annually ship one to three shipping containers of supplies to the hospitals, clinics, and schools we have determined to have the

greatest need. Through the foundation we were able to ship all our materials for the surgical team visits. The foundation has shipped from $250,000 to $1 million worth of supplies each year. Through the foundation, clinical medical teams, primarily from Scripps Clinic, have visited most of the more populated Fijian islands.

Under the auspices of the owner of Lalati (and a board member of Loloma), who travels extensively through the Pacific

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top Left: Great cheery patients.

Bottom Left: Outer Solomon Island outdoor clinics. Below: Transport to the clinics in Honiara, Guadalcanal.

As more people in need appeared I decided to ask the Ministry of Health if we could bring a surgical team to Fiji.

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Common size greeting party at a school our Solomon Islands team visited.

In 2001 and 2002, we took a cataract team to Lalati Resort on Benqa Island and performed cataract surgeries in the utility room of the resort. Some patients had not been able to see for 12 years.

Islands, Loloma Foundation organized a trip to Vanuatu in February 2005. After extensive preparations through the Ministry of Health, the group flew to Vanuatu and then boated for 12 hours to Tana, one of the southernmost islands in the group and very remote. We ran medical clinics at their 40-bed hospital in the small town of Lenakel and outer villages on the island.

The ENT, radiology, and infectious disease specialists in the group also made rounds for a day at the central hospital in Port Vila, the capital of Vanuatu.

The foundation organized a team visit to the Solomon Islands in May 2008. The team of 14 medical practitioners and seven assistants spent three days in Honiara, Guadalcanal, running medical clinics. The team then went by chartered boat for 10 days to the outer Solomon Islands, provid-

30

ing medical care for the local population.

It was very interesting visiting and working in all the World War II battle zones.

Many clinic facilities were left over from the war. After the war ended, everyone left.

No one has returned, and the country is off the edge of the world for development. It is subsistence living with rampant malaria, chronic ear and skin infections, perforated eardrums, rheumatic fever, cardiac valvular problems, several cases of post malarial meningitis hemiplegia in teenagers, and even a few cases of yaws. Included in our team were two internal medicine residents from the Scripps Clinic training program.

Needless to say, it was the experience of a lifetime for them (and for us). The team treated 4,500 patients in two weeks! We are planning a return to the Solomons this September with a clinical and a surgical team. By the time of publication, the January 2009 team will have run medical clinics and provided cataract surgery to inhabitants of the outer northwestern islands in Fiji.

The third leg of the programs in the Pacific is an academic program. The Fiji School of Medicine (FSM) has been in existence for more than 100 years. It grants an MB/BS British-type degree through the University of the South Pacific, with six years of schooling after secondary school.

They train the doctors for most of the Pacific Island nations except French Polynesia and Papua New Guinea, which has its own medical school. At the start of the surgical programs, I learned that the Australians, through their AUSAID program, had set up a postgraduate training program at FSM for surgery, internal medicine, pediatrics,

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ob-gyn, and anesthesia. Their support was ending in 2001, so I met with the head of internal medicine at FSM and offered to search for volunteers at Scripps Health to spend two weeks at a time teaching at FSM in the specialty training programs.

The beginnings of the program involved the (continuing) help of Dr. Philip Higginbottom, infectious disease, Scripps Clinic, and Dr. David Roseman, gastroenterology, Scripps Memorial Hospital. The volunteers were so well received that in 2003 a formal memorandum of understanding was signed between FSM and Scripps Health whereby Scripps would provide volunteer specialists to be visiting teaching faculty at FSM and FSM would provide temporary Fijian medical licenses, work permits, liability coverage, and housing. Since then the program has expanded to include nurses, physical therapists, ultrasonographers, biomedical engineers, and IT technicians.

The program is supported by a very generous yearly grant from one of Dr. Higginbottom’s patients that allows us to cover the cost of airfare for the visiting staff. It has been a very rewarding experience for each of the people who have traveled to Fiji and viewed as a tremendous asset by the staff at FSM. As one may surmise, the experience providing both clinical and academic help has been extremely rewarding. There are many poignant tales and many funny remembrances. Perhaps the most memorable is as our boat was readying to leave one of the isolated islands in Vanuatu, an older man came hobbling with a large walking stick out of the jungle to the shoreline. He waved as though in distress that he had missed the clinic. One of the doctors volunteered to go back to shore in the zodiac to help the poor soul we had missed. They conversed and gestured, the man lowered his head and returned to his path through the jungle. He wanted to know if we had any Viagra! How word travels. Pfizer should be proud of its advertising program.

Dr. Hendricks, SDCMS member since 1977, is a member of Anesthesia Service Medical Group, Division of Anesthesiology, Green Hospital of Scripps Clinic.

About the Author:

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ambodia,

Thailand, and Uganda

Why I Practice Medicine

By J a m es W . O chi , M D

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1

In the midst of a little casino town known as Poipet, Cambodia, thousands of people live in squalor in an area called the “slum village.”

The slum lacks running water and electricity. The stench in the air is fierce, a combination of burning trash and the smell of makeshift toilets. This is where we would set up our medical clinic.

Within minutes, hundreds of people were in line, as this would be a once-in-a-lifetime opportunity for the villagers to be seen by Western physicians and nurses.

The mother of this baby waited hours in the hot sun to be seen first. She was born with an enlarging frontal tumor that I feared had an intracranial connection. Our group paid for her transportation to and surgery at a regional children’s hospital, hours away.

I returned a year later and found she was growing and developing normally but, unfortunately, the tumor had returned and was threatening her eyesight. Although I was not able to offer any help to many of these patients, these were extremely grateful people.

picture

2

More than a thousand miles away from Poipet, we traveled to the rugged mountains of northern Thailand and held medical clinics at a remote hill-tribe village near the Myanmar border.

We would live with the members of the Lahu Tribe and provide them with medical attention for nearly a week. The villagers said we were the first group of Westerners to visit them. Many of the patients suffered from advanced disease because of their inability to see a physician. We were blessed to have several tens of thousands of dollars worth of first-quality medicines and supplies that had been donated to us to offer the villagers.

Our clinic was held in a one-room schoolhouse with a dirt floor. As is typically the case in the developing world, there was no electricity or water, and animals roamed in and out freely.

picture

3

The Lahu Tribe pride themselves on hunting and trapping animals. They live off the land and maximize all of their natural resources. The villagers showed their gratitude to us by slaughtering one of their precious pigs. They used every bit of the animal in

preparing dinner and picked fresh herbs and vegetables, which grew naturally.

I ate as much as I could, which was difficult because of the blood, hair, and organs that had been included in the meal.

4

In 2006 and 2007, I traveled to picture Uganda, spending time in Mukono, Gulu, Lugazi, and Jinja.

This little girl was seeking treatment at Kawolo Hospital. The facility has limited resources and lacks consistent electricity. People come here to get better, but most end up dying. She presented with a hematocrit of three due to advanced malaria. When I stepped into the hospital room, her eyes were fixed ahead and she was unresponsive. Her grandmother, who brought her, was clutching her hand.

Someone in our group gave the grandmother several dollars, which was enough for her to receive anti-malarial therapy.

Without this medicine, the transfusion would have only been temporarily helpful.

I returned to this village the next year and heard from people there that she had survived.

5

This infant is near death, too weak to cry or feed, suffering from HIV and malaria. About 80 percent of the inpatients at this hospital had either or both of these diagnoses.

Death is seemingly everywhere in Africa.

About one in seven children dies from malaria before age five. HIV is rampant and still carries a significant social stigma.

picture

6

Poor children such as these girls are happy despite having no toys; they enjoy simply being with one another.

I have always been touched by how grateful and humble poor people are. These are lessons I am reminded of each time I look into the eyes of the children in my photographs.

This is why I practice medicine.

picture

4

3 1. Slum in Poipet, Cambodia, November 2004. 2. Lahu hilltribe village, Thailand, November 2005. 3. Lahu hilltribe village, Thailand, November 2005. 4. Kawolo Hospital, Lugazi, Uganda, November 2006. 5. Kawolo Hospital, Lugazi, Uganda, November 2007. 6. Orphanage in Mukono, Uganda, November 2007.

Our clinic was held in a one-room schoolhouse with a dirt floor. As is typically the case in the developing world, there was no electricity or water, and animals roamed in and out freely.

picture

Dr. Ochi is a pediatric ENT doctor in solo private practice. His website is ENT4MyKids. com, and his office telephone is (858) 7924800.

About the Author:

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Purple The

Palace

Wiping the Tears Away

By T yler Youngkin , M D, and C onnie Youngkin

above: Kindergarteners at the home with their teacher, Selene. top right: Some of our 95 kids, Christmas 2008.

Not pictured are eight babies from eight months old to two years and the boys from our second home.

34

Blanca left our children’s home, wiping her tears away as she had just left her eight-month-old baby with us. She knows that we will take good care of her daughter, and she will now either choose to go to drug rehabilitation or continue in the drug/ prostitution scene in the red-light district of Tijuana, Zona Norte.

We started a home for children of Zona Norte eight years ago. It really began 10 years ago, when Connie would go around the streets with her friend, Hortensia, and help with the needs of women and children they would meet. We saw how there were children, living in the streets or in brokendown, dirty, muddy shacks, deserted most of the time by mothers on drugs and work-

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ing in the legal district for prostitution. We wanted to grab up these kids and care for them!

We first went to Costa Rica to learn Spanish and Latin culture, and work and learn in an orphanage for two years. We sold our home in Poway, and sold or gave away all our belongings except for a small closet of mementos. Our three children were all grown and out on their own, but it was still very painful to leave them.

We returned to Tijuana and rented a condo. Tyler began to work again part-time at Scripps Mercy Hospital to cover our personal expenses and also help the children.

We began to set up a place in the area of the red-light district to start a home for the kids from the worst situations.

We began with five boys, 10 years old who were sleeping in an alleyway. They would rob and beg for food and something to keep them warm. One had a gun and shot a man’s kneecap because he wouldn’t pay back some money he owed. Sometimes for “fun,” the boys would pour the 100 percent alcohol that drunks were drinking and light them on fire. Some of the boys would make money by singing on buses, cleaning cars, or bringing little girls to pedophiles for money. Little by little we found

the kids who really needed help. We started out with cots in an old storage building; we fixed it up to make it pretty nice. The kids had a warm bed, clothes, and good meals, and we enrolled them in school for the first time! We opened our girls section after two years to help the little girls severely abused sexually and physically. One little six-yearold girl was raped by her mom’s boyfriend, and then her little sister was raped in front of her before he stabbed her sister to death.

Little girls come to us not wanting any contact. But with consistent caring, embracing, and love, they are now happy, well adjusted, beautiful girls. We have three psychologists who have helped immensely to heal the hurts of the children.

Eventually, we expanded over the years to 95 kids. Now we are renting a 15,000-square-foot, beautifully renovated home with hot showers, comfortable beds, furniture, and nice clothes, thanks to hundreds who provided and still provide. God has blessed us and these children with a bright home made possible by volunteers, college students, an architect for resort ho-

tels, professional construction guys, families, We spend $250 daily for food. We trust God churches, and different groups who started to move hearts to provide for the needs. So far, the children are cared for. It has been showing up to help by word of mouth.

Our children are doing well in kindergar- and is a blessing to be part of this work that ten to high school. In a year, half of our first many have helped to make possible.

Our website is www.thepurplepalace. group of students will be going to the university or career school. Many of the chil- org. To communicate with us, email us at dren are tops in their classes, and one was tycoon_mx@yahoo.com. Tax deductible number one in his whole junior high school donations: Make check payable to Children of Promise Int’l, designate for Youngkin for all three years.

We just opened up a home that has room mission, Mail to COPI, 6844 Loop Road, for 18 boys who need help to get off drugs. Centerville, OH 45459. Thank you!

This home is two blocks away from our other home. We now have six boys from 12 to 16 years who want to change the course A b o u t t h e A u t h o r s : Dr. Tyler Youngkin, a pathologist at Scripps of their lives.

We want to not only meet basic needs Mercy Hospital San Diego, and Connie but encourage these kids to love God and Youngkin, a registered nurse, lived in Poothers. Already, the older kids have built six way where they raised their three children: basic houses for needy families. Our kids John, Mariah, and Jessica. They now also visit rest homes frequently to help in the have five grandchildren. Tyler and Concare of the elderly and disabled. They have nie learned Spanish in Costa Rica and taken various leadership courses to serve and also worked in an orphanage there for two years. For the past eight years they have help others.

Twenty-one workers care daily for the been helping abused children to get out of red light 11:22 district.AM Page 1 kids. To care for a child costs Project4:Layout $10 U.S. daily. Tijuana’s 1 9/22/08

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volunteerism

Physician

The

Mercy Outreach Surgical Team A Mission of Mercy (M.O.S.T.)

By T ho m as V ecchione , M D

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When you see a child with a congenital or acquired anomaly, you realize that this can be a member of your family, or a friend’s child, or even a child who lives in the neighbor. The empathy for that child and the desire to help can be overwhelming.

History M.O.S.T. was formed at Mercy Hospital of San Diego (Now Scripps Mercy) 20 years ago. A small number of compassionate nurses and doctors saw a need in our community and in Mexico. Many children born with cleft lip palate and other congenital anomalies, such as crossed eyes, hemangiomas, nevi, extra digits, etc., are helped by this group. We also assist children with acquired defects such as scars from trauma or burns.

Through these 20 years, M.O.S.T. has had hundreds of volunteers annually participating in two major, weeklong missions deep into Mexico and three or four weekend missions to Tijuana. During these 20 years, the team has performed and changed the lives of more than 8,000 children and adults.

M.O.S.T. is completely funded by private donations and is an all-volunteer organization with only one half-time, paid employee. With this kind of managed economy, each surgery can be done for less than $250!

Our missions in Mexico have taken us to Durgano, Zacatecas, Jerez, Nochistlan, Zamora, Apatzingan, Uruapan, Morelia, Zitacuaro, Cuernavaca, Oaxaca, Cuidad Valles, Tula, Xalapa, Tehuacan, and Chiapas.

Recent Mission: San Cristobal de las Casas, Chiapas, Mexico. October 2l– 31, 2008 Physicians on this recent mission included plastic surgeons Larry McCarthy, Mike Peters, Jeff Umansky, and Thomas Vecchione; pediatric ophthalmologist Harry O’Halleran; and anesthesiologists Doug

Arbon, Edgar Canada, Kent Diveley, John Holl, Gloria Huang, Debra Page, Alex Rodarte, and Jordan Waldman.

Our 44-member contingency completed surgeries on 250 patients. Chiapas has a large Mayan Indian population, and there is a problem in accommodating many of these people with surgical problems. Many congenital anomalies go untreated, even into the teenage years.

It is a heartbreaking experience to see a 14-year-old girl with a wide-open cleft lip unrepaired or a young child not going to school because of severely crossed eyes. It is these kinds of cases that give the team the most satisfaction.

The state of Chiapas is on the Guatemalan border. The climate is very tropical, and this land is one of the most beautiful parts of Mexico. The Mayan culture is extremely compelling. The people are very gentle, but at first they were very skeptical of our mission. Once we completed several cases, they began to come in freely, and the acceptance and trust they had for us was evident in their willingness to bring in their children.

In Chiapas, we learned about the Zapatista insurgency in the early 1990s. This organization is still active. It has risen up against the Mexican government because of the lack of support for the very poor in the state of Chiapas. The army demanded better education, land ownership, opportunity, and medical care for the indigent people living in the countryside of rural Chiapas. The Zapatistas are still a presence in Chiapas; they were all around us approving of our mission, even though they were not identified to us. We were told that they were watching over us because we came to help their poor people.

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volunteerism

Physician

and concerned members of the community. All of this is essential to the efficient execution of our mission statement, which is to help the patients and to educate the local medical caregivers.

The Logistics

San Cristobal de las Casas is a beautiful colonial city of about 150,000 people in the heart of the mountains of Chiapas.

The surrounding countryside is lush green rolling hills and mountains. At 7,000 feet elevation, there is a chill in the moist, clear air and a mist hovering over the valley.

The cathedrals and the colonial architecture are fascinating. The stonework and the 400-year-old buildings are aesthetically spectacular. There is a definite European feel to the physical makeup of this old city — a mixture of European and southern colonial Mexico rendering a magical atmosphere that we had never experienced before in Mexico.

The Organization M.O.S.T. works with the Department of Infant and Families (DIF) in the Mexican state where the mission takes place. We also have a very close contact with the Rotary Club of the area, and the partnership with our San Diego Rotary Club Number 33. The Rotarians are invaluable partners in this surgical venture. They help with logistical problems, meals, and transportation for both patients and team members.

The Rotary Clubs help us in so many ways; if we need a piece of equipment or some medical support, there is always a Rotarian who can secure the need. Rotary has smoothed the way in so many of our trips.

M.O.S.T. has nine Rotary members in the active team and is financially supported by the San Diego Rotary Club 33. We also enlist the help of local doctors, nurses, priests,

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The patients are brought in by all of these helpers, who make sure that they come to the screening clinic on the first day of the mission. Six OR tables (four plastic surgery, two pediatric ophthalmologic surgery) run for about eight hours a day for three and a half days for the mission. Local surgeons usually help us, along with the DIF, who supervise the follow-up of our patients. We keep all the records and leave a copy to the DIF to keep on file for future procedures.

The patients are all told where M.O.S.T. will be in the near future, and many patients travel to that location for a follow-up exam or for future surgeries.

Why We Do It The poverty we that we experience on these mission trips can be devastating. At certain times it is cold in the mountains of Chiapas. To keep warm, they build fires. Their small adobe homes all have fireplaces, but very little ventilation, so everyone is constantly exposed to smoke and combustion particles. Burn scars are common and we see many during our stay. Most of these children are undernourished and survive on the bare necessities of life.

With all of these problems, adding a cleft lip or palate or crossed-eyes or severe scarring makes life that much harder. They already have a very challenging life, and when you add the physical deformity to it, it seems to be so unfair. These children have such a heavy burden to carry through childhood. What a joy it is for us just to make their lives a little more joyful. The community and the family and the neighborhood indeed rejoice in the feeling that this little child will have a better life. After all, what is more uplifting or inspiring than to see a young life benefit from all of our efforts. If we can make just one life better, it is worth all the effort that our group expends to get to these children.

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Our team is a chain of very important links. The nurses, surgical technicians, trip planners, equipment supervisors, translators, and recovery room personnel are all crucial to the effective running of this surgical program. They are all very committed to helping these people. Each one makes a huge sacrifice to participate in each mission. We are very proud and appreciative of each other’s sacrifice, and that is why our program works so well.

On these mission trips, our interaction with the families and the friends of these children is reward enough for us. The smiles and the tears and the hugs are all very palpable. Watching these children go home with their mothers and knowing that their lives will be a little better is for us a soul-changing experience. We are grateful that we can offer them some comfort in this life.

I have discussed all of these ideas with our team members, and weaving through our conversation is a common thread of compassion. When you see a child with a congenital or acquired anomaly, you realize that this can be a member of your family, or a friend’s child, or even a child who lives in the neighborhood. The empathy for that child and the desire to help can be overwhelming. Consider the mother and the father who, like all of us, want only the best for their children. They do not have the resources or the mechanism to help correct a child’s devastating defect.

The feeling of helplessness is a huge weight on the shoulders of these poor people, but when a correction has taken place, we can all see the relief and the joy that permeates the post-op ward as the children are reunited with their parents. This is, indeed, the basic reason we have enlisted ourselves in the M.O.S.T. campaign.

A b o u t t h e A u t h o r : Dr. Vecchione is one of the founding physicians of Mercy Outreach Surgical Team (M.O.S.T.) in 1988. He has practiced plastic surgery in San Diego County for 35 years. Dr. Vecchione describes M.O.S.T. as the best thing he does with his life, “It is an honor and a privilege.”

Merchant Services: Credit/Debit Card Processing Potential Value: $1,500 for high-dollar, high-volume cost!

Chase Paymentech provides member physicians fast, secure, and cheaper credit card payment processing, excellent customer service, and innovative payment options. SDCMS members receive upgraded customer service, free online reporting, and a guaranteed 10–20 percent savings from current costs. Let Chase Paymentech provide you with a competitive quote today by sending three months of merchant statements to Janet Lockett at JLockett@SDCMS.org, by fax to (858) 569-1334, or call her at (858) 300-2778.

Technology Solutions Potential Value: $1,000!

Soundoff Computing Corporation provides bestof-breed hardware, software, and network technologies for your medical practice, utilizing best practices for all aspects of IT implementations.

SDCMS member physicians receive free site inspection and subsequent infrastructure recommendations; free inventory and assessment of network and hardware computing assets; free analysis of Internet/telco/ data activity and subsequent ROI recommendations.To learn more, visit www.soundoffcomputing. com or contact Ofer Shimrat at (858) 569-0300 or at ofer@ soundoffcomputing.com.

Banking Products and Services Potential Value: $2,500!

Torrey Pines Bank is a “lowmaintenance” bank that meets business owners’ high expectations while requiring of them the absolute minimum of time and effort. 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 per 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 per month, and free courier service or remote deposit service.

Contact Benjamin Pimentel at (858) 259-5317 or at bpimentel@ torreypinesbank.com.

Insurance Products and Services Potential Value: $1,000–$2,500!

Alliant Insurance Services, Inc., is California’s largest premier specialty insurance broker and ranks among the 13 largest in the

nation. SDCMS members receive discounts on a comprehensive portfolio of insurance products and services, including savings of 5–10 percent or more off of the cost of insurance, or cash rebates related to practice size, a savings of 7–12 percent on long-term disability income protection, and no-cost human resources consulting. Contact Mark Allan at (800) 654-4609 or at mallan@ alliantinsurance.com. Visit Alliant Insurance Services online at www. alliantinsurance.com.

Tamper-resistant Prescription Pads Potential Value: $300!

American Security Rx, which is a California Department of Justice and California Board of Pharmacy approved Security Printer (SP-9), provides tamperresistant California security prescription forms for controlled medications. SDCMS members receive discounts on tamperresistant prescription forms.

Contact American Security Rx at (877) 290-4262 or at info@ americansecurityrx.com. Visit American Security Rx online at www.americansecurityrx.com.

Billing Solutions Potential Value: $1,000!

CHMB Solutions 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 percent discount on startup fees and a $33 per-physician-permonth services credit, 10 percent off of outsourced IT support, 10 percent off of already discounted Dell hardware solutions, and a free coding hotline. Contact Ron Anderson at (760) 520-1340 or at randerson@chmbsolutions.com.

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

Visit CHMB Solutions online at www.chmbsolutions.com.

Contract Analysis Potential Value: 10 percent of Net Revenue!

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. SDCMS members receive a free contracting analysis, a discount on hourly rates, and a package price on services for contract negotiations, including health plan contracts!

Contact Kim Fenton, president, at (949) 481-9066 or at kimf@healthcareconsultant.

org. Visit Coastal Healthcare Consulting Group online at www. healthcareconsultant.org. For consultation scheduling, contact Marisol Gonzalez, your SDCMS physician advocate, at (858) 300-2783 or at MGonzalez@ SDCMS.org.

Practice Management Consulting Potential Value: $1,000–$2,500!

Practice Performance Group (PPG) 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

and a 7.5 percent dividend credit.

To learn more, contact Janet Lockett at SDCMS at (858) 3002778 or at JLockett@SDCMS. org. Visit TDC online at www. thedoctors.com.

Collections Services Potential Value: $350–500!

TSC Accounts Receivable Solutions has provided personalized, innovative collection and total accounts management services since 1992.

This local, family-owned business’ management team has combined experience of more than 50 years in the healthcare billing and collection field. SDCMS members receive a 10 percent discount on monthly charges. Contact Catherine Sherman at (888) 687-

SDCMS

Endorsed Partner Benefits

Total Potential Value to SDCMS Members:

$10,000–$17,000 management, market strategy and tactics, practice acquisitions, sales and mergers, and a free one-year subscription to their newsletter, UnCommon Sense.

PPG also conducts free half-day seminars for SDCMS members and their staffs at SDCMS’ offices.

Contact Jeffrey Denning or Judy Bee at (858) 459-7878 or at Jeff@PPGConsulting.com. Visit PPG at www.PPGConsulting.com.

Professional Liability Insurance Potential Value: $500–$2,500!

The Doctors Company (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. Most SDCMS members are eligible for a 5 percent discount on insurance premiums

4240, ext. 14, or at csherman@ tscarsolutions.com. Visit TSC online at www.tscarsolutions.com.

Accounting Services Potential Value: $500–$2,000!

AKT CPAs and business consulting LLP has provided audit, tax preparation and planning, accounting assistance, and business consulting to San Diego County clients for more than 50 years. SDCMS members receive a 15 percent discount on standard rates for professional services, with an unconditional satisfaction guarantee: “SDCMS members who are not completely satisfied with the work AKT performs for them pay only what they thought the work was worth.” Contact Ron Mitchell at (760) 268-0212 or at rmitchell@ aktcpa.com. Visit AKT at www. aktcpa.com.

Corporate Legal Services Receive a free consultation and discounts on corporate legal services. Call Ladd Young Attorneys at Law at (619) 5646696.

San Diego County Physician Mailing Lists Receive one free physician mailing list annually and a discount on all additional mailing lists requested in the same year.

Contact SDCMS at (858) 5658888.

SDCMS Membership Certificate Receive a free SDCMS membership certificate. Contact SDCMS at (858) 565-8888.

Investments Invest with Dunham & Associates and discount your SDCMS dues by $150. Call Jeff Dunham at (619) 308-9700.

SDCMS Pictorial Membership Directory Appear in SDCMS’ annual pictorial membership directory.

Receive a free directory each year and a 50% discount on additional directories purchased, as well as discounts on directory advertising. Contact SDCMS at (858) 565-8888.

Coding Hotline Access a free coding hotline (provided by CHMB Solutions).

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

San Diego Physician Magazine Receive a free subscription to the voice of San Diego County’s physicians. Place free classified ads and discounted display ads.

Contact SDCMS at (858) 5658888.

San Diego Magazine Receive a gift subscription (active physician members) or a discounted subscription (resident physician members).

To sign up, contact SDCMS at (858) 565-8888. To update your subscription address, contact San Diego Magazine at (888) 3500963 or at sdgm@kable.com.

SDCMS Email Newsletter, “News You Can Use” Receive the latest in medical, local, state, and federal news critical to your practice … free to members and free of advertising.

Contact SDCMS at (858) 5658888.

SDCMS Seminars SDCMS member physicians and their office staff attend free

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of charge all SDCMS seminars (including Office Managers Forums), covering legal issues, HIPAA, risk management issues, how to begin your practice, contract negotiations, getting paid, billing, and much more.

Contact SDCMS at (858) 5658888.

involved in any of a broad spectrum of engagement opportunities both SDCMS and CMA afford their member physicians, including joining an SDCMS or CMA committee or becoming a physician leader.

Contact SDCMS at (858) 5658888.

California Emergency Driving Emblem Receive a free California physician emergency driving emblem and additional emblems discounted at $10. Contact SDCMS at (858) 565-8888.

Hertz Discounts Save up to 15% on daily Hertz car rental rates. Special international discounts are also available. Visit www.Hertz.com or call Hertz at (800) 654-2200. Frequent traveler miles and bonus points may be earned for qualifying rentals. An SDCMS-CMA members-only code is needed to take advantage of this discount — email MGonzalez@SDCMS.org to receive your code.

Local, State, and Federal Physician Advocacy SDCMS and CMA continue to be vigilant in our protection of MICRA, in fighting against non-physician scope of practice expansions, in working closely with our political representatives and other healthcare stakeholders to fix our broken healthcare financing system, and in doing everything we need to do to protect physicians’ interests wherever they are challenged.

Contact SDCMS at (858) 5658888.

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

Full-time SDCMS Office Manager Advocate Let your office manager and staff know that they have a full-time office manager advocate on staff at SDCMS ready to help them with any questions they may have, free of charge. Contact Lauren Wendler at (858) 3002782 or at LWendler@SDCMS.org.

SDCMS News Alerts Stay informed of the news that affects your bottom line and your patients’ health with faxed and emailed alerts sent by SDCMS to you, free of charge … and free of advertising! Contact SDCMS at (858) 565-8888.

SDCMS and CMA Websites Access members-only SDCMS and CMA websites to find valuable resources, such as a list of San Diego County physician NPIs, updated weekly. Contact SDCMS at (858) 565-8888.

Engagement in Healthcare Issues Be part of the solution! Become

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residents receive a 50% discount.

Contact Epocrates at (800) 2302150 or visit www.cmanet.org.

CMA ON-CALL Documents You can access, free of charge, thousands of pages of medical-legal, regulatory, and reimbursement information, through CMA’s online library.

Contact CMA at (415) 882-5144, at legalinfo@cmanet.org, or visit www.cmanet.org.

CMA’s Weekly Newsletter, “Alert” Delivered directly to you, free of charge, via email or fax. Contact Katherine Gallia at CMA at (916) 551-2074 or at kgallia@cmanet. org.

Free CMA Reimbursement Hotline (888) 401-5911

SDCMS Other

Member Benefits See Page 39 for a Listing of Our Endorsed Partner Benefits

Auto Insurance Along with your spouse, receive 4.5–14% discounts on all lines of coverage from the Automobile Club of Southern California.

Contact SDCMS at (858) 5658888.

HIPAA Compliance Receive a discount on a complete, do-it-yourself HIPAA privacy and security compliance toolkit (CD ROM). Call David Ginsberg at PrivaPlan at (877) 218-7707.

Epocrates Clinical Reference Guides Receive a 30% discount off of a one-year subscription and a 35% discount off of a two-year subscription to Epocrates’ clinical reference guides. Students and

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Free CMA Legal Hotline (415) 882-5144 Free CMA Legislative Hotline (866) 462-2819 Free CMA Physician Confidential Line A 24-hour phone service for physicians, dentists, medical students, residents, and their families and colleagues who may have an alcohol or other chemical dependence or mental/behavioral problem. Completely confidential.

Using it will not result in any form of disciplinary action or referral to any disciplinary body. Call (213) 383-2691.

Do You Know of Any Other Physician Volunteer Opportunities?

JOIN

SDCMS

online today!

www.SDCMS.org

If you know of any other volunteer opportunities for physicians in San Diego County, elsewhere in California or across the United States, or anywhere else in the world, please email that information to Editor@SDCMS.org.

SDCMS will publish all physician volunteer opportunities free of charge on our website at SDCMS.org.

Classifieds OFFICE SPACE SPACE FOR LEASE: Beautiful office space available for lease in a booming location — located just outside of downtown San Diego, with ocean views, and a beautiful skyline. The space available includes two exam rooms and a physician’s office. Common areas include a third exam room for overflow, a lobby, kitchen, chart room, storage, front desk, and nurse station. The practice is fully equipped and fully staffed. Includes an EMR system, which means this is a paperless office!

The staff is very friendly, and the office manager extremely experienced. New doctor may choose to join the team or practice solo. This is a family practice, but the team also includes a PT chiropractor and podiatrist. Please contact info@ promed-financial.com or (888) 277-6633 for details. [692]

NEW MEDICAL BUILDING ALONG I-15: Pinnacle Medical Plaza is a new 80,000 SF building recently completed off Scripps Poway Parkway. The location is perfect for serving patients along the I-15 from Mira Mesa to Rancho Bernardo and reaches west with easy access to Highway 56. Suites are available from 1,000—11,000 SF and will be improved to meet exact requirements. A generous improvement allowance is provided.

build to suit, and competitive rates with tenant incentives. Ideal for sole practitioners. 1,000ft2 suite with private entrance or 700ft2 within the clinic. Ample onsite parking, public transportation nearby. Visit website at 2475 South Avenue A http://info.svn.com/Dottie.Surdi. Direct inquiries to (858) 349-2007 or dottie.surdi@svn.com.

[685] SUITES FOR LEASE, MISSION VALLEY PROFESSIONAL MEDICAL/OFFICE BUILDING: Prime location, build to suit, and competitive rates with tenant incentives make this a fabulous value. Suites approximately 1,000ft2. At RT 15 and RT 8, just minutes from six major hospitals. Ample parking. Easy freeway access and public transportation nearby. Visit website for Riverview Center, 3633 Camino del Rio South at http://lease.svn. com/3633Camino. Direct inquiries to (858) 3492007 or dottie.surdi@svn.com. [684] POWAY OFFICE SPACE TO SUBLET: Newly remodeled, 3,000ft2 office space to sublet. Ground level, high-end medical office building with easy access from both the 56 and 15. Separate administrative space with possible procedure room available. Please contact (858) 668-6502 or hsears@ sdcpms.com. [683] OFFICE SPACE TO SHARE: Low-volume family medicine physician has space to share in his 1000ft2 office at 285 N. El Camino Real in Encinitas. Can reserve as little as one half-day per week.

Please call or email Marty at (760) 436-7464 or at mschulman@ucsd.edu. [682]

For information, contact Ed Muna at 619-702-5655, ed@lankfordsd.com; www.pinnaclemedicalplaza.com

Leasing, Renewals & Sales: OFFICE AVAILABLE ON SCRIPPS ENCINITAS LOT: In desirable building on Scripps Encinitas lot. Share elegant office that has just undergone complete interior designer renovation. Includes doctor’s desk, your own exam room, front desk, common waiting area, staff bathroom including shower, and kitchen. Contact us at San Diego Vein Institute at (760) 944-9263. [688] MEDICAL OR PROFESSIONAL OFFICE SUITES FOR LEASE, EL CENTRO, CA: In historic downtown area, near County offices, courthouse, and El Centro Regional Medical Center. Prime location; build to suit, and competitive rates with tenant incentives. 6,000ft2 can be divided; with private entrances. Near I-8 and public transportation with ample parking. Visit website for 441 West State Street at http://info.svn.com/Dottie.Surdi. Direct inquiries to (858) 349-2007 or dottie.surdi@svn. com. [686] MEDICAL OR PROFESSIONAL OFFICE SUITES FOR LEASE, YUMA AZ: Directly across from new Yuma Regional Medical Center. Prime location;

Call the Healthcare Real Estate Specialists at Colliers International for a complete inventory of all available medical office space for lease or for sale in your area, or for valuable vacancy and absorption information. Use our knowledge and expertise to help you negotiate a new lease, renewal, or purchase to assure you obtain the best possible terms. There is no charge for our consulting services.

Contact Chris Ross at 858.677.5329; email chris.ross@colliers.com.

HILLCREST MEDICAL OFFICE ACROSS FROM SCRIPPS MERCY HOSPITAL: Office sublet available in the Mercy Medical Building directly across from Scripps Mercy Hospital. Great space for an adult primary care or a specialist. First floor, excellent staff, T1 line, EHR capable, voicemail, website, and more! Call for more information and a tour: (619) 205-1480. [674]

OFFICE SPACE FOR LEASE: Hillcrest, Mercy Medical Building (4060 Fourth Ave., 6th floor).

1947 usable square feet, consisting of four exam rooms, one large OR-style procedure room, two business offices, large waiting area, and small lab area. Beautiful views of San Diego. Copious shelves for medical files. Reception counter. T1 capability, and 220 volt outlet. Please call (858) 361-7300 or the onsite building manager at (619) 293-3081. Available by the end of January 2009.

[671] OFFICE SPACE TO SHARE: Currently occupied by orthopedic surgeon situated in La Mesa. Five minutes away from Alvarado Hospital and 10 minutes from Grossmont Hospital. Looking to share with part-time or full-time physician. Fully furnished, fully equipped, with X-ray equipment and three exam rooms. Please call (619) 668-0900 or email either rcham1000@aol.com or carmen@ drcham.com. [666] LA JOLLA OFFICE SPACE AVAILABLE AT XIMED MEDICAL BUILDING: Brand new, renovated office space available, preferably to a primary care MD to share. This is a rare opportunity to have a presence at the prestigious XiMed Medical Building right next to Scripps Memorial Hospital and to reduce your overhead by sharing space. Currently, the office is being used by a single physician part of the time. Flexible to any arrangement proposed. Call (858) 837-1540 or email melkurtulus@hotmail.com. [664] MEDICAL OFFICE SPACE FOR LEASE IN ENCINITAS: Available August 2009. Share space with established physician-owner. Office located in new LEED-certified professional office development on Encinitas Blvd., close to 5 freeway, Scripps Hospital, and public transportation. Free parking, private bathroom, front desk area, and additional storage space included. One to two offices 11x14 are available full or part time. Affordable lease rate in desirable area. Contact Wendy Khentigan, MD, at (760) 845-0434 or at wendykmd@aol.com. [646] ACROSS FROM SHARP CHILDREN’S HOSPITAL: Beautifully furnished, fully equipped 2,000ft2 office with five exam rooms. Share with a part-time physician. Please call (619) 823-8111 or (858) 279-8111. [385] MEDICAL OFFICE SPACE (SCRIPPS ENCINITAS CAMPUS): OB/GYN-type consultation room and one to two exam rooms with staff, receptionist, etc. Equipment is available at extra cost. Surgical center next door. Free parking. Perfect for low-volume hospital campus consultations one to five half-days per week. Email sbrooksreceptionist@yahoo.com or call (760) 753-8413. [557] OFFICE SPACE AVAILABLE: Office space at the corner of 8th Ave. and Washington St. in Hillcrest.

Surgical center in building. Ample parking and simple freeway access. Close proximity to Scripps

To submit a classified ad, email Kyle Lewis at KLewis@SDCMS.org. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $250 (100-word limit) per ad per month of insertion.

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Mercy Hospital. Call (619) 297-6100 or email rbraun@handsrus.com. [555] Newly remodeled corner building in Hillcrest (1295 University Ave, 2nd floor): Flexible space between 300 and 10,000ft2, space can be configured according to requirements, front offices have large windows overlooking University Avenue. Covered, secured parking, two elevators, granite flooring in the entrance, staircase, and elevators; ADA bathrooms and electric doors. Near major hospitals, freeway 163, public transportation and Ralphs shopping center. Generous tenant improvement allowances possible with long-term lease. Lease terms and rent negotiable. Available April 2009. Please call (858) 212-4562 or email samimi9@gmail.com for more information. [689] PHYSICIAN POSITIONS AVAILABLE OB/GYN: Well-established, busy OB/GYN practice next door to Mary Birch Women’s Hospital needs part-time associate with option to transition to full time. Inquires (858) 560-6200. [687] PRIMARY CARE PHYSICIAN FOR VETERANS HOME CHULA VISTA: The Veterans Home Chula Vista is currently seeking an additional primary care physician to provide medical care for veterans. The Veterans Home Chula Vista is a multicare level facility with capacity for 400 residents consisting of three independent living retirement units with 165 beds; a Residential Care Facility for the Elderly (RCFE) assisted living unit with 55 beds; and a Skilled Nursing Facility (SNF) with 180 beds. The tentative start date is July 2009. This position requires experience in adult primary care medicine and preferably long-term care medicine.

If you are interested in a career with our agency, please contact Paul Wagner, MD, at paul.wagner@ cdva.ca.gov. [680] SENIOR PHYSICIAN, HIV/STD/HEPATITIS BRANCH, COUNTY OF SAN DIEGO: Are you looking for a rewarding career that spans individual patient care and county-wide public health program development? As the medical director of the County STD clinic that provides HIV screening, diagnosis and treatment for sexually transmitted diseases, and hepatitis immunization, the Senior Physician manages a team responsible for providing excellence in clinical services. We are looking for a candidate who has strong leadership skills and the ability to work collaboratively with team members. Functional application of data, aptitude with technical writing and the desire to build bridges in the community are also desirable skills.

We require a license to practice medicine in the State of California and at least three (3) years of post-internship training. Particularly suitable is a background in Internal Medicine, Family Practice, Ob-Gyn, Urology or Infectious Diseases. Please be aware that availability to work flexible schedules at multiple sites, including some evenings, is expected. If you meet the above, we are interested in YOU! Please visit www.sdcounty.ca.gov/hr to file an application. [675]

MOONLIGHTING PSYCHIATRIST WANTED: Flexible 1+ weekends/month at Pomerado Inpatient Geropsychiatric Unit. Must be board eligible or board certified. $200+/hr. Contact Jason Keri, MD, at (619) 299-4374. [676]

PART-TIME PA OR NP: Small family practice in Chula Vista, two blocks north of Scripps Chula Vista Hospital, is seeking a bilingual PA or NP for part-time employment. Please call Drs. Jenkin or Tetteh if interested at (619) 804-7252. [669]

PT/FT PSYCHIATRIST WANTED: To join respected multi-specialty group serving nursing homes. Office and hospital optional. Partnership and growth opportunities. Highly flexible schedule. $180k+. Contact Jason Keri, MD, at (619) 2994374. [677]

REGISTERED NURSE (RN): Family medicine office in Torrey Hills seeking a full-time, experienced RN. Previous clinical experience required. Salary and benefits are negotiable. Please call (858) 350-8100 or email résumé to admin@torreyhillsfamilymedicine.com. [577]

PART-TIME RESEARCH PHYSICIAN: Profil Institute for Clinical Research, an independent carbohydrate metabolism research institute, is seeking a part-time (4pm – 8pm) research physician to supervise clinical studies. Candidate should be trained in internal medicine (fellowship in endocrinology preferred) and have practice experience in diabetes management or a clinical research background in metabolism. Unrestricted medical license required (CA preferred). Email resumes to hrpicr@profil-research.com. Visit www.profilresearch.com for further information. [670]

PART-TIME MEDICAL ASSISTANT/BACK OFFICE: Two years experience required including phlebotomy. Busy specialist office near Alvarado Hospital. Submit résumés via email to dlpotter22@hotmail.com. [576]

INTERNAL MEDICINE PRIVATE PRACTICE, UNUSUAL FLEXIBILITY, UNIQUE OPPORTUNITY: North San Diego County, part-time position, looking for board-certified internist. If interested, please call (619) 248-2324. [668] NEUROLOGY POSITION: Position available immediately for board-certified/board-eligible neurologist in Mission Valley. Experience with forensics or workers’ compensation preferred. Physician must go out on medical leave and needs coverage. This is a very busy practice that does include some pain management. Currently we have an MD with musculoskeletal experience (fellowship at UCLA in acupuncture) and foreign graduate MD serving as PA to assist with practice. Position has potential to evolve into permanent position or partnership depending upon compatibility issues. Respond to dovemd@sbcglobal.net for further details. [667] KAISER PERMANENTE — CARDIOLOGY EPS OPPORTUNITY: At Kaiser Permanente Southern California, we believe our achievements are best measured by the health and wellness of the community we serve. That’s why we provide a fully integrated system of care guided by values such as integrity, quality, service, and, of course, results. If you would like to work with an organization that gives you the tools, resources, and freedom you need to get the best outcomes possible for your patients, come to Kaiser Permanente.

For consideration, please forward your CV to: Bettina.X.Virtusio@kp.org or call Bettina at (800) 541-7946. We are an AAP/EEO employer. http:// physiciancareers.kp.org/scal. [665] NONPHYSICIAN POSITIONS AVAILABLE MEDICAL ASSISTANT/BACK OFFICE: Busy OB/GYN practice needs experienced MA to start 08/09. Competitive wage and benefits. Spanish a plus but not required. Fax resume to (619) 2984250. [673]

M a r ch

PHYSICIAN POSITIONS WANTED MD SEEKING PART-TIME EMPLOYMENT: Elderly MD in North San Diego with prior legal, weight, etc., experience seeking part-time employment.

Call (949) 492-0198. [651] PRACTICES FOR SALE FAMILY PRACTICE FOR SALE — NORTH COUNTY COASTAL:Solo practice, established 15 years with strong patient base. Beautiful beach community. Excellent lifestyle. No HMO, no ER call. Call (760) 809-2390. Email wlljkd5@aol.com. [679] DEL MAR-AREA GENERAL PRACTICE: Prime location, huge potential for practice expansion in fast growing Carmel Valley community. Established in 1990; terms available. Inquiries call (858) 755-0510. [185] MEDICAL EQUIPMENT MEDICAL EQUIPMENT FOR SALE: Contour operating table, plastic surgery components, now Dexta surgical. Perfect for oral surgery, plastic surgery, ENT dermatology. Built in mayo stands, monitor brackets, equipment brackets, power foot controls, arm boards, head rest, Burton surgical light, heavy duty casters, table lock, auto trendelenberg, dual back rest position controls, articulating back. A mobile operating room! Contact Keith Wahl, MD, at kwahl@san.rr.com or on cellular at (858) 518-2190. [681]

Place your advertisement here Contact Dari Pebdani at 858-231-1231 or DPebdani@sdcms.org

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Creative Writing

By Michael Goldman

To Dylan Thomas

A Sonet, By Steven Ngai, MS III “Do not go gentle” — so the verse will say: To rage and buck against that coming night Whose baleful tread has never turned away, Nor ever failed to claim the mortal fight.

Invocation Delivered at CMA’s 2008 Annual Session (Oct. 4 in Sacramento)

And thus in abject failure ends each day, The fiercely raging, thinking he is right, But dies amidst chaotic disarray With eyes subdued that could have been so bright.

If he had ceded worldly stakes to pray, And fearless, weighed his soul’s impending flight — Then, liberated by his brave survey, Gained peace to see the day’s declining light.

For rage against the night that’s soon begun But clouds the beauty of the setting sun.

Autumn in San Diego

By Dewan-Syed Adnan Majid, MS I

Weeks ago on the eve of the Ninth Month, I stood upon the sandy beach alone and waiting to greet the ruddy dusk as it approached me.

W

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hen speaking to a large group of people, I am sensitive to the various faith traditions represented, as well as to those who may not have any religious traditions. Consequently, rather than praying “to whom it may concern,” I ask you to go to that special place from which you seek strength when things are difficult as well as express gratitude when life is generous … and place it here, on the altar in your heart.

er, a spouse, or a loved one … someone no different than you and those you love.

May you always see each patient as an individual person with wants and needs far beyond disease.

May you always be worthy of the gifts of trust from those who seek your care.

May you seek excellence in all aspects of your profession, trusting in a higher wisdom.

Amen

ay your patients know that they are in M a place of compassionate healing.

May they feel cared for by loving hands and open hearts.

May they always feel seen and heard in this place.

May they find even greater strength because their prayers are linked with yours.

May you always see in every face a moth-

A b o u t t h e A u t h o r : After 35 years of employment at CMA, Mr. Goldman retired from his position as senior vice president. Currently, he serves as a chaplain associated with San Francisco General Hospital’s Sojourn Multi-faith Chaplaincy, as well as in the San Francisco County jail hospital’s medical/surgical and psychiatric units.

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I wasn’t looking for any overt sign nor expecting the slither of a new-born moon to pursue the sun for slumber below the roaring purple waves.

I couldn’t really tell what I sought but flung the sand from upon my shoes and watched the sea race up then flee to leave upon on the moistened shore a evanescent chain of foam.

I’ve never numbered my slips and falls, or spent time counting all those foams or grains of sand that built the earth beneath my feet.

And were the trees but wooden pens and the oceans, their blackest ink, I’d never complete the books they’d fill or recite each word addressed to me.

Under the banner of a violet sky, my face in rest upon the grass, I knew of no one as loved as I, and left to climb the towering hills — left behind the weights I bore — having found what I came looking for.

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