July 2009 by San Diego Physician

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

ethics in medicine

reflections on leaving san diego P.6 interview with nick macchione, HHSA director P.16 commercial credit is available P.20 “ P H Y S I C I A N S U N I T E D F O R A H E A LT H Y S A N D I E G O ”

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Contents VOL. 96 | NO. 7

ethics in medicine

22 • SDCMS Bioethics Commission Model Policy on “Non-beneficial Treatment” 24 • Approaching Ventilator Withdrawl When Survival Is Not Expected 28 • With Liberty and Justice for All: Reflections on the Ethics of Access to Care 32 • Ethical Considerations in Pandemics 36 • Challenging Symptoms? Expert Advice: New Palliative Medicine Resource Hotline 38 • Myrtle’s Story: A Bioethics Case Study 39 • Physician Orders for Life-Sustaining Treatment (POLST) Form

[Departments]

4 6 8 10 12 16 2

18 20 37 42 44

Contributors

This Issue’s Contributing Writers

Editor’s Column

Reflections on Leaving San Diego

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

Nick Macchione, Director, HHSA, County of San Diego

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public health

You’ve Reported a Disease to Public Health; What Happens Next?

Practice management Commercial Credit Is Available

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With SDCMSF’s Project Access San Diego

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Our Knowledge is your Property

Contributors Ellen Beck, MD Dr. Beck, SDCMS and CMA member since 2004 and a family physician, is the director of community education at the UC San Diego School of Medicine and the founder of, and adviser to, the UCSD Student-Run Free Clinic Project.

Committee, and chairs Kaiser Permanente’s Institutional End-of-Life Committee. Laurel H. Herbst, MD Dr. Herbst, SDCMS and CMA member since 1990, is chief medical officer and vice president of medical affairs at San Diego Hospice and The Institute for Palliative Medicine. Dr. Herbst can be reached at lherbst@ sdhospice.org.

Lynette Cederquist, MD Dr. Cederquist, SDCMS and CMA member since 2005, co-chairs SDCMS’ Bioethics Commission along with Paula Goodman-Crews. Dr. Cederquist is as well clinical professor of medicine at UC San Diego, chairs UCSD’s Ethics Committee, and is associate medical director of Silverado Hospice.

Steven Oppenheim, MD Dr. Oppenheim, SDCMS and CMA member since 2001, is clinical medical director and chair of the Institutional Review Board at San Diego Hospice and The Institute for Palliative Medicine. Dr. Oppenheim can be reached at soppenheim@sdhospice.org.

Michele Ginsberg, MD Dr. Ginsberg is the chief of the Community Epidemiology Branch in the Public Health Services Division of the Health and Human Services Agency for the County of San Diego. The Branch includes Public Health Laboratory and Vital Records. Dr. Ginsberg is a voluntary clinical professor of medicine at UCSD and adjunct faculty at the SDSU School of Public Health.

Benjamin Pimentel Mr. Pimentel, who has a long history of providing financing and cash management business solutions to business owners and executives, is a relationship manager at Torrey Pines Bank. Joseph E. Scherger, MD, MPH Dr. Scherger, SDCMS and CMA member since 2003, is clinical professor of family medicine at UCSD. He is also vice president for primary care at Eisenhower Medical Center in Rancho Mirage, Calif. Dr. Scherger, along with editing San Diego Physician, is chair of the SDCMS Communications Committee.

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. Paula Goodman-Crews, MSW, LCSW Ms. Goodman-Crews is a licensed clinical social worker by training and a bioethics consultant. She has worked for over 25 years in the healthcare arena and presently co-chairs SDCMS’ Bioethics Commission, the Kaiser Permanente San Diego Bioethics

Brian Snyder, MD Dr. Snyder is associate clinical professor in the Department of Emergency Medicine at UC San Diego Medical Center. He serves on the UCSD Medical Ethics Committee and performs ethics consultations. ✚

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

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Editor Joseph E. Scherger, MD, MPH Managing Editor Kyle Lewis Editorial Board Van Chang, MD, Adam Dorin, MD, Robert Peters, MD, PhD, David Priver, MD, Roderick Rapier, MD, Joseph E. Scherger, MD, MPH Marketing & Production Manager Jennifer Rohr Sales Director Dari Pebdani Project Designer Lisa Williams Copy Editor Adam Elder SDCMS Board of Directors Officers President Lisa S. Miller, MD Immediate Past President Stuart A. Cohen, MD, MPH President-elect Susan Kaweski, MD Treasurer Robert E. Wailes, MD Secretary Sherry L. Franklin, MD geographic directors East County William T. Tseng, MD, Heywood “Woody” Zeidman, MD Hillcrest Roneet Lev, MD, Thomas V. McAfee, MD Kearny Mesa Adam F. Dorin, MD, John G. Lane, MD La Jolla J. Steven Poceta, MD, Wayne Sun, MD North County Arthur “Tony” Blain, MD, Douglas Fenton, MD, James H. Schultz, MD South Bay Vimal I. Nanavati, MD, Anna Sanchez Seydel, MD At-large Directors John W. Allen, MD, David E.M. Bazzo, MD, V. Paul Kater, MD, Jeffrey O. Leach, MD, Mihir Parikh, MD, Robert E. Peters, MD, PhD, David M. Priver, MD Communications Chair Theodore M. Mazer, MD Young Physician Director Kimberly Lovett, MD Retired Physician Director Glenn Kellogg, MD Medical Student Director Jane Bugea CMA Trustees Theodore M. Mazer, MD, Albert Ray, MD, Robert E. Wailes, MD, Catherine D. Moore, MD, Diana Shiba, MD AMA Delegates Robert E. Hertzka, MD, James T. Hay, MD AMA Alternate Delegates Albert Ray, MD Lisa S. Miller, MD Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org. All advertising inquiries can be sent to cpinfo@sandiegomag.com. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

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Editor’s Column By Joseph E. Scherger, MD, MPH

Reflections on Leaving San Diego

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an Diego is a very special medical community. The problems that seem to plague other communities are rare here. We have physicians in medical groups of all sizes who get along with each other. We have one of the top medical school faculties in the country that integrates well with community physicians. We have large and powerful health systems that compete for market share, yet the physicians among them are colleagues. Maybe it is our nice weather or relaxed atmosphere, but San Diego County physicians mostly blend with each other in agreeable partnership. We are physicians united for a healthy San Diego. It has been my great privilege for the past three and a half years to serve as editor of San Diego Physician and as your Communications Committee chair for SDCMS. Representing you to the public has been fun and challenging. I receive nothing but positive feedback for my editorials, even when I challenge the status quo. I like to be provocative, to push the envelope, to embrace the future over the present, yet in San Diego I never get the animosity I sometimes receive when I speak or publish elsewhere. This summer I am taking a new position that moves my professional work out of San Diego County. By the time you read this, I will be at Eisenhower Medical Center in Rancho Mirage as vice president for primary care. I will be launching a new, personalized medical home primary care practice in La Quinta that may become a model for the region. I will get to “walk the walk” about practice redesign that I have published in San Diego Physician. I will also be the academic officer guiding the development of a new, regional medical education campus with residency training in family medicine, internal medicine, and a fellowship in geriatrics. These specialties are in short supply and in great need, yet few are choosing them. We plan to help change that by developing an attractive and well-compensated model of practice that emphasizes care coordination outside of visits, and the use of health information technology (HIT), including secure, online communication. The practice of medicine has entered a period of rapid change. The traditional appointment-based delivery system does not meet today’s expectations of “on-demand” service and the ability to improve the health of whole populations. Like other service industries in this new information

age, new models of care are emerging. In general, medical groups in San Diego have been slow to change. Most large and small practices have yet to implement advanced information systems and online communication and care. Kaiser has made the transition with its new HealthConnect platform, and more than 500,000 people in San Diego County are experiencing that. UC San Diego has also moved forward with its MyChart application of the Epic record system. Some small practices have implemented advanced HIT and online communication, but most have not. This is understandable since, nationwide, HIT application is still less than 30 percent. With the new HITECH funding from the Obama administration, $44,000 per physician, this is likely to change quickly over the next three to five years. The San Diego County Medical Society (SDCMS) stands out among the medical societies in California as being proactive and aggressive in helping physicians adjust to change. Organized medicine has a reputation for staunchly defending the status quo. Sometimes this is important, but when inevitable change is happening, SDCMS helps physicians rather than fight futile battles.

It has been my honor and pleasure to serve you these past three and a half years. I am not really leaving San Diego. We are keeping our home here and will return on weekends. Not a bad life to have a home in San Diego and one in Palm Desert. I welcome any of you to visit Eisenhower Medical Center and see what we are doing. I will continue as a volunteer clinical professor at UCSD, so I may be reached at: jscherger@ ucsd.edu or jscherger@emc.org. It has been my honor and pleasure to serve you these past three and a half years. ✚ About t he Aut ho r : Dr. Scherger is clinical professor of family medicine at UC San Diego. He is also vice president for primary care at Eisenhower Medical Center in Rancho Mirage, Calif. This is Dr. Scherger’s last issue as editor of San Diego Physician.

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If you know of any volunteer opportunities for physicians in San Diego County, California, across the United States, or anywhere else in the world, please email the information to Editor@SDCMS.org. SDCMS will publish all physician volunteer opportunities free of charge on our website at SDCMS.org.

SAN DIEGO P H Y SICIAN . o r g

SDCMS Members-only Benefits

2009

Seminars and Events

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.

July 9 Thursday 11:30am – 12:30pm SDCMSF Project Access San Diego (PASD) Training 22 Wednesday 6:30pm – 7:30pm Risk Management Webinar “Who Can Be Told What? Communicating in a HIPAA World” 23 Thursday 11:30am – 12:30pm Risk Management Webinar “Who Can Be Told What? Communicating in a HIPAA World”

August 12 Wednesday 11:30am – 1:00pm Regulations Seminar/Webinar “OSHA Updates”

October 15 Thursday 11:30am – 1:00pm Financial Issues Seminar/ Webinar“10 Strategies for Economic Survival”

SAN DIEGO P H Y SICIAN . o r g

23, 30 & Nov. 6, 13, 20 Five Fridays 8:00am – 4:00pm Certified Medical Coder (CMC) Course “Become a Certified Medical Coder in Five Days!” (Upon Successful Completion of Exam)

November 14 Saturday 8:30am – 3:30pm Resident and New Physician Seminar “Preparing to Practice: What You Need to Know BEFORE You Begin Your Practice” 18 Wednesday 6:30pm – 7:30pm Risk Management Webinar “Electronic Health Records: Are you ready?” 19 Thursday 11:30am – 12:30pm Risk Management Webinar “Electronic Health Records: Are you ready?”

Watch Previous SDCMS Seminars Online Now!

Available to Members at SDCMS.org SDCMS Member Physicians and Staff: Don’t forget that you can view all previous SDCMS seminars online whenever you like. Seminars currently available for viewing include: • “Managing Your Contracts: A Focus on Payor Contracting (2009.06.25) • “Getting Paid: Maximize Your Cash Flow” (2009.06.25) • “Keep Your Legal *** Out of Trouble” (2009.06.19) • “Best Practices in Revenue Cycle Management” (2009.05.07) • “How to Handle Legal Notices: Summons, NOIs, and Subpoenas” (2009.04.23) • “The Red Flags Rule: Keeping It Simple” (2009.04.22) • “What the Health Is Happening in Washington, DC, and Sacramento” (2009.04.20) • “Dealing With Problem Employees: How to Get the Best of Your Team” (2009.04.16) • “The Patient-centered Medical Home” (2009.04.09) • Coding Seminar: Optimize Compliance and Reimbursement (2009.02.18) • Contract Negotiations Seminar: Contract Negotiations for Medical Office Managers (2009.02.12) • Contract Negotiations Seminar: “Work Smarter, Not Harder: Health Plan Contracting Savvy for Physicians” (2009.02.11) • “ Coding to Optimize Compliance and Reimbursement” (2009.02.19) • Marketing Seminar: “Practical Practice Marketing: How to Attract and Keep the Best Patients” (2009.01.28)

• “Medicare Update 2009” (2009.01.21) • E-prescribing for Dummies (2009.01.20) • Collections Seminar: “Top 10 Procedures to Cover Your Assets: Collections” (2009.01.01) • Electronic Medical Records (2008.11.20) • Sexual Harassment (2008.10.15) • E-prescribing: Facts and Myths (2008.10.09) • Medicare Transition to Palmetto Seminar (2008.08.21) • Hospital Medical Staff Leadership Seminar (2008.08.15) • Best Practices for Disciplinary Procedures and Terminations (2008.05.22) •P reparing to Practice (2008.04.19) • 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) • OSHA for Dummies (filmed January 29, 2008) • Frightening Times, Risky Conversations: Handling Disclosure (filmed January 23, 2008) • Joe Dunn Hospital Hop (filmed March 23, 2007)

For assistance in locating a seminar or in logging into SDCMS’ website, please contact Kyle Lewis at (858) 3002784 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! ✚

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SAN DIEGO P H Y SICIAN . o r g

Community Healthcare Calendar To submit a community healthcare event for possible magazine and website publication, email KLewis@SDCMS.org. All events should be physician-focused and should take place in San Diego County.

Riverside County Medical Association’s 5th Annual “Cruisin’ Thru CME” (Eastern Mediterranean)

American Academy of Urgent Care Medicine’s 2009 Urgent Care Medicine Conference

July 6–17. Call (800) 745-7545.

September 23–25. Visit www.aaucm.org.

San Diegans for Health Care Coverage (SDHCC) Forum on Health Reform

4th Annual Clinical Update on Heart Failures and Arrhythmias: From Prevention to Cure

July 17. Email Kamal Muilenburg at kmuilenburg@sdbhc.org.

October 17–18 at the Hilton La Jolla Torrey Pines. Visit www.scripps.org/conferenceservices.

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. July 25–26, September 12–13, and November 7–8 at the Center for Surgery of Encinitas. Visit www. freshstart.org.

26th Annual Primary Care Summer Conference August 7–9 at the Paradise Point Resort, San Diego. Visit www.scripps.org/ conferenceservices.

New Advances in Inflammatory Bowel Disease September 12 at the Hilton San Diego Resort, San Diego. Visit www.scripps. org/conferenceservices.

9th Annual Destination Health: Renewing Mind, Body, and Soul October 18–23 at the Marriott Kauai Resort, Kauai, Hawaii. Visit www.scripps. org/conferenceservices.

20th Annual Coronary Interventions October 28–30 at the Hilton La Jolla Torrey Pines. Visit www.scripps.org/ health-education.

2009 San Diego Day of Trauma October 30 at the Joan B. Kroc Institute for Peace and Justice, USD. Visit www. scripps.org/conferenceservices.

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, San Diego. Contact (858) 534-3940 or ocme@ ucsd.edu.

New Developments and Best Practices in Colorectal Cancer Screening November 12 at the Admiral Baker Clubhouse (Presidio Room). Contact (858) 458-9439 or sbazzo@sandiegoafp.org.

Melanoma 2010: 20th Annual Cutaneous Malignancy Update January 16–17, 2010, at the Hilton San Diego Resort, San Diego. Visit www. scripps.org/conferenceservices.

7th Annual Natural Supplements: An Evidence-based Update January 21–24, 2010, at the Paradise Point Resort, San Diego. Visit www. scripps.org/conferenceservices.

Scripps Cancer Center’s 30th Annual Conference: Clinical Hematology and Oncology February 13–16, 2010, at the Omni San Diego Hotel. Visit www.scripps. org/conferenceservices. ✚

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TRUSTED PARTNER OF SDCMS

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hosen by more healthcare providers for our commitment to excellence and breadth of product knowledge, Alliant Healthcare Solutions offers custom-tailored services and products to meet the needs of any practice. Our highly skilled healthcare insurance professionals can deliver: Medical malpractice through our partnership with The Doctors Company ■■ Property and casualty ■■ Employee benefits ■■

For more than eight decades, Alliant Insurance Services has provided innovative and solutions-oriented programs and services for our clients. As the nation’s largest specialty insurance brokerage firm, Alliant Insurance Services has the experience and drive to meet the needs of SDCMS members.

Noted

Ask Your

Physician Advocate

By Marisol Gonzalez

Charging for Medical Record Copies Reporting Tuberculosis • Buying the CPLH

UESTION: I have a patient whom I saw for one visit. We made plans for further care, but they decided not to go through with the procedure. Now an attorney is requesting a copy of the patient’s medical record. Can I charge this attorney, or do I have to provide this record for free?

Your SDCMS Physician Advocate Has the Answers!

SAN DIEGO P H Y SICIAN . o r g

ANSWER: According to CMA ON-CALL document #1127 (“Attorney Pre-litigation Request for Medical Information”), “All reasonable costs incurred by the physician may be charged to the person whose written authorization required the availability

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of the record.” This includes: • Copying Costs: $0.10 per page for standard reproduction of documents of a size of 8½” x 14” or less, or $0.20 per page for records copied from microfilm, or actual costs for reproduction of oversize documents or those that require special processing, and … • Clerical Costs: Reasonable clerical costs incurred in locating and making the record available (clerical costs incurred in making the copies are included in the copying costs set forth above), billed at the maximum rate of $4 per ¼ hour, $16 per hour, and … • Postage Costs: Actual postage costs, and … • Retrieval Costs: Actual costs, if any, charged to you by a third person for retrieval and return of the record held by that third person, and … • Copying Service: If the record is to be produced at your place of business for either the attorney or the attorney’s representative to photocopy or inspect, you may collect a fee of no more than $15 plus actual costs, if any, charged to you by a third person for retrieval and return of the record held by that third person. The costs of the copy service are paid by the party seeking the record.

UESTION: I have a patient whom I’ve diagnosed with tuberculosis. What are my reporting obligations? ANSWER: In accordance with California regulations, all patients with suspected or confirmed active TB disease must be reported to San Diego County TB Control within 24 hours of initial suspicion. This can be done via The Tuberculosis Suspect Case Report form, which can be found on the County of San Diego’s Health and Human Services Agency’s website at www. sdcounty.ca.gov under “All Services A–Z.” Reporting forms may be faxed to (619) 692-5516 or the information can be called into (619) 692-8610.

UESTION: Our office would like to purchase the print version of the 2009 California Physician’s Legal Handbook (CPLH). Where can we purchase this, and how much is it? ANSWER: The California Physician’s Legal Handbook (CPLH) can be purchased via CMA’s website at www.cmanet.org. Mem-

bers can purchase the print version of the CPLH for $798. ✚ About t he Aut ho r : Ms. Gon-

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

Does Your Office Manager Have a Question Too? Lauren Wendler, your SDCMS office manager B of A_SDP_08:Layout 1 advocate, 10/9/08is on 2:38 PM 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.

Welcome New and Rejoining SDCMS-CMA Members! New Members Christen Marie Benke, DO Family Medicine San Diego (858) 793-2727

Sabiha Pasha, MD Hospice and Palliative Medicine San Diego

Frank Kevin Yoo, MD Neurological Surgery Poway (858) 485-8022

Thomas Laighton Carter, MD Internal Medicine La Jolla (858) 554-7225

Elise A. Reed, DO Psychiatry Vista (760) 941-6062

Farah Jalal Yousif, MD Internal Medicine San Diego

PageDerya 1 Jim Coskun, MD

Neurology Chula Vista (619) 421-6741

Eric Jeffrey Topol, MD Cardiovascular Disease La Jolla (858) 554-5279

Kathleen Anne Erwin, MD Psychiatry Encinitas (760) 635-5631

Amy Breckenridge Witman, MD Internal Medicine San Diego

Rejoining Member Aeron Dean Wickes, MD General Practice San Diego (858) 679-9262 ✚

Achieve your practice goals with Bank of America. At Bank of America, we earn our reputation by focusing on practices like yours. Whether you need to accelerate revenue, improve collections, or reduce your exposure to check fraud, we offer solutions designed to address your current and future challenges. Managing cash flow is an essential part of any healthcare practice. Let us address your financial needs so you can attend to those who matter most to your practice. Your patients. To learn more, contact your healthcare specialist/client manager: Katrin Engel San Diego 888.852.5000 ext. 8260 katrin.engel@bankofamerica.com Karen Turner North County 888.852.5000 ext. 8277 karen.turner@bankofamerica.com bankofamerica.com/healthcare12 ©2008 Bank of America Corporation.

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SAN DIEGO P H Y SICIAN . o r g

Noted Eric J. Topol, MD, Named Gary and Mary West Chair of Innovative Medicine

Happy Birthday SDCMS! July 19, 1870

What is ethics? … Ehrfurcht vor dem Leben, or “reverence for life,” according to Albert Schweiter (1875—1965)

Project Acccess

San Diego

he Gary and Mary West Foundation has made a $5 million endowment to Scripps Health to establish the Gary and Mary West Chair of Innovative Medicine. Eric J. Topol, MD, SDCMS and CMA member since 2009, chief academic officer of Scripps Health, and director of Scripps Translational Science Institute, has been named the inaugural chair. In addition, Dr. Topol has been appointed to the board of directors of the newly formed West Wireless Health Institute. “I am honored to be named as the Gary and Mary West Chair of Innovative Medicine,” says Dr. Eric J. Topol. “Through the development of wireless technologies, there is an extraordinary opportunity to change the future of medicine in an unprecedented way. As medicine focuses on digital technology and the use of wireless sensors to elegantly track individual patient data, the opportunities for better prevention and treatment are limitless.” Congratulations, Dr. Topol! Above: Mary and Gary West (standing) recently made a $5 million endowment to Scripps Health to establish the Gary and Mary West Chair of Innovative Medicine. Eric J. Topol, MD, (center) has been named the inaugural chair to support the advancement of wireless health. ✚

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Project Access is actively recruiting physicians, hospitals, and ancillary service providers to participate in our program. Together we can ensure that our vulnerable populations have access to needed healthcare services. Your commitment to Project Access is required for our success!

Please visit our website at SDCMSF.org to learn more and to sign up.

Get in Touch Your SDCMS and SDCMSF Support Teams Are Here to Help! SDCMS Contact Information Address: 5575 Ruffin Road, Suite 250, San Diego, CA 92123 Telephone: (858) 565-8888 Fax: (858) 569-1334 Email: SDCMS@SDCMS.org Website: SDCMS.org • SanDiegoPhysician.org CEO/Executive Director: Tom Gehring at (858) 565-8597 or at Gehring@SDCMS.org COO/CFO: James Beaubeaux at (858) 3002788 or at Beaubeaux@SDCMS.org Director of Membership Development: Janet Lockett at (858) 3002778 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 Director of Communications and Marketing: Kyle Lewis at (858) 300-2784 or at KLewis@SDCMS.org Specialty Society Advocate: Karen Dotson at (858) 300-2787 or at KDotson@ SDCMS.org Letters to the Editor: Editor@SDCMS.org General Suggestions: SuggestionBox@ SDCMS.org

Personal: • Income Tax Planning • Wealth Management • Financial Planning

Local: • Employee Benefit Plans • Profitability Reviews • Outsourced professional services (CFO, Controller)

Ron Mitchell, CPA Director of Health Services rmitchell@aktcpa.com 760-431-8440

Global: • Organizational Structure • Succession Planning • Internal Control Review and Risk Assessment

SDCMSF Contact Information Address: 5575 Ruffin Rd., Ste. 250, San Diego, CA 92123 Fax: (858) 560-0179 Executive Director: Kitty Bailey at (858) 300-2780 or KBailey@SDCMS.org Associate Executive Director: Tana Lorah at (858) 300-2779 or at TLorah@SDCMS.org Patient Care Manager: Barbara Rodriguez at (858) 300-2785 or at BRodriguez@ SDCMS.org Patient Care Manager: Brenda Salcedo at (858) 565-8161 or at BSalcedo@SDCMS.org Program Manager, Surgery Days: Alisha Mann at (858) 565-8156 or at AMann@ SDCMS.org Healthcare Access Manager: Lauren Radano at (858) 565-7930 or at LRadano@ SDCMS.org

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IEGO SAN D A LT H Y

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nOw P.9 P.16 l e Online S Viewabl e SCreening tOO SeMinar enC > SDCMS FaMily ViOl are P.18 nting a healthC > iMPleMe > ChineSe

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Contact Dari Pebdani at 858-231-1231 or dpebdani@sdcms.org

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SAN DIEGO P H Y SICIAN . o r g

Interview

Nick Macchione, MS, MPH, FACHE Director, San Diego County HHSA

San Diego Physician: You’ve been the director of the County’s Health and Human Services Agency since June 2008. Describe your vision for the Agency, where you’d like to be in two to five years. Nick Macchione: I spend a lot of time with my team talking about how the entire organization needs to grow and evolve in response to the rapidly changing healthcare environment. We talk about how the entire organization will be transformed with a new culture of doing business. For instance, we talk about how we can become more innovative and proactive in the way we serve our community, especially those who need it the most. I find these discussions extremely energizing for frontline staff, managers, and executives. It is also important to me to create an atmosphere of “buy-in” from the 5,700 people who work for this organization. To be successful across all our programs, each person in my organization should be passionate about the ways we directly and indirectly influence health. For example, I’m spending an enormous amount of time helping the employees that issue Medi-Cal or food stamp benefits realize they’re not just pushing an application; they’re part of an extended care team. They’re not just giving people money to buy something; they’re helping people get access to needed medical care. They’re influencing people’s health, which impacts our entire community. In addition, within the next several years I would like to see our community as a whole embrace the World Health Orga-

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nization’s definition of health, which encompasses the total person. Health is not the episodic, not just the physical piece or the mental piece, but rather the wellbeing of the total person. Part of embracing the broader definition of the total person’s health involves aligning services. It’s not just merging, for example, behavioral health and a new “physical health” department. My team will pursue a more holistic approach, and our innovation has the power to improve the health of thousands of people. To that end, we’re actively pursuing Healthy People 2010 and 2020. Our challenge is figuring out how we can best optimize our resources and talents — including our dedicated physicians, nurses, social workers, and eligibility workers — to improve the overall health, wellbeing, and self-sufficiency of children and families in San Diego County. For instance, we will work to leverage the resources of our social workers, eligibility workers, and our physicians, nurses, and community partners. We are looking to break down some of our departmental barriers so that everyone is on board with the same laser-like focus and priorities. That is my goal and our vision.

San Diego Physician: What specifically have you done to move the Agency in that direction? Macchione: It’s about constantly engaging staff to achieve a shared vision of total health. So, this past fall I held forums with about 120 mid- and high-level staff across the entire Agency to plan our health strategy agenda for the next 10 years. I reached within and outside the Agency to find a dozen top-notch visionaries and experts in the fields of medicine, public health, and behavioral health. Dr. Joe Scherger, who was the medical director of the County Medical Services (CMS) program, is a great example of both a visionary and an expert who spoke on the topic of care and treatment services. Dr. Scherger and the other experts provided timely information in their respective fields, from trends, historical perspectives, technology innovations, cutting-edge models, and future needs to meet the changing environment. Most importantly, they challenged our assumptions and provided valuable insights as to where the health field is heading. We listened to their wisdom and experience and gleaned some powerful advice to employ in our own strategic planning process. We all came back and said “OK, what does this

mean to us and our partners? What does it mean to our clients and community?” That process helped us begin to formulate some transformational goals. And so, more importantly than the transformational goals we’re pursuing, such as, the 3-4-50 initiative — smoking, diet, and exercise cause four major diseases and approximately 50 percent of deaths — more importantly than everything is creating a meaningful and everlasting organizational culture change. With the right attitude and beliefs, we will be able to achieve many of our goals, including improving the utilization of care by frequent-users and looking at how we shift more of our workforce to be a mobile, remote workforce — meaning literally in the field — to really augment the clinicians, the clinics, and the hospitals. I think if we can get all 5,700 strong to see that they’re part of something bigger and more meaningful than the routine, transactional work that they’re doing, we’ve created knowledge workers who care about making a difference in the lives of people. And so what we’re after, more than the metrics to me, is, have I done a good enough job in creating knowledge workers with the right balance of heart, mind, and guts? Those are the people that connect with our physician offices, our nurses, community clinics, hospitals, and other health community-based agencies. That’s what I’m trying to accomplish.

San Diego Physician: Have you looked at the spiritual side of the “total person’s” health? Macchione: If we’re talking about total health, we can’t lose sight of the importance of spiritual health. I’ve been talking with Vision San Diego and other members of the faith community about ways we can collaborate. It’s not about bringing religion into government, but rather how we address the health needs — physical, safety, and shelter needs — in addition to the spiritual needs of individuals in our community. I recently talked with about 100 representatives of the local faith community. In Biblical terms, there is a responsibility to assist those who have been marginalized. I think there is an incredible opportunity for us to partner in some respect. Both government and the faith community have a certain duty to assist the most vulnerable individuals among us. It’s wonderful that we have a new na-

tional focus for healthcare reform. Unfortunately, I think the focus has been predominately about access. Access is an onramp to the highway, but the highway is broken, and we have to repair the system as a whole. Access is a first step. To achieve overall system-wide change, we will continue looking for opportunities to partner with private, nonprofit, and faith-based organizations to improve the health of San Diegans. Together, we improve our ability to develop a more comprehensive and strategic approach to help those in our community who are suffering the most.

“Privileged to Provide Care and Clinical Research Since 1975”

The San Diego Arthritis Medical Clinic is a leading investigational site for the study and treatment of: Rheumatoid Arthritis Osteoarthritis Osteoporosis Fibromyalgia Low Back Pain Hip Pain Knee Pain Lupus Gout

San Diego Physician: What would you want every physician to know if you had five minutes with them? Macchione: First and most importantly, how much I and the entire Health and Human Services Agency appreciate what you, physicians, are doing in improving the health of our community. Next, I would like physicians to know that we’re ultimately on the same team. We’ve got to get away from the “badge syndrome.” We’ve got the government badge. We’ve got the private physician badge. We’ve got the CEO badge. There are lots of different badges that often get in the way of working together. We can’t lose sight of the fact that we’re on the same health team. We have to look beyond our titles and remember that none of us can stand alone. Patients and community residents are dependent on all of us, government, private physicians, dentists, clinics, and hospitals. We need to work together and break down the barriers that stand in the way of a cohesive, high-quality system of care. And yes, there are a lot of effective partnerships out there in our region. That certainly applies to our relationship with Tom and his entire team at the San Diego County Medical Society and all of its physician members. But if there was ever a time to fully optimize partnerships at every level of the health field, it’s right now. We have some serious challenges, but we can minimize or even overcome them together. What we need to rethink, as a health team, is how we provide the necessary quality care, and a holistic approach, in the face of the current economic crisis. It’s a huge challenge, and I think it’s a mistake to think that the federal government alone can solve this for us locally. We need to come together, move forward, and begin to address the healthcare needs of our community. ✚

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

619.287.1966 San Diego Arthritis Medical Clinic 3633 Camino del Rio South, 3rd Floor (1.7 mi east of Texas Street)

San Diego, CA 92108

Michael I. Keller, M.D., Director Puja Chitkara, M.D. Ara H. Dikranian, M.D. Oleg Gavrilyuk, M.D. G. Paul Ignat, M.D. Smitha Chiniga Reddy, M.D. Timothy F. Lazarek, N.P.

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

SAN DIEGO P H Y SICIAN . o r g

County Public Health Officer’s Update By Michele M. Ginsberg, MD

he Community Epidemiology Branch (CEB) provides services and investigates diseases of all people in San Diego County. Community Epidemiology includes the San Diego County Public Health Laboratory, Vital Records, HIV/AIDS Surveillance, and the Childhood Lead Prevention Program. There are many conditions that are, by law, reportable to the County of San Diego Public Health Services. Once a report is made to public health, the Community Epidemiology Branch’s job of responding, investigating, and intervening begins. Here are some highlights of recent activities following disease reports.

Surveillance of Enteric Pathogens in San Diego County Using Pulsed Field Gel Electrophoresis (PFGE) and PulseNet: What’s in My Peanut Butter?

You've Reported a Disease to Public Health What Happens Next?

Contributing Authors

Samantha Tweeten, PhD, MPH, Annie Kao, PhD, MPH, Diane Rexin, PHN, Robert Wester, MA, MPH, Lisa Yee, MPH

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PulseNet is the national molecular surveillance network for food-borne infections. Sub-typed information on bacterial foodborne pathogens is posted on a secure national web board. Analyzing PFGE data allows members to detect clusters of disease with probable common exposures over time and distance. The San Diego County Public Health Laboratory (SDC PHL) has been an active member of PulseNet USA since 2001. All cultures of E. coli O157:H7, Salmonella, Shigella, and Listeria submitted to the SDC PHL for identification or confirmation are routinely analyzed using PFGE; PFGE surveillance has resulted in increased recognition of food-borne outbreaks. In a 12-month period, 30 local clusters were detected by PFGE; among others, CEB investigated two large daycare clusters of Shigella sonnei involving 20 cases and affecting 150 children and their families. Twenty-five multistate outbreaks were identified with PFGE-matched cases from San Diego County. In November 2008, CEB and SDC PHL posted a cluster of 2 S. enterica Typhimurium isolates with an unusual pattern (Xbai PFGE pattern JPXX01.1818) to the web board. An epidemiologic assessment of this cluster by federal and state partners showed this pattern to be unique in the PulseNet database on the web board. Multiple jurisdictions began posting additional PFGE matches as cases confirmed with this out-

break strain increased in numbers nationally. Ultimately, two strains of S. enterica Typhimurium with similar PFGE patterns were determined to be the causative agents associated with 714 salmonellosis cases in 46 states (seven from San Diego County), epidemiologically linked with peanut butter-containing products.

The Graying of AIDS in San Diego County The proportion of AIDS cases aged 50 years and older diagnosed in San Diego County has increased over time; older AIDS cases now make up more than 19 percent of all those reported in the county, similar to the 20 percent reported nationwide. In recent years (2004–2008), these cases are more likely to be female; both male and female older cases are more likely to have heterosexual transmission than younger cases. While older cases are more likely to be white, they are less likely to be Hispanic than younger cases. Older people are being diagnosed with STDs at increasing frequency and use condoms less often in sexual encounters than younger persons. They are less likely to think of themselves at risk and seem to be less likely to be thought of as “at risk” by healthcare providers. Medications have increased the lifespan of older people diagnosed with HIV disease substantially, and many are now living into old age. Therefore, these patients may go on to develop cardiac disease, cancers, dementia, and other diseases associated with old age. Providers in HIV/AIDS practice may follow these patients for specialist care, but all healthcare providers should be aware of this aging population as they are seen for routine care.

Leading Cause of Death in San Diego County in 2007: It’s Not the Same List From Medical School Community Epidemiology Branch’s Vital Records Division reports mortality data to California Department of Public Health (CDPH); cumulative data from all California counties is maintained for public use by CDPH Center for Health Statistics in the California Death Statistical Master Files (DSMF). CEB analysis of 2000–2007 DSMF data demonstrates a trend away from heart disease as the leading cause of death in San Diego County. Mortality trends in the United States

public health officials; the business was unknown to environmental health. On August 28, 2008, with five cases of giardiasis confirmed, Siskiyou County discontinued the company’s operations. Diagnostic stool examination and reporting are key elements in identifying and eliminating sources of infection.

indicate heart disease (HD) mortality rates have decreased by 64 percent since 1950, with cancer mortality rates decreasing by 15 percent since 1990. Nationally, HD remains the leading cause of death from all causes, followed by cancer. In San Diego County, gradual declines of both HD and cancer coincide with national trends, but HD mortality rates dropped below cancer rates, making cancer the county’s leading cause of death in 2007. • Deaths From Cancer in 2007: 4,812 • Deaths From Heart Disease in 2007: 4,743

Lead Poisoning in Children 2009 recommendations from the CDC Advisory Committee on Childhood Lead Poisoning Prevention reflect an increased awareness of the potential for neurodevelopmental damage at lower blood lead levels (BLLs), and the importance of primary prevention. Children with BLLs approaching 10 μg/dL of blood should be rescreened more frequently; affected families should be referred to agencies and sources of information to facilitate establishment of a lead-free environment.

Once a report is made to public health, the Community Epidemiology Branch’s job of responding, investigating, and intervening begins

The CEB Communicable Disease Report In 2008, CEB used electronic disease reporting data for 2003–2007 to produce a Communicable Disease Report. This report provides a descriptive overview of 16 select communicable diseases in San Diego County over a five-year period in comparison to disease incidence in California, and the United States, among the general population, and in special populations.

Regional differences were noted: In North Central, North Inland, and North Coastal regions, cancer is the leading cause of mortality, with noted rate increases in North Coastal and North Inland regions in 2006–2007. In East, Central, and South regions, heart disease remained the leading cause of mortality. Ongoing analysis is needed to account for regional differences, with more intensive subgroup analysis (ethnicity and gender). Trends may also reflect coding changes from ICD-9 to ICD-10.

Communicable Disease Reporting In San Diego County, communicable diseases are reported to the Community Epidemiology Branch (CEB) of the County of San Diego Health and Human Services Agency. To reach CEB during weekdays, call (619) 515-6620, or, for assistance afterhours, dial (858) 565-5255 and ask for the epidemiologist on call. For additional information, visit www.sdepi.org. ✚

Swift Action on a Cluster of Illness: It All Starts When You Order a Test Providers are required to meet a number of mandates, including prompt disease reporting; the following illustrates a preventive public health action resulting from investigation of a physician report. On August 27, 2008, a group travel exposure was identified by individual investigators discussing an unusual cluster of giardiasis cases; CEB identified 77 local church youth and chaperones who camped and rafted at a northern California commercial facility that provided meals, showers, sleeping arrangements, and drinking water from a hose. Cases reported seeing giardia warning signs posted for swimmers. CEB notified Siskiyou County environmental and

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Abo u t t h e Aut hor: Dr. Gins-

berg is the chief of Community Epidemiology Branch in the Public Health Services Division of the Health and Human Services Agency for the County of San Diego. The Branch includes Public Health Laboratory and Vital Records. Dr. Ginsberg is a voluntary clinical professor of medicine at UC San Diego and adjunct faculty at the SDSU School of Public Health.

SAN DIEGO P H Y SICIAN . o r g

Practice Management By Benjamin Pimentel

Commercial Credit Is Available

But How Should You Capitalize on It?

every payment. Amortization will be less than the estimated life span of the equipment. Leases, however, can be more flexi-

re you considering acquiring a new piece of equipment of a significant dollar amount? You should know that the way you finance it can cost or save you money. There are two main financing options: purchase loans or leases. Each has its own unique characteristics, and using the best structure for your situation can have a significant impact on your practice finances. These are some of the basic differences between the two credit facilities you should consider before making a final determination.

Purchase loans or leases — each has its own unique characteristics, and using the best structure for your situation can have a significant impact on your practice finances.

Down Payment: Purchase loans will typically require a down payment, while leases can be more flexible to finance up to 100 percent of the cost of the equipment, installation, and taxes. Of course, the higher balance will increase the size of the monthly payments, but the low down payment will allow you to hold more of your cash.

ble with payment plans. For example, by allowing lower payments during the first few months, payments can also be tailored to fit estimated cash flows (smaller payments at first, higher payments toward the end). Actual payment size will also vary depend-

Payment Structure: There are exceptions, but, typically, purchase loans are designed to gradually reduce the loan principal with

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ing on your down payment and residual. Cost: Measuring the cost of the two options can be tricky, and one option is not always a better choice than the other, given that the lease and loan differ. What to Look for: Loans: interest rate, down payment required, prepayment penalty, and loan fees (origination, processing, etc.); Leases: down payment, first payment up front, interest rate, fee to purchase at maturity, lease fees (origination, processing, etc.). Get a breakdown of estimated costs from your lender to compare the two options. There is no cookie-cutter best option. Consider also the opportunity cost of a larger down payment and your potential need of that cash. Capitalization vs. Expense: Something to consider is the financing structure impact on taxes. Generally, when purchasing through loans, the principal portion of a purchase is capitalized and offset by

gradual equipment depreciation over estimated life span or Section 179 (potentially 100 percent depreciation in one year), and interest is expensed. Section 179 could be used to offset an estimated large tax bill due to high income in one given year. Tax leases can allow you to expense the whole lease payments (essentially both principal and interest portion), thus reducing your taxable income over the life of the payments. Consult your CPA for your specific tax implication. Residual: Residuals are applicable to leases only. Equipment loans are generally fully amortized with no balloon payments at the end. Example of residual: A machine costs $50,000 and is financed through a $40,000 lease for five years. At maturity, the residual (the portion of cost that has not been paid) would be $10,000. Although having a payment of a residual at the end of a lease might be discouraging, it may have its advantages. First, you have benefited from using the equipment for only a portion of the cost to purchase. If you decide to purchase, the purchase price will be based on the estimated market value

“

plain the differences between the two but should be able to offer both options. ✚

of the equipment at the end the lease. Secondly, you benefit from not having an initial down payment, so your cash position was not impacted when the equipment was acquired. Lastly, after use of the equipment, you may or may not want to purchase it if there is a better model available. The lease gives you the option of purchasing it at the market value of a “used” piece of equipment or walking away altogether.

t h e Aut hor: Mr. Pimentel is a relationship manager at Torrey Pines Bank, a “low-maintenance” 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/month, and free courier service or remote deposit service. Potential Value: $2,500. For further information, contact Mr. Pimentel at (858) 259-5317 or at bpimentel@torreypinesbank.com.

Abo u t

Have a Plan: Consider the overall plan. Not all purchases qualify for either loan or lease financing. Typically, large equipment can be financed, while smaller, easy-tocarry items or supplies are excluded; however, you may be able to finance some of the smaller items if you purchase them as a bundle with the larger equipment. So plan your purchase. These are some of the basic differences between equipment loans and leases. Opting for one over the other will have implications to your monthly cash flow, cash position, and taxes, so consult your CPA and banker about what structure might be best for you. A good banker will not only ex-

When times are good, you should advertise. When times are bad, you MUST advertise.*

”

Advertise in the San Diego County Medical Society 2010 Pictorial Membership Directory

The SDCMS Pictorial Membership Directory is published annually and mailed to all member physicians (approximately 3,000). It is also available for purchase by non-member physicians and other interested parties. Advertising in the SDCMS Pictorial Membership Directory is a cost-effective and profitable way to get referrals and put your message in front of physicians, office staff, and patients who utilize this critical resource on a daily basis.

SDCMS Member Physicians Receive

25% off

ad v ertising rates

Color advertisements and premium positions are limited and available on a first-come, first-served basis. Contact Dari Pebdani today: 858-231-1231 or DPebdani@SDCMS.org *From an article by American Business Media entitled “Making a Recession Work for You.”

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SAN DIEGO P H Y SICIAN . o r g

ethics in Medicine

Model Policy on “Non-beneficial Treatment”

Adopted by SDCMS’ Bioethics Commission

by Lynette Cederquist, MD 22

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For most of us, facing the imminent death of a beloved family member can be the most heart-wrenching experience of our lives. Because most people still die in hospitals, they are usually receiving aggressive, life-sustaining treatments prior to death. Families have to grapple with decisions regarding withholding and withdrawing such support to allow their family member to die. These situations, unfortunately, often result in conflict between families and the healthcare team. While no policy will ever make these decisions easy, they can certainly help guide clinicians through a difficult situation by establishing guidelines and standards of practice. There is ongoing debate within the bioethics field around who determines the point of futility and how that determination is reached, but the consensus of clinicians is that we must be able to set limitations of treatment based on our clinical experience and expertise. Expecting distraught family members to make such emotionally laden decisions, in my opinion, increases their burden of suffering as they are trying to come to terms with a major loss. My experience has been that some family members feel compelled to “demand everything” as a way of expressing their love and devotion to their family. In the majority of cases, they do in the end accept limitations set by a caring, communicative clinician. Some physicians use the rationale of legal liability when they continue treatment they feel is no longer beneficial but that the family demands. Last year, we had one of our University of California lawyers review all of the cases filed against University of California Medical Centers, and she did not identify one successful lawsuit based on limitation of life-sustaining treatment based on futility determination. Thus, I am convinced that our fears are way out of proportion to reality and result in excessive, burdensome treatment. The San Diego Bioethics Commission, chaired by myself and Paula Goodman-Crews, LCSW (Kaiser Permanente), was developed within the San Diego County Medical Society with a vision of bringing together San Diego’s medical community to develop standards in bioethics practices. So far, our commission has representation from UCSD, Kaiser Permanente, Sharp Grossmont, Sharp Coronado, the Veterans Health Administration, Rady Children’s Hospital, Sharp Memorial, Sharp Mission Park, Scripps Mercy, Edgemoor, Navy Medical Center, San Diego Hospice, Silverado Hospice, Scripps La Jolla, and Palomar Medical Center. The first issue the commission has

Some family members feel compelled to “demand everything” as a way of expressing their love and devotion to their family. tackled is “non-beneficial treatment,” also referred to as “medical futility.” This is an issue with which every hospital and every ethics committee wrestles on a regular basis. In a recent review of UCSD’s ethics consultations, close to 50 percent of consults were requested because of conflicts surrounding perceptions of medical futility or medically ineffective treatment. This has been identified by all of the commission’s participants as a major source of conflict, especially intractable cases that are not remediated by ethics facilitation. The nearly universal consensus has been that when faced with cases where physicians have determined treatment is non-beneficial, but the patient or surrogate continues to insist on treatment, most physicians continue treatment. Physicians tend to default to continuation of treatment even if their institution’s policies support withdrawal of non-beneficial treatment. We believe that by developing a community standard to guide policy, each individual institution’s policies and practices will be better enforced. Last year, after input from all the members of the commission, we adopted our first model policy: “Model Hospital Policy on Non-beneficial Treatment and Conflict Resolution.” This is a major step toward establishing a community standard. Bioethics Commission members will now be able to take this policy back to their individual institutions, with the added force of community consensus. ✚ Abo u t t h e Au t hor: Dr. Cederquist, SD-

CMS and CMA member since 2005, co-chairs SDCMS’ Bioethics Commission along with Paula Goodman-Crews. Dr. Cederquist is as well clinical professor of medicine at UCSD, chairs UCSD’s Ethics Committee, and is associate medical director of Silverado Hospice.

Model Hospital Policy on Non-beneficial Treatment and Conflict Resolution To read the complete model hospital policy, visit SDCMS.org.

I. Abstract: Frequently, conflicts arise when parties disagree on the best course of action in the care of a patient. If the treating team believes that: 1 ) continuing treatment is nonbeneficial, or … 2) the burden of suffering and intrusiveness of treatment significantly outweighs any potential benefit, or … 3) a treatment is contrary to generally accepted medical standards, but the patient or surrogate continue to request the disputed treatment, steps must be taken to resolve the dispute. ✚

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SAN DIEGO P H Y SICIAN . o r g

ethics in Medicine

Approaching ventilator withdrawal When Survival Is Not Expected

by Laurel H. Herbst, MD, and Steven Oppenheim, MD 24

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The decision to extubate a patient who is ventilatordependent is usually difficult. Problems may arise in communication with the patient and/or family, issues of differences in beliefs and culture with regard to lifesustaining treatment, certainty of prognosis, practical issues of location (in the ICU, on a med-surg floor, at home, or referral to a hospice inpatient care center) and care delivery. The following case illustrates some of these. E.F. is an 89-year-old woman who has been ventilated in an ICU for three months following cardiac surgery. All attempts at ventilator weaning and withdrawal have failed, and recently she developed worsening renal function. When her creatinine reached five and she developed anasarca, dialysis was recommended. The patient (who was alert and capable of decision-making) refused dialysis. Instead she requested that she be sent home, extubated, and allowed to die in her own bed. Her family (daughter, son, grandson) arrived with many questions. They were generally in agreement with her decision but had three different opinions about how long she should be home before extubation (immediate, next day, a “few” days). The patient and all the family members declined extubation in any other setting. A hospice agency agreed to take on the challenge of getting her home. The initial problem was in locating a ventilator that could be used in the patient’s home — there are few agencies that can supply a ventilator on short notice. Additionally, Medicare regulations prohibit home health or hospice nurses from “managing” a ventilator without being certified. In usual circumstances of home-ventilator care, the family is responsible for the ventilator between visits from a respiratory therapist. Transportation of the patient from the ICU to another level of care outside the hospital requires critical care transport with a portable ventilator. This unit must leave with the ambulance when the patient is settled (at home, long-term care facility, or hospice inpatient care center). In this patient’s situation, when it looked unlikely a ventilator for home use would be found, immediate extubation after arrival at home was offered to the family and patient. The patient agreed that this was better than staying in the ICU, but some family members were very unhappy with the idea. They wanted to have more time

While it is said that the physician is not obligated to provide futile care, it is clearly a better outcome if reluctant families can be given the time, support, and information to come to agreement with the physician. for goodbyes. Finally, a ventilator was located shortly before the patient arrived home on Friday evening. A physician and the respiratory therapist from the rental company instructed the family in ventilator management, and round-the-clock nursing care was instituted to administer medications for comfort. The patient was alert until late the second full day home. The physician returned on the third day, at the family’s request, and the patient died one hour following extubation with her family present. Approaching the patient and family communication issues depends on the patient’s decision-making capacity and the capacity of both patient and family to communicate. If the patient is alert enough to have decisional capacity, the patient needs to be included in the discussions. Whenever feasible, it is helpful for the patient to be interviewed with the family present so the family is fully aware of the patient’s desires. No matter where the extubation is planned to occur, these things need to be addressed.

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SAN DIEGO P H Y SICIAN . o r g

1. Begin with inquiry: Does the patient/family and/ or decision-maker understand the medical issues and consequences of the choice between continued ventilatory support and withdrawal of the ventilator? Are the patient’s overall goals of care known, and is extubation consistent with these goals? If the patient is alert, does he or she have a preference about level of sedation after extubation (alert carries more risk of dyspnea; asleep is unable to communicate). Ascertain that the patient is DNR. 2. Explain how and what medications will be used to prevent anxiety and dyspnea. 3. Confirm that death may or may not be immediate. 4. Reassure the patient and family that extubation is ethical as withdrawal of unwanted therapy. 5. Ascertain which other issues exist for the patient: a. Is there another symptom to treat (such as nausea, pain)? b. Does the patient have questions, fears, or other unmet security issues? c. Is everyone whom the patient wants present able to be present? Is time needed for travel?

d. Is everyone being treated with respect and dignity? Does the patient desire grooming? e. Are spiritual and existential issues addressed? Are there religious rites to be observed (such as anointing of the sick for Catholic patients)? f. Are final arrangements (mortuary, cremation, or burial) in place? Approaching delivery of care requires coordination. We would suggest putting one individual in charge with a checklist, especially for an extubation at home. 1. Arrange critical care transport. 2. Arrange in-home ventilator and respiratory therapist to arrive before patient. 3. Arrange medication to be present before patient (opioid plus sedative, such as a benzodiazepine for IV or subcutaneous administration). Glycopyrrolate for excessive secretions may be helpful as well. 4. Arrange for suction equipment to be available. 5. Arrange for nursing care for medications and assessment. 6. Arrange for physician home visit to titrate medication. 7. Arrange for family to be present. 8. Arrange for pastoral care if part of the plan of care. To extubate in a facility, the same issues should be

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addressed but may be done without the travel component: respiratory therapy or trained nurse, available medication and physician, and presence of family and pastoral care. When preparing to extubate, reconfirm the patient/ decision-maker goal to withdraw ventilatory support and that the patient continues to elect DNR. Determine that the patient has those present who can and wish to be there. Begin a line for IV (or subcutaneous access) if implanted line not present. Allow pastoral care. Administer small dose of opioid. Administer the benzodiazepine if patient has desired sedation or is anxious. Wean ventilator and extubate. Clean face (if ET tube) and allow family to be with patient. Titrate the opioid for dyspnea and the benzodiazepine for anxiety until the desired level of sedation is reached. Continue to dose these medications only as necessary to maintain patient comfort. It is not the goal to hasten death. These issues can become even more difficult if there is disagreement between physician and patient/ family about ventilator withdrawal. When the patient and family want to withdraw, the physician usually must comply or transfer the patient unless he/she can prove the request is irrational and does not take into account the consequences. When the physician

requests the withdrawal because the intervention is “futile” and the patient/family refuses (generally this is family because in futile situations the patient is usually unresponsive), much more conversation is necessary. While it is said that the physician is not obligated to provide futile care, it is clearly a better outcome if reluctant families can be given the time, support, and information to come to agreement with the physician. ✚

Abo u t t h e Aut hors : Dr. Herbst, SDCMS

and CMA member since 1990, is chief medical officer and vice president of medical affairs at San Diego Hospice and The Institute for Palliative Medicine. Dr. Herbst can be reached at lherbst@sdhospice.org. Dr. Oppenheim, SDCMS and CMA member since 2001, is clinical medical director and chair of the Institutional Review Board at San Diego Hospice and The Institute for Palliative Medicine. Dr. Oppenheim can be reached at soppenheim@sdhospice.org. TCS_SDP_08:Layout 1

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SAN DIEGO P H Y SICIAN . o r g

ethics in Medicine

with liberty and justice for all Reflections on the Ethics of Access to Care

by Ellen Beck, MD 28

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Liberty and justice. Let us look at each of these two core values of the American experience in light of the current access to healthcare crisis. Liberty is freedom: freedom from bondage, freedom from want, freedom to choose, freedom to be and to do. A key libertarian text by Isaiah Berlin, titled “Two Concepts of Liberty,” defines freedom as the absence of obstacles to possible choices and activities, obstacles put there by alterable human practices. It would seem that lack of access to care is a huge and alterable obstacle to life, liberty, and the pursuit of happiness in our society. Currently, individual freedom is severely limited by our fragmented, market-based healthcare system. We all know people and have patients who can’t leave their jobs because they need to maintain their health benefits, for themselves or their children. People are not free to start new businesses or take creative leaps because they cannot afford to lose benefits. An elderly person may lose his or her home and savings in order to gain access to a nursing home. Medical bills are the number one cause, over 62 percent, of personal bankruptcy, with three-fourths of those having health insurance when their illness strikes. (Himmelstein 2009) In his 1991 encyclical, the pope spoke of the task of the state and of “the idolatry of the market.” From a moral standpoint, Pope John Paul II warned, “There are many human needs that find no place in the market. It is a strict duty of justice and truth not to allow fundamental human needs to remain unsatisfied, and not to allow those burdened by such needs to perish.” (Catholic Conference of Kentucky 2008) To me there are several signs of a mature nation, one key sign being access to healthcare for all its residents. Sometimes I feel that our country is like a teenager, who says, “I know, I know, I know,” refusing to listen to advice, and then crashes the family car. If one looks at healthcare in America, the car has already crashed. Another obstacle to our achievement of universal access to healthcare may be the belief that, even if our situation is bad, it is American and still the best. A mature America would learn from other nations that a universal healthcare system does not have to

The great learning before us is that social responsibility, appropriately taken, can increase rather than decrease individual freedom. hinder personal choice; it can encourage it. In nations with true universal access to care, a person with a disease knows that they will receive healthcare. They know if they change jobs, if they lose their job, or if they start their own business, they will still have healthcare. They know that if their disease worsens and they need extensive healthcare costing a great deal, they will not reach their policy’s financial limit. They need not fear that their benefits will run out before their disease is cured. Many philosophers describe a classic conflict between liberty and equality, that they are mutually exclusive. Others say that the ideal solution is a balance between the two. I believe that “equality” in healthcare can lead to increased liberty, or, differently put, that social responsibility, well taken, can increase individual freedom. Freedom is the core of being American. Looking at access to healthcare through the lens of freedom may help us move the dialogue forward. Universal access to care, using a single-payer model, would increase freedom from fear, freedom from poverty, and freedom from want. It would also increase freedom to act and freedom to choose. In the past, employer-provided or individually purchased private health insurance plans provided greater freedom of choice. With each year the plans have more limits and additional charges. With these limits, liberty and autonomy are diminished rather than enhanced. In many ways, one could say that many of these plans have become unjust.

Note: May I acknowledge my belief (and bias), based on my life experience, that a single-payer system would best serve the nation.

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Often in life, out of our fear, we create what we fear. I would like us to recognize that in our fear of loss of freedom to choose our healthcare, we have given away our freedom and created a very unfree nonsystem. I would like us to, as Bob Marley, teaches, “emancipate ourselves from mental slavery and free our minds” around this issue. The other ethical term we will address today is justice. In Judaism, the word for charity is the same as the word for justice: tzedakah, i.e., to do what is just, what is fair. It is not only charity to help the poor, it is justice. Islam, as well, teaches that doing justice between two people is sadaqah, which means voluntary charity. Thus we use the term “underserved medicine” rather than “charity” or “poverty medicine” because implicit in the term is that our society is underserving a large segment of the population. “A just society will not allow the marginalization of the poor and the exclusion of the disenfranchised from access to healthcare. Decent healthcare available to all is a moral imperative. (U.S. Catholic Con-

In Judaism, the word for charity is the same as the word for justice: tzedakah, i.e., to do what is just, what is fair. It is not only charity to help the poor, it is justice. ference of Bishops 2004, and CCK 2008) So if we feel it is good and just, as a mature nation, to provide access to healthcare for all, what is stopping us? How do we stymie ourselves? As when we embark on anything new in our lives, we often stumble over fear of change, fear of loss of freedom, fear that we won’t do it right, fear that we

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will waste money. If there are 47 million people without medical access and 108 million without dental access, we certainly aren’t doing right. Studies from the Government Accountability Office repeatedly indicate our system wastes enormous amounts of money. In our yearning for what used to be, i.e., affordable health insurance that gave freedom, we have not faced the fact that that situation is long past. What we now have is a system that is very ill. So, who will lose freedom in a universal healthcare single-payer system? The pharmaceutical companies will probably have to face price controls and negotiated prices. The insurance companies certainly will be less powerful, although they will still be able to insure people for perks that are not always medically needed, e.g., a private nurse or a single-bedded room. The for-profit medical companies, such as one large healthcare corporation that recently published an almost billion-dollar profit in the first quarter of 2009, will probably have less room for profit. These groups may feel less free, but if we can create a system that leads to a greater sense of individual freedom for the patient — who we must remember is the first priority — as well as increased freedom for the practitioner to practice medicine the way they believe, and not to have to worry about a patient’s coverage, then perhaps it is time to look at those choices. The current administration would invite everyone to the table. I find this disturbing. To use an extreme analogy, in the waters off Somalia, we would not invite the pirates to the table and say, well, with what solution could you keep your piracy within limits, but you would still have adequate piracy income? I am worried that in the current healthcare discussions in Washington, DC, with everyone at the table, the table will become so heavy that it will sink. The proposal of a healthcare mandate, a requirement that everyone acquire some sort of health insurance, limits liberty and is unjust. It shifts the concept of a right to healthcare and a society’s responsibility to provide healthcare to a requirement to individuals to purchase healthcare. In shifting the argument, it sidesteps the issues of liberty, justice, and rights. It equates healthcare, a life necessity, with other activities that are options, e.g., if you want to hunt, you need a hunting license, if you want to drive, a driver’s license, but health and illness are not always within our control. Although good health and prevention activities help to reduce the need for healthcare, we all know of individuals who have lived very healthy lives and still developed cancer or other conditions. Healthcare is not a lifestyle choice; it is a life necessity. To require it shifts the argument away from the core right of a human being to health and the core responsibility of a mature society to provide it. That does not mean that healthy behavior should not be rewarded,

Healthcare is not a lifestyle choice; it is a life necessity. single payer

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but it does not substantiate the goal of a mandate. I do believe that a healthcare system that values a humanistic, preventive, empowerment approach, will prove the most cost-effective, but it must be for all. It saddens me that a nation as wealthy as we are and a leader in so many other ways has not matured to face our responsibility to provide access to care. The great learning before us is that social responsibility, appropriately taken, can increase rather than decrease individual freedom. As a nation of individuals, we must look at the values of liberty and justice, as well as compassion and responsibility, and act maturely, acknowledging a right to healthcare, as the United

Introduction to Project Access San Diego: Training

Help Us Help Those Patients Who Are Most in Need!

Nations has proposed, and letting go of fear. We must get about the task of achieving that right. ✚

Abo u t t h e Aut hor: Dr. Beck, SDCMS and

CMA member since 2004 and a family physician, is the director of community education at the UC San Diego School of Medicine and the co-founder of, and adviser to, the UCSD Student-Run Free Clinic Project and Fellowship in Underserved Healthcare. She is also on the board of the San Diego County Medical Society Foundation.

Please join the SDCMS Foundation on Thursday, July 9, 2009, from 11:30am to 12:30pm — in person at our seminar or via the web at our webinar — for a free, one-hour training to learn more about Project Access San Diego (PASD). Lunch will be provided and four lucky attendees will win $20 Starbucks gift cards! PASD is a program of the SDCMS Foundation that coordinates and manages volunteer healthcare for low-income, uninsured San Diegans. We are currently seeking physician volunteers and office managers who want to learn more about how to make a difference in the lives of the medically underserved.

When? Thursday, July 9, 2009, 11:30am–12:30pm Where? SEMINAR: SDCMS Meeting Room: 5575 Ruffin Road, Suite 250, San Diego 92123. WEBINAR: Wherever You Are, So Long As You Have a Computer and an Internet Connection! Registration or questions? Contact Lauren Radano, SDCMS Foundation Healthcare Access Manager, at (858) 565-7930 or at LRadano@SDCMS.org J u ly

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SAN DIEGO P H Y SICIAN . o r g

ethics in Medicine

Pandemics Ethical Consideration

by Brian Snyder, MD 32

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At the time of writing (mid-May), the early experience with H1N1 (swine derived) influenza A virus has not lived up to the initial predictions of widespread morbidity and mortality, with most infections being self-limited. However, this novel influenza virus may eventually cause infection in up to a third of the earth’s population. With a case fatality rate around 0.4 percent, it will likely contribute to the death of millions of people worldwide (1). Recent concern about the spread of another influenza virus (H5N1 avian influenza with a case fatality rate of more than 50 percent) had led to discussion about the ethical principles involved in pandemic planning and response. There are many ethical issues involved in the delivery of medical care during an infectious disease pandemic, and this paper can only address a few. Issues of distributive justice — that is, who should be treated when not all can be treated — will likely be most important in the public mind. To be discussed here include the ethical aspects of delivery of medical care when the demand for treatment overwhelms the ability to provide such treatment (because of a lack of staff, space, equipment, or medication), public perception of medical care delivery when treatments may be refused to patients based on scarcity, and the obligations of medical personnel to work during an infectious disease outbreak with its inherent danger of disease contraction. It is becoming increasingly acknowledged that our hospitals, clinics, and emergency departments may lack the surge capacity to effectively treat all patients during a pandemic. Additionally, scarcity of medications or equipment (e.g., ventilators) will surely reduce the ability to provide treatment to all. One intuitive model summarizing the likely progression of the pandemic response in the setting of scarce resources is that developed in the Swiss influenza pandemic plan: 1. P hase 1: During the first phase, everyone who needs treatment will receive it. This phase will continue until the number of those requiring treatment exceeds the capacity of the enhanced treatment facilities. In this phase treatment is administered to individuals on a “first come, first served”

Healthcare professionals possess unique skills that are essential to the treatment of disease, and a moral obligation to provide care should be argued. However, this obligation cannot be considered absolute. basis or to those who are already being treated for another illness. 2. Phase 2: The second phase begins when it is no longer possible to treat everyone because the therapeutic capacity is exhausted, and some have to be turned away. In this phase, the scarce therapeutic resources are reserved for those whose condition is most threatening. 3. Phase 3: Finally, there is the third phase, which corresponds to the triage used in war or disaster situations. Right from the outset of this phase, the scarce resources should be reserved for influenza patients in a life-threatening condition. When all those who are in a life-threatening condition can no longer be treated, priority will be given to those who are expected to have the best chance of survival as a result of treatment. Conversely, treatment in this phase will, if possible, be withheld only from those who are unlikely to benefit from it. Individuals with a poor prognosis will only be treated palliatively in this phase; intensive treatment, for example, will not be initiated (2). (emphasis original) Putting this model into classic ethics language, in the setting of scarce resources, the utilitarian principle of maximizing the most good for the most people will be employed. However, because of changing of local and regional capabilities in relation to number of patients, difficult decisions to treat or not treat will also be in flux, based on current information and imperfect predictions. For instance, because of the current prediction of a future scarcity of antiviral medications, these drugs have been withheld in “mild” H1N1 disease (perhaps unjustifiably), putting the current response, in a certain sense, already in phase 2 of the Swiss model.

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Medical professionals generally understand that in a pandemic with a highly virulent organism, not all patients needing it will necessarily receive maximal treatment (especially critical care). Although most people may agree that scarce treatment is best provided to those most likely to benefit, the difficulty lies in determining which patients may best benefit. Without prior public notification and involvement in pandemic planning, medical decisions to withhold medical treatment based on scarcity of resources may appear arbitrary at best or discriminatory at worst, unless grounded in previously developed guidelines. The World Health Organization emphasizes transparency, public engagement, and mobilization in order to “contribute to the development of adequate and effective plans and increase public confidence that policies are reasonable, responsive, nondiscrimi-

Issues of distributive justice — that is, who should be treated when not all can be treated — will likely be most important in the public mind. natory, and in line with local circumstances and values” (3). National, state, and local health agencies and policymakers must ensure public participation in the planning, implementation, and evaluation of a pandemic response. It is only through this process of lay public involvement that the medical profession will prevent public concerns of “unethical behavior” when the reports of prioritization of treatment (described, of course, as the withholding of treatment) begin to circulate. There are ethical issues involving healthcare workers’ obligation to provide care during an infectious

disease pandemic. Providing medical care is, of course, not without risk, infectious pandemic or not. Healthcare professionals possess unique skills that are essential to the treatment of disease, and a moral obligation to provide care should be argued. However, this obligation cannot be considered absolute. Situational factors of the provider (for instance, personal, high-risk factors for severe disease, pregnancy, or family care requirements) may provide justification to decline or limit provision of care. Although there may be moral, professional, or legal obligations to provide care during a pandemic, governmental and professional bodies need to define such obligations, and any potential sanctions if such obligations are not met. Furthermore, government and other regulatory agencies must ensure the reciprocating obligation of providing safe practice environments and protections for providers, such as priority to vaccines or treatment and legal protections, or support to those who become ill while providing care. There are many other issues involved in pandemic planning and response that have ethical implications that are not discussed here. To list a few: individual civil rights in the setting of involuntary quarantine, triage guidelines in a mass-casualty setting, mutual aid, vaccine allocation schemes, and the obligation of regions or countries with more resources to those with less. The current H1N1 outbreak provides a perfect setting to investigate or reflect upon our understanding of resources, regulations, and obligations, and our individual readiness to provide care during this looming pandemic. ✚ References: 1) F raser C, Donnelly CA, Cauchemez S, et al. Pandemic Potential of a Strain of Influenza A (H1N1): Early Findings. Science. Electronically published May 11, 2009. 2) Federal Office of Public Health, Switzerland. Swiss influenza pandemic plan version 2007. page 250. 3) World Health Organization. Ethical considerations in developing a public health response to pandemic influenza, 2007. page 3.

Abo ut t h e Au t hor: Dr. Snyder is associate clinical professor in the Department of Emergency Medicine at the UC San Diego Medical Center. He serves on the UCSD Medical Ethics Committee and performs ethics consultations.

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SDCMS Endorsed Partner Spotlight:

MEMBER BENEFIT

CHMB

SDCMS members receive a 50% discount on startup fees, a $33 per-physician-per-month services credit, a 10% discount on Dell hardware solutions, and free access to CHMB’s coding hotline.

CHMB is California’s leading Medical Billing and Business Services Company

Potential Value: $1,000

CASE STUDIES 1. A busy primary care group with 11 providers had just undergone major practice reorganization. They needed immediate results, could not afford any dip into cash flow, and didn’t want to add any administrative overhead. Their results with CHMB: • A 12% increase in collections. • A 21% decrease in billing costs. • Business decisions made based on high-level, detailed reporting. • Improved patient satisfaction with increased efficiency at time of service. 2. A group of surgeons had outsourced their billing to a national billing service firm to minimize administrative overhead. With lackluster results and declining reimbursement rates, they felt they were not getting the appropriate attention. The group wanted to engage a business partner who would provide consistent local support for their accounts receivable and increase reimbursement rates to an acceptable, sustainable levels. Their results with CHMB: • A 15% increase in collections. • A 14% reduction in accounts receivable over 90 days. • No increase in overhead costs related to billing and revenue cycle management.

• A 7% increase in collections. • A 7% decrease in internal billing operation costs. • The group was able to focus on practice investment/growth.

SDCMS Member Testimonials “During the four and a half years with CHMB, I have nothing but admiration for everyone involved on my account. This extends from my account manager and her team, who work hard to keep my month-end pain-free, to the IT department, who are priceless in their efforts to keep the systems errorfree. It is reassuring to know our accounts are being worked on daily to ensure all claims are submitted in a timely manner.” — Dee Bertussi, Office Administrator, Internal Medical Associates Medical Group of San Diego

CONTACT To take advantage of this members-only benefit, contact Ron Anderson at (760) 520-1340 or at randerson@chmbsolutions.com, or Geoff Doyle at (760) 520-1343 or at gdoyle@chmbsolutions.com.

3. In 2004, a dynamic group of orthopedic surgeons formed their own group. The new group added adventure/extreme sports medicine and rehabilitative services and required an interface between CHMB’s information system to a new cutting-edge PAC (picture archiving and communication) system. In addition to stable cash flow, the practice required decision support tools and reporting to assess the most cost-effective and profitable paths for the best financial results. Their results with CHMB:

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SAN DIEGO P H Y SICIAN . o r g

ethics

in Medicine

challenging symptoms? Expert Advice New Palliative Medicine Resource Hotline Available to Physicians

Abo u t t h e Au t hor: Dr. Herbst, SDCMS and CMA member since 1990, is the chief medical officer for The Institute for Palliative Medicine at San Diego Hospice and a national leader in advancing hospice and palliative medicine.

by Laurel H. Herbst, MD 36

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Physicians are required, by California law, to obtain continuing education in pain management and palliative care. But few community physicians — particularly those practicing in medically underserved areas — have the time or resources to keep abreast of cutting-edge therapies for managing the varied symptoms associated with serious illnesses. To address this, The Institute for Palliative Medicine (IPM) at San Diego Hospice has created the PAL-MED CONNECT hotline at 1-877-PAL-MED4. PAL-MED CONNECT allows convenient access to expert guidance on options for managing pain and other distressing symptoms. The goal is to advise physicians when challenging symptoms arise, provide options and information when needed, and to share the resources of IPM with other clinicians. The hotline provides the convenience of a “curbside consultation” over the phone. Physicians, physician assistants, nurse practitioners, and pharmacists can speak with palliative medicine experts at IPM, Monday through Friday, 8 a.m. to 6 p.m. Outside of these hours, calls will be answered the next business day, or an expert will be paged for after-hour emergencies. Physicians can use PAL-MED CONNECT as a resource for questions on serious patient symptoms (shortness of breath, fatigue, nausea); opioid rotation and conversion; dosing; drug side effects and interactions; and best practices on palliative care. For instance, a physician calls in with questions about a cancer patient receiving chemotherapy and experiencing both immediate and delayed nausea. Through the PAL-MED CONNECT hotline, the experts at IPM can provide information on a full range of anti-nausea drugs, send monographs, and recommend publications for further reading. Pharmacy consultation is also an integral part of the hotline. The hotline project is funded by a grant provided by UnitedHealth Group/PacifiCare as part of an ongoing commitment dedicated to improving healthcare services through enhanced technology opportunities, supporting clinical education and driving preventative health initiatives. This generous grant permits IPM to provide this service free of charge to California physicians, physician assistants, nurse practitioners, and pharmacists. We anticipate a win-win for patients and their healthcare providers: enhanced symptom control for patients and enhanced career satisfaction for the providers. For further questions on palliative medicine, contact the PALMED CONNECT hotline at 1-877-PAL-MED4. ✚

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Project Acccess

San Diego Project Access takes the hassle out of volunteering, with our staff doing the legwork so that you and your staff can focus on patient care.

The heart of the program is to assist patients who cannot afford medical services and who do not have insurance or qualify for the public health insurance programs.

•E nrolling 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 Project Access 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-on-one to coordinate followthrough 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, hospital services, and even a defined pharmacy benefit.

Your commitment to Project Access is required for our success! Please visit our website at SDCMSF.org to learn more and to sign up.

We need your volunteer commitment to help even one patient. Our Medical Community Liaison, Rosemarie Marshall Johnson, MD, can answer your questions. Dr. Johnson can be paged at 619.290.5351. J u ly

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ethics in Medicine

Myrtle's story

A Bioethics Case Study

Adapted by Lynette Cederquist, MD, and Paula Goodman-Crews

Physician Orders for Life-Sustaining Treatment (POLST) legislation was passed in California and went into effect on January 1, 2009. Though healthcare providers are not required to use the POLST form, they are required to honor it. An adjunct to an advance directive, the POLST form is signed by the physician and the patient (or legally designated decision-maker) and outlines a plan of care that reflects the patient’s end-of-life wishes. The bright pink form (see next page) is designed for patients who are seriously ill and who are ready to make choices about limiting treatment, and it travels with patients across the continuum of care. The following narrative depicts how the use of the POLST form can facilitate patient preferences at the end of life. Continued on page 41

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When Myrtle Anderson’s husband died, she was troubled that he seemed to suffer so needlessly before his death, spending the last six weeks of his life in the intensive care unit on a ventilator. To ensure that she would not face a similar situation, she created an advance directive stating that she did not want extraordinary measures taken to keep her alive if she was terminally ill or permanently unconscious and put it in her safe deposit box. One day, when Myrtle’s nephew Tom could not reach her by phone, he went to check up on her and found her lying on the floor, confused, and unable to speak. He called 911, and she was admitted to the hospital. At the hospital, the physician’s evaluation revealed a brain hemorrhage. When asked if she had drafted an advance directive, Tom reported that he didn’t know. Once Myrtle was stabilized, the physician called her daughter, Carol, to discuss Myrtle’s current and future treatment. Carol and her mother had not spoken for several years. Carol stated that she had no idea what her mother would want and that she was unable to make any treatment decisions for her. As well, when Myrtle’s primary care physician was contacted, he reported that he and Myrtle had never discussed her wishes should she became ill and unable to speak for herself. Myrtle’s condition improved slightly. Though she wasn’t able to speak clearly and had some difficulty swallowing, she was no longer confused. Tom helped arrange for her transfer to a skilled nursing facility (SNF) for speech rehabilitation. When she was asked at SNF admission if she had an advance directive, to everyone’s surprise, she nodded her head emphatically, “Yes!” Tom agreed to retrieve it. When the physician caring for Myrtle at the SNF reviewed the advance directive with Myrtle, she indicated that her preferences for treatment were consistent with the statements in the document. Myrtle had not chosen an agent/decision-maker. The doctor asked if she could choose a surrogate, and Myrtle appointed Tom as her surrogate. The physician documented this in her record and suggested she complete a new advance directive that reflected this appointment. The doctor also told Myrtle and Tom about the POLST form. The physician asked Myrtle about CPR, and she shook her head emphatically, “No!” The physician recognized and documented that Myrtle had decision-making capacity and checked “Do Not Attempt Resuscitation” on her POLST. Myrtle recognized that she had become quite debilitated and would, most likely, never be able to live independently. She chose “Limited Additional Interventions” in Section B and “No Artificial Nutrition by Tube” in Section C. She also

said that she wanted Tom to make all her decisions for her, starting immediately, and told the physician not to bother her daughter. The POLST form went home with Myrtle when she was discharged. Myrtle’s daughter, Carol, came to visit. The visit was pleasant, and Myrtle did not want to “stir things up” by telling Carol about the decisions she had made. While Carol was visiting, however, Myrtle collapsed, and Carol called 911. The emergency medical personnel found Myrtle’s bright pink POLST form on her refrigerator and transported it with her, along with her advance directive, to the hospital with her. In the emergency room, EMS gave the staff the POLST form. They noted that Myrtle had chosen “Do Not Attempt Resuscitation” (DNR) and “Limited Additional Interventions.” Carol wanted everything done to save her mother and did not understand why the doctors were following the POLST form to guide her care. Due to the severity of the stroke, Myrtle died. She was comfortable during the dying process. Tom was asked about tissue donation, and following Myrtle’s wishes, he consented to the donation of any tissue that might be useful. Myrtle’s story is typical of many isolated elderly patients. Fortunately, there were adequate checks and balances in place at the hospital and at the SNF such that Myrtle’s wishes were solicited, documented, and ultimately followed. The use of POLST at a time when it was clear that Myrtle was ready to limit future treatment enabled her to die according to her values and beliefs.

t h e Au t hors : Dr. Cederquist, SDCMS and CMA member since 2005, co-chairs SDCMS’ Bioethics Commission along with Ms. Goodman-Crews. Dr. Cederquist is as well clinical professor of medicine at UC San Diego, chairs UCSD’s Ethics Committee, and is associate medical director of Silverado Hospice. Ms. Goodman-Crews is a licensed clinical social worker by training and a bioethics consultant. She has worked for over 25 years in the healthcare arena and presently co-chairs SDCMS’ Bioethics Commission, the Kaiser Permanente San Diego Bioethics Committee, and chairs Kaiser Permanente’s Institutional End-of-Life Committee.

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SAN DIEGO P H Y SICIAN . o r g

Classifieds CLINICAL STUDIES USE GENETIC INSIGHT TO HELP TAKE CONTROL OF YOUR HEALTH FUTURE AND HELP FURTHER SCIENCE: Join the Scripps Genomic Health Initiative (SGHI), a first-of-a-kind study that uses the latest advancements in technology and medicine to give you insight into your DNA using a simple saliva sample. Lead by principal investigator and SDCMS member, Eric Topol, MD, this study is designed to find out how personal genetic testing will improve health by motivating people to make positive lifestyle changes. Participation includes a scan of your genome that assesses your genetic risk for over 20 health conditions, which includes several types of cancer, type 2 diabetes, Alzheimer’s, and more. You can sign up or learn more at: www.navigenics.com/partners/sdcms. [714]

6th floor). 1,947 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. [671]

Class “A” Medical Building For Sale or Lease: 3-Story, 55,450/SF located at 838 Nordahl Road in San Marcos, CA. Suites from 1,000/SF. Premier location. Easy freeway access & close proximity to restaurants & sprinter. Shower & locker facilities. Resort quality restrooms. Tropical landscaping. Koi ponds. Panoramic views. Latest in “green” building design standards with utility cost savings. Scheduled for completion in July 2009.

OFFICE SPACE CHULA VISTA OFFICE SPACE TO SHARE: Two OB/GYNs occupy an office space over 5,000ft2. A third physician retired, and that space is available immediately. Located on the Sharp Chula Vista campus, this space is ideal for an OB/GYN medical practice or compatible. Contact Dorina at (619) 427-8892, ext. 113, or Gail at (619) 4278892, ext. 109, or fax letter of interest to (619) 422-7660. [728]

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. FREE RENT INCENTIVES and a generous improvement allowance is provided.

For more information contact Mark Avilla (760) 431-4223 /mavilla@breb.com www.nordahlmedicalcentre.com LEADED PROCEDURE ROOM IN KEARNY MESA FOR SUBLEASE: Located directly across for Sharp Memorial Hospital in the new, Class A Physician’s Medical Center. Perfect for non-sedated, minor procedures, including spinal injections. The space includes an integrated workstation with phone and Internet access. Common areas include kitchen (break room), private restroom, staff work stations, front desk, and patient lobby. A back way entrance accommodates gurney access. This is a potential alternative to costly surgical centers. Terms negotiable. Contact carla.young@clyoungmdinc.com for more details or fax a letter of interest to (858) 5654146. [722]

Leasing, Renewals & Sales:

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

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.

LOOKING TO SUBLEASE SPACE IN ENCINITAS: Allergy-immunology specialists interested in subleasing space in Encinitas area. Ideally desire two days a week, three exam rooms and one consultation room. Contact Trudy at (858) 2921144 or at trudybrass@msn.com. [727] MEDICAL OFFICE SPACE AVAILABLE ON SHARP CHULA VISTA MEDICAL CENTER CAMPUS: 752 Medical Center Court, Chula Vista, CA 91911. Available July 5, 2009. Rental sublease office space: two (2) exam rooms, share consultation room, front desk space, turnkey operation, clean and friendly environment. For further information, please contact Connie Espinoza, office manager, at (619) 527-7700, ext. 236, or at conniee4@gmail.com. [723] HILLCREST OFFICE SPACE FOR LEASE: Hillcrest, Mercy Medical Building (4060 Fourth Ave.,

Contact Chris Ross at 858.677.5329 email chris.ross@colliers.com ESCONDIDO OFFICE/SURGICAL SUITE TO SHARE: Plastic surgeon has 2,000ft2 office with AAAASF-accredited surgical suite to share two days a week. Five minutes to Palomar Medical Center and I-15, this freestanding, single-level office is wheelchair and stretcher accessible. It contains doctor’s office, four staff work stations, three exam rooms, PACU, kitchen/eating area,

and two bathrooms equipped for disabled. OR is fully equipped and supplied, and approved for general anesthesia. Save money over surgicenters. Ample parking. Minimum one day per week. Please call Yale Kadesky, MD, at (760) 741-5466 or email yalekadeskymd@gmail.com. [719] 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] 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] BEAUTIFUL, 2,000FT2 MEDICAL SUITE IN PRIME LOCATION AVAILABLE FOR SUBLEASE: Women’s healthcare office located next to Sharp Hospital in Chula Vista is available for sub-lease on Mondays, Wednesdays, and Thursdays beginning June 1. For more information, please contact Jessica at (619) 397-2950, ext. 200. [713] BEAUTIFUL BANKER’S HILL OFFICE SPACE: Available for one or two doctors to share in multi-specialty office. Recently remodeled, ocean views, lab on site, underground parking. Share staff or bring your own. Please call Chris Bobritchi at (619) 233-4044 or email HIVDOCS@ yahoo.com. [712] ENCINITAS OFFICE SPACE SUBLEASE: Beautiful, top-floor office on the Scripps Encinitas Hospital campus has available space to sublet part time or full time. Set up well for any specialty. Available at competitive rates. If interested, please contact us at (760) 753-1104, ext. 1107. [710] UTC MEDICAL OFFICE SPACE AVAILABLE: One day a week. UTC area. Telephone (619) 229-5340 or email pam@sdspineinstitute.com. [704] SCRIPPS ENCINITAS CONSULTATION ROOM / EXAM ROOMS: Available consultation room with two examination rooms on the campus of Scripps Encinitas. Will be available a total of four days per week. Receptionist help provided if needed. Contact Stephanie at (760) 753-8413. [703] 3998 VISTA WAY, SUITE D, IN OCEANSIDE: Medical office space (approximately 2,080ft2) available for lease. Close proximity to Tri-City Hospital with pedestrian walkway connected to parking lot, and ground floor access. Lease

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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Classifieds price: $2.40/ft2 + NNN. Move in incentives offered: tenant improvement allowance and rent abatement. For further information, please contact Lucia Shamshoian at (760) 931-1134 or at shamshoian@coveycommercial.com. [702] LA MESA OFFICE SPACE TO SHARE: Over 6,000ft2 OB/GYN office of four doctors with one leaving, available immediately. Space is ideal for a medical practice or clinical studies, and is located on Grossmont Hospital campus. Contact La Mesa OB/GYN at (619) 463-7775 or fax letter of interest to (619) 463-4181. [648] PHYSICIAN POSITIONS AVAILABLE PHYSICIAN NEEDED IMMEDIATELY: Position for California-licensed physician. Percentage of gross + residuals. Full time/part time. Semiretired welcome. No experience necessary. Will train. Please call Betty at (858) 342-8394. [724]

Small group seeks parttime, afternoons, Family Medicine, Internal Medicine or Pediatrics physician: Must be bilingual (Spanish/English or Tagalog/ English); EMR familiar; team oriented; no On-Call, office only. Chula Vista. Opportunity to increase hours, as desired. Medical and dental insurance. Flexible hours. Malpractice paid. Low and middle income patients; established and walk-ins. Send resume to MD, Inc., P.O. Box 533, Chula Vista, CA 91912

pense and time) and licensure. This is an opportunity to make a difference in the lives of patients who are under-insured or do not have insurance coverage, without having overhead expense or management concerns. Spanish language knowledge helpful but not required. Please send CV to C. Bekdache at cynthia.bekdache@nchs-health.org or fax to 760-736-8740. [718] PRIMARY CARE JOB OPPORTUNITY: Home Physicians is a fast growing group of doctors who make house calls. Great pay ($60–$100+/ hour), flexible hours, choose your own days (full or part time). No weekends, no call, transportation and personal assistant provided. Call Chris Hunt, MD, at (858) 279-1212. [711]

people and communication skills. Excellent benefits. M–F. Email résumé to framirez@ivfcmg. com. [721] NURSE PRACTITIONERS NEEDED: Part-time and per-diem opportunities available for family medicine, pediatric, and OB/GYN nurse practitioners. Vista Community Clinic is a private, nonprofit, outpatient clinic serving the communities of North San Diego County. Must have current Calif. license. Malpractice coverage provided. Bilingual: English/Spanish preferred. Forward resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. Visit our website at www.vistacommunityclinic.org. EOE/M/F/D/V [701] MEDICAL EQUIPMENT 2007 NOVASURE EQUIPMENT IN EXCELLENT CONDITION FOR SALE: The NovaSure System is intended to ablate the endometrial lining of the uterus in premenopausal women with menorrhagia (excessive bleeding) due to benign causes for whom child bearing is complete. The NovaSure procedure takes approximately 90 seconds to perform, has excellent patient outcomes and reimbursement for physicians. The 2008 National Average Medicare Reimbursement Rate is 2,014.80 for in-office procedures. Bought New in 2007 for $25K, lightly used. Price $18K. Please call (760) 473-4002. Please visit www.novasure.com/novasure-procedure. [720]

Place your advertisement here Contact Dari Pebdani at 858-231-1231 or DPebdani@sdcms.org BC/BE INTERNAL MEDICINE/FAMILY PRACTICE/HOSPITALIST NEEDED: Spanish-speaking (Portuguese-speaking a plus) BC/BE internal medicine/family practice/hospitalist needed for immediate opening in fast-growing community. Salary, benefits, and generous incentives. H1B and J1 VISA waiver qualified. Send resume to sdhospitalist@hotmail.com. [706]

FAMILY PRACTICE PHYSICIAN — ENCINITAS: North County Health Services, a Joint Commission, federally qualified community health center, celebrating 35 years of service, has an opportunity for BC/BE family practice MD for a lead position in our Encinitas health center. Work-life balanced hours, include occasional Saturdays (shared with other clinicians). Attractive compensation, including bonus for call and incentive. Benefit program includes extensive health and welfare benefit choices, retirement plan (403b) with match, generous time off (PTO), holidays, malpractice, and reimbursement for CMEs (expense and time) and licensure. This is an opportunity to make a difference in the lives of patients who are under-insured or do not have insurance coverage, without having overhead expense or management concerns. Spanish language knowledge helpful but not required. Please send CV to C. Bekdache at cynthia.bekdache@nchs-health.org or fax to (760) 736-8740. [717]

PHYSICIANS NEEDED: Full-time, part-time, and per-diem opportunities available for family medicine, pediatric, and OB/GYN physicians. Vista Community Clinic is a private, nonprofit, outpatient clinic serving the communities of North San Diego County. Must have current Calif. and DEA licenses. Malpractice coverage provided. Bilingual: English/Spanish preferred. Forward resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. Visit our website at www. vistacommunityclinic.org. EOE/M/F/D/V [700]

OB/GYN PHYSICIAN — ENCINITAS: North County Health Services, a Joint Commission, federally qualified community health center, celebrating 35 years of service, has an opportunity for BC/BE OB/GYN. Hours and call shared with other clinicians and NMWs. Attractive compensation, including bonus for call and incentive. Benefit program includes extensive health and welfare benefit choices, retirement plan (403b) with match, generous time off (PTO), holidays, malpractice, and reimbursement for CMEs (ex-

WOMEN’S HEALTH NURSE PRACTITIONER: Progressive Mission Valley office looking for a part-time/full-time nurse practitioner with strong gynecological experience, including HRT. Fax resume to (619) 220-8567. [726]

MISCELLANEOUS DO HOBBIES MAKE DOCTORS BETTER?: Eric Anderson, MD, a local, now-retired physician — and an occasional contributor to San Diego Physician in the ’80s — has an assignment from Medical Economics to write about physicians’ hobbies and whether the hobbies might help them be better doctors. For example, does photography make a physician more observant? Does the discipline of flying make a physician more organized in the office? Dr. Anderson would appreciate the chance to talk to any physicians about their hobbies. Interested physicians should contact Dr. Anderson at eander1@cox.net, at (619) 794-0005, or on his cell at (858) 775-0774. [707] <end> Practice Management

PHYSICIAN POSITIONS WANTED OPHTHALMOLOGIST: Retired, early, given current events. Board certified. Spent entire ophthalmology career in San Diego. Seeks part-time office association. Very flexible. Impeccable local references. Email MJB6520@sbcglobal.net or call cell (858) 382-0552. [715] NONPHYSICIAN POSITIONS AVAILABLE

MEDICAL CODING SUPERVISOR: Experienced, with California coding certificate needed for multi-specialty physician group in Imperial County. Knowledge of all aspects of billing necessary. IT experience a plus. Must have great

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PRACTICE MANAGEMENT SERVICES/PRACTICE MANAGER/KEY STAFF JOB SEARCHES: Let the practice professionals find you the right person. Plus, you are not identified. We place the ads, receive the applications, interview the better candidates, do reference checking and bring you the best 2 to 4 candidates for final interviewing. We also do the salary and benefits negotiation with the preferred candidate. We know the medical office and can pinpoint what you need. Reasonable fees. Contact Regina Reading or George Conomikes of Conomikes Associates, Inc.; (858) 720-0379 or email rreading@conomikes.com.

SAN DIEGO P H Y SICIAN . o r g

Medical Students By Niousha Moini, MS IV

Remembering

Jan

In Memory and Dedication to My Patient Jan

Lonely old woman resting quietly in your bed, Your name is Jan. Here in a room at the San Diego Hospice, you will meet the very last moments of your life. I pull a chair forward and extend my hand, grasping your cold, wrinkled hands. Your body drowning in a sea of fibromas.

[Originally published in the 2009 issue of The Human Condition.]

Let me lift you. Open those eyes my beautiful Jan. Let me lift the darkness.

Note (taken from http://meded.ucsd.edu/osa/publications/HumanCondition): The Human Condition, the annual art and literary magazine of the UC San Diego School of Medicine, was born of the imaginative stories written by medical students in the elective “The Good Doctor: The Works of Anton Chekhov.” It is a forum for the creative work of medical students, residents, and faculty of the UCSD School of Medicine. Medicine teaches us much about biological life and how to prolong it. However, we must not forget in the midst of the curriculum why one should live or what it means to live well. As a reminder of these central ideas and the art that resides in medicine, we are proud to present The Human Condition.

“Sing me a pretty song. Comb the tangles of my hair. Soothe this dry throat of mine. Yes, lift the darkness, lift the darkness.” Two daughters have you. Abandoned now. Do not worry; I am here for you. As days pass you tell me of your pain. “I am damaged.” How my Jan? “By Father’s hand. His strong grip, pushing me down, my face against the pillow praying that it would stop. This is my pain. Yet it is also a gift. A box full of sadness wrapped with lessons. Lessons that I now have unwrapped for you. Learn from my pain. Seek and heal it in others. I tell you because, even with this thirst, I have lived.” ✚

About t he Au tho r : Mr. Moini

is a fourth-year medical student at the UC San Diego School of Medicine.

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Superior Standards.

“

From the business structure of this physcian owned and governed company, to the proactive approach to risk management, CAP’s priorities are consistent with my own style of practice and business philosophies.

“

– Tammy Wu, MD CAP District Council Member

The Cooperative of American Physicians, Inc. (CAP)

is the only physician owned and governed company whose

core product, Mutual Protection Trust, is Rated A+ (Superior) by A.M. Best Company. Superior physicians are dedicated to excellence. They should expect nothing less from their medical professional liability provider.

For more than 30 years, CAP has rewarded the dedication of superior physicians with superior protection for less. We keep our costs low by keeping our standards high. Membership might not come easy,

but once you get in, you know you’re in good company. To find out more, call 800-252-7706, or visit www.superiorphysicians.com.

C ooperative

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a meriCan p hysiCians , i nC . | 333 s. h ope s t ., 8 th f loor | l os a ngeles , Ca 90071 |

ORANGE

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The Mutual Protection Trust (MPT) is an unincorporated interindemnity arrangement among physicians authorized by Section 1280.7 of the California Insurance Code. Members do not pay insurance premiums. Instead, they pay tax-deductible assessments, based on risk classifications, for the amount necessary to pay claims and administrative costs. No assurance can be given as to the amount or frequency of assessments. Members also make a tax-deductible Initial Trust Deposit, which is refundable according to the terms of the MPT Agreement.

$5.95 | www.SANDIEGOPHYSICIAN.org San diego County Medical Society 5575 RUFFIN ROAD, SUITE 250 SAN DIEGO, CA 92123 [ RETURN SERVICE REQUESTED ]

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