January 2010

january 2010

official publication of the san diego county medical society

wellness “ 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 ”

We fight frivolous claims.

We smash shady litigants.

We over-prepare, and our lawyers do, too. We defend your good name. We face every claim like it’s the heavyweight championship.

We don’t give up. We are not just your insurer. We are your legal defense army.

We are The Doctors Company.

Robert D. Francis Chief Operating Officer, The Doctors Company

The Doctors Company built its reputation on the aggressive defense of our member physicians’ good names and livelihoods. And we do it well: Over 82 percent of all malpractice cases against our members are won without a settlement or trial, and we win 87 percent of the cases that do go to court. So what do you get for your money? More than a fighting chance, for starters. To learn more about our medical professional liability program for San Diego County Medical Society members, call (800) 328-8831, extension 4390 or visit us at www.thedoctors.com.

Endorsed by

B

SAN DIEGO PHYSICIAN. or g January 2010

At VITAS, the Focus is on Life VITAS Innovative Hospice Care® brings care near the end of life right to the home, whether that is a private residence, a nursing home or an assisted living community.

We manage pain and other symptoms while focusing on quality of life for the patient and his or her family. And we do it one patient at a time, just as we did at the beginning.

What began in 1978 as a volunteer effort supported by donations for a lucky few is now a Medicare benefit available at no cost to every qualified patient and family.

With VITAS, there are no limits on quality of life.

1.800.93.VITAS • 1.800.938.4827 VITAS.com

January 2010 SAN DIEGO PHYSICIAN . o rg

1

thismonth Volume 97, Number 1

features 28 INTEGRATING INTEGRATIVE MEDICINE

by Robert Alan Bonakdar, MD 32 UPSTREAM MEDICINE: THE CASE FOR PRESCRIPTIVE HEALTH-RELATED BEHAVIORS

by E. Lee Rice, DO 38 A STRATEGIC FRAMEWORK FOR HEALTH IMPROVEMENT IN SAN DIEGO COUNTY: THE 3-4-50 IMPERATIVE

by Nick Macchione, MS, MPH, and Wilma Wooten, MD, MPH

22

departments

wellness

4 Contributors This Issue’s Contributing Writers

w 6 SDCMS Seminars/webinars/Events T e healthhe, ecsondition of goo ll·ness (we˘ l’n˘is pecially w d8 p Community ) Calendar hen mahinysical and menHealthcare ta ta in l e die 10 Briefly d t, exercise byNoted , and hparoper s.

Ask Your Officebit Manager Advocate and More …

14 MEDICARE UPDATE SGR Cuts, Consultation Codes, Helpful Resources 16 PUBLIC HEALTH Physicians Partnering With WIC to Build Healthy Families 19 WIC Program Changes — Editorial Comment

26

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20 AMA Interim Meeting Report 22 SUCK IT UP, AMERICA 37 SDCMS Endorsed partner benefits Potential Value: $10,000–$17,000 42 Physician Marketplace Classifieds 44 San Diego Physician Reader Survey

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UR gazine O Y e v pro ician MaGift Certificate! m I s U HelpDiego Phndyenst Will Win a $100 zine by answering! the maga ank you San rvey Respo 334. Th hysician

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Take a Moment to Help Us Improve YOUR San Diego Physician Magazine Please help SDCMS improve the content of San Diego Physician magazine by telling us which topics you’d like to see covered more, which less, and which about the same.

One Lucky Survey Respondent Will Win a $100 Gift Certificate!

See Page 44

site?

MS’ web sit SDC Er you vi o NE v do LY n te tH of o MON 4. How O NO EEk LY S oN W YE o YE S o o ILY ber? ber? o NO 2010 o DA S mem S mem YE S o SDCM SDCM ber? o you an er of an em ag m 5. Are an ce m MS non r C offi u e SD is yo an you th , what ager of 6. Are anager e man

January 2010 SAN DIEGO PHYSICIAN . o rg

3

contributors THE AMERICAN RED CROSS — WOMEN, INFANTS, AND CHILDREN PROGRAM For more than 30 years, The American Red Cross' Women, Infants, and Children (WIC) Program — funded by the U.S. Department of Agriculture — has helped pregnant women, new mothers, and young children eat well, stay healthy, and be active.

Agency, overseeing an annual budget of more than $1.4 billion and a workforce of more than 5,000 employees.

E. LEE RICE, DO

Dr. Bonakdar, SDCMS and CMA member since 2005, is the director of pain management at the Scripps Center for Integrative Medicine and the co-director of the Scripps conference "Natural Supplements: An Evidence-based Update."

Dr. Rice, SDCMS and CMA member since 2009, is the founder and CEO of the Lifewellness Institute, specializing in preventative medicine, wellness, and health promotion. He is the Dr. Jerry C. Lee Endowed Chair at National University, charged with furthering the goals of the Center for Integrative Health, a clinical professor at Western University of Health Sciences, and an associate clinical professor at UCSD School of Medicine.

STUART A. COHEN, MD, MPH

The doctors Company

ROBERT ALAN BONAKDAR, MD

Dr. Cohen, SDCMS and CMA member since 1988, is in private practice with Children’s Primary Care Medical Group. He is an American Academy of Pediatrics delegate to AMA and CMA, and is SDCMS’ immediate past president.

THOMAS A. DOYLE, MD Dr. Doyle is a specialist in emergency medicine who practices in Sewickley, Pennsylvania. This is an excerpt from a book he is writing entitled Suck It Up, America: The Tough Choices Needed for Real Healthcare Reform. Dr. Doyle can be reached at tomdoy@aol.com.

JAMES T. HAY, MD Dr. Hay, SDCMS and CMA member since 1985, is a family physician in full-time private practice in Encinitas. He founded North Coast Family Medical Group in 1978 and North County Physicians’ Medical Group (an IPA) in 1990. He is past president of SDCMS, past president of the SDCMS Foundation, current “Champion” of the Foundation’s Project Access San Diego (PASD), and is the current speaker of CMA’s House of Delegates.

The Doctors Company is the largest national insurer of physician and surgeon medical liability.

LAUREN WENDLER Ms. Wendler is your SDCMS office manager advocate. She can be reached at (858) 3002782 or at LWendler@SDCMS.org with any questions your office manager may have.

WILMA J. WOOTEN, MD, MPH Dr. Wooten, SDCMS and CMA member since 2006, is the public health officer for the County of San Diego, Health and Human Services Agency. She is board-certified in family medicine and has a master’s degree in public health. From 1990 to 2001, she practiced medicine as a faculty member in the UCSD Department of Family and Preventive Medicine; she joined the County of San Diego in March 2001. Dr. Wooten remains a UCSD volunteer associate clinical professor and is an adjunct professor at SDSU’s Graduate School of Public Health.

Managing Editor Kyle Lewis Editorial Board Van Le Cheng, MD, Adam F. Dorin, MD, Kimberly M. Lovett, MD, Theodore M. Mazer, MD, Robert E. Peters, MD, PhD, David M. Priver, MD, Roderick C. Rapier, MD 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 and geographic alternate Directors East County William T. Tseng, MD, Heywood “Woody” Zeidman, MD (Alternate: Venu Prabaker, MD) Hillcrest Steven A. Ornish, MD, Niren Angle, MD (Alternate: Eric C. Yu, MD) Kearny Mesa Adam F. Dorin, MD, John G. Lane, MD (Alternate: Jason P. Lujan, MD) La Jolla J. Steven Poceta, MD, Wayne Sun, MD (Alternate: Matt H. Hom, MD) North County Arthur “Tony” Blain, MD, Douglas Fenton, MD, James H. Schultz, MD (Alternate: Steven A. Green, MD) South Bay Vimal I. Nanavati, MD, Michael H. Verdolin, MD (Alternate: Andres Smith, 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 At-large alternate Directors James E. Bush, MD, Richard O. Butcher, MD, Ben Medina, MD, Jerome A. Robinson, MD, Alan A. Schoengold, MD, Edward L. Singer, MD, Carol L. Young, MD Communications Chair Theodore M. Mazer, MD Young Physician Director Kimberly Lovett, MD Young Physician alternate Director Van Le Cheng, MD Resident Physician Director Katherine M. Whipple, MD Resident Physician Alternate Director Steve H. Koh, MD Retired Physician Director Glenn Kellogg, MD Retired Physician alternate Director John A. Bishop, MD Medical Student Director Jane Bugea Medical Student alternate Director Iain J. Macewan CMA Speaker of the House James T. Hay, MD CMA Past Presidents Robert E. Hertzka, MD, Ralph R. Ocampo, MD CMA Trustees Catherine D. Moore, MD, Theodore M. Mazer, MD, Albert Ray, MD, Diana Shiba, MD, Robert E. Wailes, MD AMA Delegates James T. Hay, MD, Robert E. Hertzka, MD AMA Alternate Delegates Lisa S. Miller, MD, Albert Ray, MD

NICK MACCHIONE Mr. Macchione is the director of the County of San Diego, Health and Human Services

››Send your letters to the

editor to Editor@SDCMS.org 4

SAN DIEGO PHYSICIAN. or g January 2010

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 DPebdani@SDCMS.org. 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.]

150 BEST ONE OF MEDICAL ECONOMICS

s For docTors

FINANCIAL ADVISORS

nt, but do charge a minimum you keep a pre-set amount don’t have that much, the e advisers are flexible about FOR n an adviser but don’t meet ght want to inquire anyway. o require $1 million or less

DOCTORS

ked each adviser against the s and Exchange Commission arry has over 27 years experience as a wealth advisor, with hority to confirm that they had more than 10 of those years with Morgan Stanley Smith oing on a national level.

B

Barney. In addition to providing financial planning services,

Printed in U.S.A.

he provides a variety of other advisory and non-advisory financial

Technician,SM Certified Financial PlannerTM Practitioner and a Chartered Mutual Fund CounselorSM. Barry Masci brings broad-based financial experience and is committed to professional excellence.

options, including brokerage services to clients who seek such assistance. Barry earned his MA from the University of San Diego.

WHAT DO

ATIONS

e A n?

His credentials include Chartered Financial Analyst, Chartered Market

MorganStanley SmithBarney

fications in finance and l types of credentials, but ost well-known. er: Advisers are INDIVIDUAL SOLUTIONS ONE-TO-ONE ATTENTION

CERTIFICATIONS MEAN?

Many advisers on our list have certifications in finance and financial planning. There are several types of credentials, but we’ve limited our listing to those most well-known.

CFP

Certified Financial Planner: Advisers are knowledgeable about all phases of financial planning including insurance, estate and retirement planning.

as focuses one of the t: This designation onindustry’s premier wealth management firms. We focus our firm’s resources on serving a wide variety of clients, from corporations, ancial analysis forworldwide stocks and institutions and foundations, to private business and affluent individuals. de of ethics.

CFA

Chartered Financial Analyst: This designation focuses on portfolio management and financial analysis for stocks and investing.

Adheres to strict code of ethics.

nselor: Extensive Morgan analysisStanley of Smith Barney is known for being an innovator, providing areas: selection, risk, portfolio customized financial solutions to some of the most sophisticated institutional urement and retirement planning. investors who require strong relationships and penetrating insights. We apply cs and professional theconduct. same thinking in our efforts to help individuals build, manage and preserve

CMFC

Chartered Mutual Fund Counselor: Extensive analysis of mutual funds in the following areas: selection, risk, portfolio allocation, performance measurement and retirement planning.

Adheres to strict code of ethics and professional conduct.

CMT

Chartered Market Technician: A “technician,” also known as a “chartist,” looks to take the emotion out of investing by applying rules that usually apply to almost every investment that fluctuates in price in a free market. Demonstrates integrity and knowledge in ethical standards.

ases of financial planning and retirement planning.

Built on over 130 years of experience, Morgan Stanley Smith Barney is recognized

their wealth.

an: A “technician,” also known is a paidby advertisement. he emotion out of This investing ply to almost everyInvestments investment and services are offered through ee market. Demonstrates Morgan Stanley Smith Barney, member SIPC. ical standards.

nvestment ducation,

rience e than organ

© 2009 Morgan Stanley Smith Barney

CONTACT FOR A COMPLIMENTARY CONSULTATION: Barry D. Masci CFP®, CFA, CMFC®, CMT SM

Toll Free: 800-473-1331 Direct: 619-238-6243 • Fax: 619-235-9313 barry.masci@morganstanley.com www.morganstanley.com/fa/barry.masci

Morgan Stanley Smith Barney ddition 101 West Broadway. 18th Floor • San Diego, CA 92101 ervices, visory andSource: non-advisory 150 Best Financial Advisors for Doctors, September 18, 2009 as identified by the Medical Economics using quantitative and qualitative criteria and selected from a pool of nominations. Financial Advisors in the 150 Best Financial Advisors for rage services clients Doctorsto should have a minimum of ten years of experience; require at least a minimum investment of at least one million dollars; acceptable compliance records and are not commission only based. Other factors considered were certifications that require continuing education and if they specialized in the physician business or the medical fields. The rating may not be representative of any one client’s experience. The rating is not indicative of the Financial Advisor’s future performance. Neither earned hisMorgan MAStanley fromSmith the Barney nor its Financial Advisors pay a fee to Medical Economics in exchange for the rating.

January 2010 SAN DIEGO PHYSICIAN . o rg

O N E O F W O R T H M AG A Z I N E ’S TO P 2 5 0 W E A LT H A D V I S O R S F O R 2 0 0 8

5

sdcmsseminars/webinars/events

Free to Member Physicians and Their Office Staff!

Don’t See What You Need? Let Us Know!

For further information, visit SDCMS.org or contact Lauren Wendler, your SDCMS office manager advocate, at (858) 300-2782 or at LWendler@SDCMS.org.

SDCMS 2010 Seminars / Webinars / Events Date

Day

Time

Topic

Presenter

S W E

JAN 7

THU

11:30am – 1:00pm

Collections

Catherine Sherman, TSC Accounts Receivable Solutions

x

JAN 9

SAT

8:00am – 11:00am

Advocacy Training

Tom Gehring, SDCMS

x

JAN 20

WED

6:30pm – 7:30pm

Risk Management (“Scope of Practice of Allied Health Professionals”)

The Doctors Company

x

JAN 21

THU

11:30am – 12:30pm

Risk Management (“Scope of Practice of Allied Health Professionals”)

The Doctors Company

x

JAN 27

WED

11:30am – 1:00pm

Human Resources Law

Elizabeth Koumas, Koumas Law Group

x

x

FEB 4

THU

11:00am – 1:00pm

Practice Management (“Treating Patients Right”)

Judy Bee, Practice Performance Group

x

x

FEB 11

THU

6:00pm – 9:00pm

Young Physician Winter Social

SDCMS

FEB 17

THU

10:00am – 12:00pm

Palmetto / Medicare

Michele Kelly, California Medical Association

FEB 25

THU

9:00am – 7:00pm

EMR / EHR Trunk Show

Maxwell IT, Multiple Exhibitors

FEB 27

SAT

9:00am – 1:00pm

Retirement (“End-game Planning”)

Jeffrey Denning, Practice Performance Group

x

9:00am – 4:00pm

Certified Medical Office Manager Course

Practice Management Institute

x

MAR 5–26 4 FRIDAYS

6

x

x x

x x

MAR 18

THU

11:30am – 1:00pm

Contract Management

Kim Fenton, Coastal Healthcare Consulting Group

x

x

MAR 24

WED

9:00am – 12:00pm

Billing and Collections Procedures (“Back to Basics”)

California Medical Association

x

x

APR 2

FRI

6:00pm – 9:00pm

New Member Social (T)

SDCMS

APR 17

SAT

8:30am – 3:30pm

Resident Physician Workshop (“Preparing to Practice”)

Multiple Presenters

x

APR 21

WED

6:30pm – 7:30pm

Risk Management (“eHealth: Telemedicine and Telehealth”)

The Doctors Company

x

x

APR 22

THU

11:30am – 12:30pm

Risk Management (“eHealth: Telemedicine and Telehealth”)

The Doctors Company

x

x

APR 28

WED

11:30am – 1:00pm

Medi-Cal

(TBD)

x

x

MAY 6

THU

11:30am – 1:00pm

IT

Ofer Shimrat, SOUNDOFF Computing Corporation

x

x

SAN DIEGO PHYSICIAN. or g January 2010

x

January 2010 SAN DIEGO PHYSICIAN . o rg

7

communityhealthcarecalendar

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

Anesthesiology Update Conference 2010

33rd Annual San Diego Postgraduate Assembly in Surgery

Jan. 13–16 • Kona Kai Spa Resort and Spa, San Diego • cme.ucsd.edu

Feb. 18–20 • Omni San Diego Hotel • cme.ucsd.edu

10th Annual San Diego Heart Failure and Hypertension Symposium for Primary Care and Internal Medicine Jan. 16 • Estancia La Jolla Hotel and Spa • cme.ucsd.edu

Melanoma 2010: 20th Annual Cutaneous Malignancy Update Jan. 16–17 • Hilton San Diego Resort and Spa • scripps.org/conferenceservices

7th Annual Natural Supplements: An Evidence-based Update Jan. 21–24 • Paradise Point Resort and Spa • scripps.org/conferenceservices

Minimally Invasive Robotics Association 5th International Congress Jan. 27–30 • Manchester Grand Hyatt, San Diego • cme.ucsd.edu

Headaches: Easing the Pain (15-Minute Evaluation Tools for the Busy Primary Care Physician) Feb. 27 • The Dana on Mission Bay • scripps. org/conferenceservices

Topics and Advances in Internal Medicine Mar. 4–10 • Hilton San Diego Resort and Spa • cme.ucsd.edu

The Future of Genomic Medicine III

Feb. 4–6 • Estancia La Jolla Hotel and Spa • cme.ucsd.edu

Scripps Cancer Center’s 30th Annual Conference: Clinical Hematology and Oncology Feb. 13–16 • Omni San Diego Hotel • scripps. org/conferenceservices

8

SAN DIEGO PHYSICIAN. or g January 2010

Mar. 26 • The Hilton Harbor Island Hotel • prt@cwsl.edu

5th Annual Brain Injury Rehabilitation Conference Mar. 26–27 • The Schaetzel Center, Scripps Memorial Hospital, La Jolla • scripps.org/ conferenceservices

25th Annual New Treatments in Chronic Liver Disease Mar. 27–28 • Hilton La Jolla Torrey Pines • scripps.org/conferenceservices

Mar. 5–6 • The Neurosciences Institute Auditorium, San Diego • scripps.org/conferenceservices

15th Annual Primary Care in Paradise

Topics and Advances in Pulmonary and Critical Care Medicine

23rd Annual Review of Vascular and Interventional Radiology

Mar. 11–12 • Hilton San Diego Resort and Spa • cme.ucsd.edu

3 Annual UCSD Urology Postgraduate Course rd

29th Annual Advanced Nephrology: Nephrology for the Consultant

6th Annual San Diego Health Policy Conference

Mar. 13–15 • Hilton La Jolla Torrey Pines • cme. ucsd.edu

20th Annual Nelson Butters’ West Coast Neuropsychology Conference Mar. 25–28 • Hilton San Diego Resort and Spa • cme.ucsd.edu

Mar. 29–Apr. 1 • Marriott Kauai Resort, Kauai, Hawaii • scripps.org/conferenceservices

Apr. 3 • Hotel del Coronado • cme.ucsd.edu

30th Annual Residents’ Radiology Review Course Apr. 4–9 • Hotel del Coronado • cme.ucsd.edu

Research Summit Apr. 9 • The Schaetzel Center, Scripps Memorial Hospital, La Jolla • scripps.org/conferenceservices

3rd Annual Sudden Cardiac Arrest: From Awareness to Prevention Apr. 17–18 • Hyatt Regency La Jolla • scripps. org/conferenceservices

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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. One of the nation’s leading specialty insurance brokerage firms, Alliant Insurance has the experience and drive to meet the needs of SDCMS members.

Contact us at (713) 470-4154

January 2010 SAN DIEGO PHYSICIAN . o rg

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brieflynoted Your Office Manager Advocate Has the Answers!

By Lauren Wendler

medication?

information, visit EXP’s website at www.expworld.com.

Answer: According to the Drug Enforcement Agency (DEA), if the office cannot return the medication back to the pharmaceutical company for credit, then they can call the only distributor in California, EXP Pharmaceutical Services Corporation, at (800) 350-0397, to take these drugs and dispose of them properly. EXP will mail out a box for the medication with directions on how to ship it back. The quantity does not matter, so even small packages are accepted. For further

Question: A patient that I evaluated for a workers’ compensation case is now requesting a copy of his medical records. Do I have to comply with the patient access laws with respect to persons I have evaluated for judicial or administrative proceedings?

Answer: We are of the opinion that treating physicians must comply with these disclosure requirements regardless of how they are paid. Thus, the fact that a treating physi-

Question: What should I do with expired

›› Expired Medications ›› Medical Record Requests ›› Valuing a Medical Practice 10

SAN DIEGO PHYSICIAN . or g January 2010

cian is paid by a workers’ compensation insurer does not affect the patient’s right to information. However, the opinions and/or conclusions of a physician retained as an expert in a workers’ compensation case are not subject to disclosure pursuant to the patient access law because the individual in that case is not a “patient” of the expert. Physicians acting as experts should consult with the attorney who retained them concerning requests for information by an individual they evaluate. Physicians should be aware that people they examine at the direction of attorneys pursuant to Code of Civil Procedure §§2032.010 et seq. are entitled to a copy of the physician’s report pursuant to Code of Civil Procedure §§2032.610 et seq. For further information, consult CMA ON-CALL document #1150, “Patient Access to Medical Records,” available free to SDCMS-CMA members at www.cmanet.org. For assistance in logging onto CMA’s website, contact me at (858) 300-2782 or at LWendler@SDCMS.org.

PubMed Changes ✱

H

Get Help When You Need It

Have you noticed all of the recent changes in PubMed, including a totally new look to the interface?

While the search process is basically the same, some of the links and icons have moved or been rearranged. If you need help figuring out how to search PubMed, limit your results, find full text articles, or learn about some of the new features, contact the UC San Diego Biomedical Library for assistance or sign up for a free PubMed training session at the library.

You can reach the librarians at the UCSD Biomedical Library by phone, by email, by instant messaging, or in person.

Contact details are located at biomed.ucsd.edu/ask. Note that these services are available weekdays from 9 a.m. to 4 p.m. It is also possible to chat with a librarian around the clock, 24/7. However, depending on the hour, you may be chatting with a librarian from another academic library. If your question is UC San Diego-specific, a UC San Diego librarian will follow up with additional information.

The library is offering two free PubMed workshops during the winter quarter: an introductory workshop — “Essential PubMed” — on January 20, 2010, from 10:00 a.m. to 11:30 a.m., and Upcoming PubMed Workshops an advanced workshop — “Beyond the Essentials” — on March 11, FREE TO ATTEND! 2009, from 2:00 p.m. to 3:30 p.m. To sign up for a workshop, fill out “Essential PubMed” (introductory workshop) the form located at libraries.ucsd.edu/locations/bml/guides/workWednesday, January 20, 2010, 10:00 a.m. – 11:30 a.m. shops-at-bml.html or contact Vicky Anderson at vkanderson@ucsd.

“Beyond the Essentials” (advanced workshop) edu or at (858) 822-4760. Biomedical Library workshops are open to Thursday, March 11, 2009, 2 p.m. – 3:30 p.m. all local healthcare professionals.

Question: Our physician is considering retirement in the next year. Does SDCMS have any endorsed partners who would be able to determine the value of the medical practice?

Answer: SDCMS-endorsed partner, Practice Performance Group (PPG), provides assistance in valuing medical practices, offering them for sale, and coaching physicians through the process. Jeff Denning may be reached at (858) 459-7878 or at Jeff@PPGConsulting.com. SDCMS-CMA members receive discounts from PPG on management consulting. SDCMS will also be hosting a Retirement Seminar, “Endgame Planning,” on Feb. 27, 2010. For further information, visit our list of upcoming seminars on page six or visit SDCMS’ “Calendar of Events” at SDCMS.org.

{About the Author}

Ms. Wendler is your SDCMS office manager advocate. She can be reached at (858) 3002782 or at LWendler@SDCMS.org with any questions your office manager may have.

SDCMS Physician Wellbeing Commission

S

SDCMS’ Physician Wellbeing Commission — chaired by Lawrence Cooper, MD, and staffed by Karen Dotson — is charged with serving as a forum for San Diego County physicians and hospitals for the discussion of impaired physician issues and the ethical tensions associated with impaired physicians, the sharing of best practices in dealing with impaired physicians, the development of nonbinding standards in San Diego County for dealing with impaired physicians, communications to, for, and from physicians and hospitals in matters of physician wellbeing, and the education on physicians in general in impaired physician matters.

For further information, contact SDCMS at (858) 565-8888 or at SDCMS@SDCMS.org.

January 2010 SAN DIEGO PHYSICIAN . o rg

11

brieflynoted {risk tip}

Informed Refusal M

By The Doctors Company

ore adults of sound mind are exercising their right to refuse test or treatment options. Documentation of a patient’s refusal is the key to minimizing your risk exposure.

Patient refusal of procedures or tests doesn’t equate with their incompetence. Refusal to comply, however, can be an important cautionary flag. Physicians should take a close look at their recommendations and at the reasoning behind the patient’s refusal to follow them.

In Truman v. Thomas, 27 Cal.3d 285 (1980), the California Supreme Court held that physicians are responsible for making sure patients are aware of all significant risks that could result from noncompliance. Physicians’ obligations apply equally to all tests and procedures, whether simple and routine

or unusually complex. The obligation also applies to a recommendation that a patient see a specialist, holding that physicians must inform patients of the possible consequences of not getting a consultation.

Documentation in a patient’s medical record of a refusal should include the following notations: • Information that the physician gave the patient concerning his or her condition and the proposed treatment or test. Reasons for the treatment or test should be noted.

• Patient was advised of the possible risks and consequences, including the loss of life or limb, of failing to undergo treatment or a test.

• Physician’s referral of the patient to a specialist, including the reasons for the referral and possible risks of not seeing

the specialist.

• Patient’s refusal of the physician’s treatment/testing plan or advice. In this circumstance, consider asking the patient to sign a specific refusal of treatment form (available in the “Miscellaneous” category of The Doctors Company informed-consent form resource center at TheDoctors.com/Consent). Although such a form is optional, it offers physicians the strongest protection against claims alleging a lack of informed consent.

For more risk management tips, articles, and information, please visit www.thedoctors.com/ knowledgecenter.

Physicians Get Noticed!

Wish Your Legislators a Happy Birthday!

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SAN DIEGO PHYSICIAN . or g January 2010

Physicians: Let your legislators know that you’re paying attention and that you vote by wishing them a happy birthday!

Birthday: January 28 Congressman Brian Bilbray United States Congress 2348 Rayburn House Office Building Washington, DC 20515 T: 202-225-0508 F: 202-225-2558 E: www.house.gov/bilbray

Birthday: January 12 Senator Dennis Hollingsworth California State Senate P.O. Box 942848 Sacramento, CA 94248-0036 T: 916-651-4036 F: 916-447-9008 E: senator.hollingsworth@sen.ca.gov

Birthday: February 11 Assemblyman Joel Anderson California State Assembly P.O. Box 942849 Sacramento, CA 94249-0077 T: 916-319-2077 F: 916-319-2177 E: assemblymember.anderson@assembly.ca.gov

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) 300-2788 or at Beaubeaux@SDCMS.org Director of Membership DevelopmenT Janet Lockett at (858) 300-2778 or at JLockett@SDCMS.org Director of Membership Operations and Physician Advocate Marisol Gonzalez at (858) 300-2783 or at MGonzalez@SDCMS.org Office Manager Advocate Lauren Wendler at (858) 300-2782 or at LWendler@SDCMS.org Director of Engagement Jennipher Ohmstede at (858) 300-2781 or at JOhmstede@SDCMS.org 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 administrative assistant Betty Matthews at (858) 565-8888 or at BMatthews@SDCMS.org Letters to the Editor Editor@SDCMS.org General Suggestions SuggestionBox@SDCMS.org

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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January 2010 SAN DIEGO PHYSICIAN . o rg

13

medicare By the Alameda-Contra Costa Medical Association

Medicare Update SGR Cuts • Consultation Codes • Helpful Resources [Note: Thank you to the Alameda-Contra Costa Medical Association for compiling the following and permitting SDCMS to reprint it here.]

21.2 Percent Medicare SGR Cut Stopped Responding to organized medicine advocacy, President Obama signed legislation preventing the scheduled 21.2 percent cut in Medicare payments from taking place on Jan. 1, 2010. The cut is delayed for 60 days, until Feb. 28, 2010, giving Congress time to adopt a longer-term solution to the unfair Medicare payment formula known as the “Sustainable Growth Rate” (SGR). This means that the fee schedule posted on Dec. 17, 2009, by Medicare contractor Palmetto GBA — see Fee Schedules under the “Self-service Tools” list at www.palmettogba.com/J1B — is 21.2 percent lower than it actually was on Jan. 1, 2010.

Passage of legislation to stop the 21.2 percent cut prompted Medicare to extend the 2010 “participation” enrollment deadline again, until March 17, 2010. The effective date for any participation status change during the extension, however, remains Jan. 1, 2010, and will be in force for the entire year.

Consultation Codes Eliminated and Other Codes Revalued Effective Jan. 1, 2010 Unfortunately, changes in payment policies and valuations of individual codes that were incorporated into the Medicare payment rule for 2010 remain in effect, and Medicare has refused to delay or reverse these changes.

This includes elimination of payment of consultation codes and reduced valuation of many procedural codes. E&M codes will receive increases in valuation under the rule.

The expected results are modest increases in average Medicare pay for physicians in primary care and reductions in average pay for some specialists. Projected changes are as follows (from highest to lowest): • Ophthalmology +5 percent • Family Practice +4 percent • General Practice +3 percent • Geriatrics +3 percent • Internal Medicine +2 percent

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• Interventional Radiology -3 percent • Urology -4 percent • Radiology -5 percent • Cardiology -8 percent • Nuclear Medicine -18 percent

CMA to Offer Webinar on Billing for Consultations and Making a Decision on “Participation” CMA will host a webinar on Wednesday, January 20, 2010, from 12:15pm to 1:15pm, to assist member physicians and their office staff who might be unsure how to bill for consultations and who might also like guidance on making a decision about whether to be a “participating” or “nonparticipating” physician in Medicare in 2010. To register to attend this webinar, call SDCMS at (858) 565-8888

Initial Guidance on Billing for Consultations

(Prepared From Information Provided by the California Medical Association)

The eliminated consultation codes comprise 99241–99244 for office or other outpatient consults and 99251–99255 for inpatient consultations. According to the new rules, Medicare is requiring physicians instead of billing for consultation services to bill using evaluation and management (E&M) codes from the Office and Other Outpatient Services, Initial Hospital Care, and Initial Nursing Facility sections of the 2010 CPT coding guidelines. Physicians using electronic medical and health records (EMR/EHR) software and practice management and other coding systems should contact their vendors for any necessary program updates. Guidance on coding is as follows: Office and Other Outpatient Services: For consultative services provided in physician offices or other outpatient settings, physicians will need to report the level of care provided based on CPT coding requirements for E&M services (i.e., history and exam, medical decision making and contributory factors presenting problem [severity], counseling, coordination of care,

and typical face-to-face time). For example, instead of using criteria for consultation CPT codes 99241–99245, physicians will need to follow AMA CPT coding guidelines for CPT codes 99201–99205 and 99211–99215 to determine the appropriate level of care (new or established) provided to the patient. “The descriptors for the levels of E&M recognize seven components, six of which are used in defining the levels of E&M services. The first three components (history, examination, and medical decision making) are considered the key components and are required in selecting the appropriate level of E&M services. The next three components (counseling, coordination of care, and the nature of the presenting problem) are considered contributory factors and, while important, they are not required to be provided during each patient encounter” (source AMA CPT 2010). It is important to note that there is time variance between consultation codes and office visit codes that the physician typically spends face-to-face with the patient according to CPT coding guidelines. However, time references in CPT guidelines are only averages, and therefore coding should depend on the actual clinical circumstances.

Given the change in these rules, physicians should familiarize themselves with CPT coding guidelines when 50 percent or more of the visit is spent on counseling and/or coordination of care, and the use of CPT Prolonged (Face-To-Face) Service Add-on codes (99354–99357). Figure 1 illustrates the crosswalk between outpatient consultation codes and corresponding E&M codes.

Inpatient and SNF Services: Physicians will no longer use CPT codes 99251–99255 for reporting consultative services provided to patients in inpatient hospital or skilled nursing facility settings. Instead, physicians (and qualified nonphysicians) are required to report these services by selecting the appropriate CPT Initial Hospital Care codes (99221–99223) or nursing facility care codes (99304–99306). There is no direct crosswalk between hospital consultation codes and initial hospital care and nursing facility codes.

To crosswalk, physicians should choose the corresponding initial hospital care or nursing facility care code that meets all three levels of the key components (History & Exam, Medical Decision Making; Presenting Problem(s)).

(For detailed guidance on determining the

appropriate E&M code that describes the level of service provided in a consultation, refer to the E&M guidelines in the American

Figure 1

Medical Association’s CPT 2010). As a result of this change, multiple billings of initial hospital and nursing home visit codes could occur even in a single day.

Coding Crosswalk — New Patient (requires all three key components)

CPT Crosswalk — Established Patient (requires two of three key components)

99241

99201 •Problem focused History •A problem focused examination •Straightforward medical decision making

99211 •Problem focused history •A problem focused examination •Straightforward medical decision making

99242

99202 •An expanded problem focused history •An expanded problem focused examination •Straightforward medical decision making

99212 •An expanded problem focused history •An expanded problem focused examination •Straightforward medical decision making

99243

99203 •A detailed history •A detailed examination •Medical decision making of low complexity

99213 •A detailed history •A detailed examination •Medical decision making of low complexity

99244

99204 •A comprehensive history •A comprehensive examination •Medical decision making of moderate complexity

99214 •A comprehensive history •A comprehensive examination •Medical decision making of moderate complexity

99245

99205 •A comprehensive history •A comprehensive examination

99215 •A comprehensive history •A comprehensive examination •Medical decision making of high complexity

CPT Consultation Code

•Medical decision making of high complexity

Modifier “-AI”: Another important change is that the modifier “-AI,” defined as “Principal Physician of Record,” must be used by the admitting or attending physician who oversees the patient’s care, as distinct from other physicians who may be furnishing specialty care. The principal physician of record must append modifier “-AI” in addition to the initial visit code. All other physicians who perform an initial evaluation on this patient shall bill only the E&M code for the complexity level performed.

CMS Links for More Information: • Consultation Rule: www.cms.hhs.gov/MLNMattersArticles/downloads/MM6740.pdf • 1995 coding guidelines: www.cms.hhs.gov/ MLNProducts/Downloads/1995dg.pdf • 1997 coding guidelines: www.cms.hhs.gov/ MLNProducts/Downloads/MASTER1.pdf • E&M Guide: www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_ guide.pdf

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January 2010 SAN DIEGO PHYSICIAN . o rg

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publichealth

By The American Red Cross — Women, Infants, and Children Program

Pediatricians, Obstetricians, and Family Practice Physicians Partnering With WIC to Build Healthy Families

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SAN DIEGO PHYSICIAN . or g January 2010

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The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has recently instituted monumental changes to its food packages to improve the nutritional intake of mothers and children as well as to promote breastfeeding. Pediatricians, obstetricians, and family practice physicians can partner with WIC to ensure that these food package changes benefit families, increase breastfeeding rates, and reduce the risks of obesity and other chronic diseases.

Currently, more than 50 percent of women, infants, and children in the United States are eligible for WIC. In San Diego County, there are approximately 100,000 WIC participants.

Along with enhanced food packages for breastfeeding mothers, WIC provides additional information, incentives, and support services to encourage breastfeeding.

Food Package Changes The new WIC food packages are based on recommendations from the Institute of Medicine (1) and were introduced in California on Oct. 1, 2009. The food packages align with the Dietary Guidelines for Americans (2) and infant feeding practice guidelines of the American Academy of Pediatrics (3). WIC has been educating its participants about the new foods for several months. Some of the major changes to the WIC food packages include the following: • Enhanced food package for mothers who choose to breastfeed, including baby foods for children over six months of age, and fish for the mother.

• Cash value vouchers to purchase fresh fruits and vegetables.

• Whole-grain bread and tortillas.

January 2010 SAN DIEGO PHYSICIAN . o rg

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publichealth • Whole milk for children ages 12–23 months; 1 percent or fat-free milk for children 2–4 years of age (whole milk for older children requires a physician’s prescription).

• Required documentation of a qualifying condition from a physician for special formulas or diets.

• Less formula after six months of age for partially breastfed infants and older babies.

Breastfeeding Support Along with enhanced food packages for breastfeeding mothers, WIC provides additional information, incentives, and support services to encourage breastfeeding. To help new mothers establish their milk supply, WIC encourages mothers to exclusively breastfeed in the first month of their baby’s life. Formula is not routinely provided to breastfeeding mothers in the first month of the baby’s life unless there is a medical reason for formula supplementation. All newborn babies are screened for feeding prob-

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Additional Resources To access the following additional resources, visit the January issue of San Diego Physician online at SDCMS.org/publications: • Institute of Medicine Report • New WIC Requirements • WIC Information for Health Professionals • UC Davis Human Lactation Center lems upon enrollment in the WIC program and are referred to their healthcare provider if problems are evident.

Many new mothers wonder if they have enough breast milk for their baby, especially if their baby cries or wakes up more often than they expected (4). To help reassure new mothers that their baby is getting enough milk, WIC provides them with information about normal baby behavior, including crying and sleep patterns.

Reinforcing Nutrition and Breastfeeding Messages WIC and physicians can work together to build healthier families and communities.

Physicians can reinforce the following nutrition messages that families receive from WIC: • Eat a rainbow of fruits and vegetables every day.

• Make half your grains whole.

• Lose the fat, keep the vitamins — drink low-fat milk.

Physicians can also support a mother’s decision to breastfeed by: • Encouraging her to exclusively breastfeed for at least the first four weeks to build up a full milk supply.

• Reassuring her that it is normal for newborn infants to wake up frequently to breastfeed.

• Encouraging her to seek breastfeeding support from her WIC office.

Conclusion The introduction of the new WIC food packages provides an important opportunity to improve the health of mothers and children and to promote breastfeeding. Physicians can incorporate similar messages into their counseling to reinforce the nutritional information that families receive from WIC and to maximize the benefits of the new food packages for thousands of families in San Diego County.

References 1. I nstitute of Medicine of the National Academies Committee to Review WIC Food Packages Food and Nutrition Board.

WIC food packages: Time for a change.

National Academies Press: Washington DC. 2006.

2. www.health.gov/DietaryGuidelines 3. Breastfeeding and the Use of Human Milk. Policy Statement. Section on Breastfeeding. Pediatrics Vol. 115 No. 2 February 2005, pp. 496-506.

4. Heinig et al. Barriers to Compliance With Infant-Feeding Recommendations Among Low-income Women. J Hum Lact 2006 Feb;22(1):27-38.

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Changes in the WIC Program Editorial Comment

by Stuart A. Cohen, MD, MPH Optimum time for initiation of complementary foods in infants is controversial. Based on avoidance of allergic manifestations in later life, some feel a more flexible range of 4–6 months is acceptable.

• The American Academy of Pediatrics (AAP) and the U.S. Department of Agriculture’s Food Guide Pyramid (MyPyramid.gov) recommend up to 32 ounces of formula at 8–12 months of age and 16 ounces (four half-cups) at 12–24 months of age.

• The WIC guidelines could be bolstered by a more precise definition of this transition, helping to prevent milk overfeeding and obesity in this age group.

{About the Author} Dr. Cohen, SDCMS and CMA member since 1988, is in private practice with Children’s Primary Care Medical Group. He is an AAP delegate to AMA and CMA, and is SDCMS’ immediate past president.

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January 2010 SAN DIEGO PHYSICIAN . o rg

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americanmedicalassociation

By James T. Hay, MD

Report of AMA’s Interim Meeting

T

N o v e mb e r 6 – 1 0 , 2 0 0 9

(Report Written November 2009)

The American Medical Association’s Interim Meeting was held in Houston Nov. 6–10, 2009. More than a thousand delegates and alternate delegates debated 66 resolutions and 25 reports and heard many informational presentations. It was one of the most important meetings in more than a generation because of the simultaneous discussions in Congress about health system reform.

Clearly that reform effort and the House and Senate bills that will make it happen were the major items of business at this meeting. Highlights of the meeting written by CMA’s extraordinary staff, Ginnie Yee, can be accessed

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SAN DIEGO PHYSICIAN . or g January 2010

at SDCMS.org. This report will attempt to address the subject most on everyone’s mind — reform — and only a few others.

Health System Reform AMA — and CMA for that matter — has attempted to place itself in a balanced position between full supporter and constructive critic as it has met with congressional and administration leaders crafting the legislation in Washington, DC. The nuanced use of the word “support” as used by AMA has been misrepresented by some legislators and by the media to imply AMA’s 100 percent

endorsement of HR 3962, the House bill awaiting action as I write. Many physicians at AMA, as well as some of you here in San Diego County, feared AMA had gone too far in supporting legislation that includes parts that may be harmful to patients, physicians, and the physician-patient relationship. AMA President James Rohack, MD, spent much of this meeting reassuring delegates that AMA supports, but does not currently “endorse” the legislation being considered. He and others reminded attendees many times that the process is in its very early stages and that much is yet to come.

By the time of this writing, the Senate will have introduced a bill for consideration as well. If and when it is passed in the Senate, the two bills will then be considered in a “conference committee” of legislative leaders from both houses and a compromise bill reported out, which will then need passage by both the House and the Senate before it can be sent to the president’s desk for signa-

It was one of the most important meetings in more than a generation because of the simultaneous discussion in Congress about health system reform. ture. Prior to the meeting of that conference committee, AMA leaders and lobbyists (and CMA) will be informing the legislature about the parts of the legislation that will be harmful to patients and physicians and that would need to be amended if AMA is to support the final language.

AMA’s House of Delegates engaged in lengthy debate about what constraints it wished to place on AMA’s board of trustees and staff as they proceed with this effort.

While a substantial minority wanted greater limits on what AMA could support, in the end, the majority voted for an amended set of principles that must be considered in order to support the effort at reform. First and foremost AMA does want a good reform bill to be written and passed. Much can be made better in our healthcare system. However, it must not carry with it unintended (or intended) consequences we and our patients will regret after the legislature has moved on to other things. The things we want are enumerated in the following “Seven Critical Components”: 1. H ealth insurance coverage for all Americans.

2. Insurance market reforms that expand choice of affordable coverage and eliminate denials for pre-existing conditions or due to arbitrary caps.

3. Assurance that healthcare decisions will remain in the hands of patients and their physicians, not insurance companies or government officials.

4. Investments and incentives for quality improvement and prevention and wellness initiatives.

5. Repeal of the Medicare physician payment formula that triggers steep cuts and threaten seniors’ access to care.

6. I mplementation of medical liability re-

forms to reduce the cost of defensive medicine.

7. Streamline and standardize insurance claims processing requirements to eliminate unnecessary costs and administrative burdens.

The AMA House adopted 13 additional clauses to more specifically outline for the leadership what it wanted to see and not see in legislation. These addressed outlawing payer coverage rescissions, maintenance of pluralism in the system, freedom of choice and practice, the right to privately contract, and support for comparative effectiveness research only if it is for improvement in patient care and not in the interest of reducing payments or access. They specifically oppose an “Independent Medicare Commission” or anything like it that would take the control away from Congress and give it to unelected officials. They outlined what an insurance “exchange” must look like, including being self-supporting, not funded by government,

Like it or not, AMA is our voice in Washington, DC, and speaks for us as this potentially profession-changing legislation goes forward. paying at negotiated rates, and being entirely voluntary for both patients and physicians.

Finally, the AMA House specified what must be opposed, including any reduction in payment for failure to report quality data until systems are perfected for the collection of that data; any system that mandates automatic payment reductions; reduction in payments for higher utilization unless data is properly attributed and risk-adjusted; redistribution of payment among physicians based on faulty, unscientific data; transfer of payments from one specialty to another; and arbitrary restriction on referrals to facilities the referring physician may have an interest in.

Like it or not, AMA is our voice in Washington, DC, and speaks for us as this potentially profession-changing legislation goes forward. Our specialty societies are in many cases advocating for positions opposing each other, a circumstance guaranteed to allow

those who would harm our profession and the care we can offer our patients the opportunity they crave. Never has AMA’s motto been truer: “Together we are stronger.”

Other Business-Consultation Codes, Medicare Participation Options Yes, there actually were many important issues other than health system reform discussed, including 18 resolutions and 10 reports on subjects relating to public health and education.

Of note was resolution 807 that was adopted and calls on AMA to “oppose all public and private payer efforts to eliminate payments for inpatient and outpatient consultation service codes, and support legislation to overturn recent CMS’ action to eliminate consultation codes.”

A nine-page “Medicare Participation Options for Physicians” paper was distributed and included language of a sample Medicare private contract for those who might want to consider that option. AMA members can access that document at SDCMS.org/publications.

The Speaker’s Advisory Task Force Report recommended elimination of the Interim Meeting and consolidating some of the business traditionally done there with the spring National Advocacy Conference. The AMA House referred that recommendation for further consideration, and San Diego will host AMA as planned November 5–9, 2010.

Finally, San Diego County’s own Al Ray, MD, was elected vice chair of the California delegation to AMA. Congratulations, Al!

Conclusion Your San Diego County delegates, Bob Hertzka, MD, and I, and alternate delegates Al Ray, MD, and Lisa Miller, MD, are there to speak for you. We welcome your feedback and input.

{About the Author}

Dr. Hay is a family physician in full-time private practice in Encinitas. He founded North Coast Family Medical Group in 1978 and North County Physicians’ Medical Group (an IPA) in 1990.

He is past president of SDCMS, past president of the SDCMS Foundation, current “Champion” of the Foundation’s Project Access San Diego (PASD), and is the current speaker of CMA’s House of Delegates.

January 2010 SAN DIEGO PHYSICIAN . o rg

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healthcarefinancing

By Thomas A. Doyle, MD

Suck It up,

America We Have Become a Nation of Whining Hypochondriacs

Note: This opinion piece was originally published in the Sunday, October 11, 2009, issue of the Pittsburgh Post-Gazette.

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Emergency departments are distilleries that boil complex blends of trauma, stress, and emotion down to the essence of immediacy: What needs to be done, right now, to fix the problem. Working the past 20 years in such environments has shown me with great clarity what is wrong (and right) with our nation’s medical system. ¶ It’s obvious to me that despite all the furor and rancor, what is being debated in Washington currently is not healthcare reform. It’s only healthcare insurance reform. It addresses the undeniably important issues of who is going to pay and how, but completely misses the point of why.

Healthcare costs too much in our country because we deliver too much healthcare. We deliver too much because we demand too much. And we demand it for all the wrong reasons. We’re turning into a nation of anxious wimps.

I still love my job; very few things are as emotionally rewarding as relieving true pain and suffering, sharing compassionate care, and actually saving lives. Illness and injury will always require the best efforts our

medical system can provide. But emergency departments nationwide are being overwhelmed by the non-emergent, and doctors in general are asked to treat what doesn’t need treatment.

In a single night I had patients come in to our emergency department, most brought by ambulance, for the following complaints: I smoked marijuana and got dizzy; I got stung by a bee and it hurts; I got drunk and have a hangover; I sat out in the sun and

got sunburn; I ate Mexican food and threw up; I picked my nose and it bled, but now it stopped; I just had sex and want to know if I’m pregnant.

Since all my colleagues and I have worked our shifts while suffering from worse symptoms than these (well, not the marijuana, I hope), we have understandably lost some of our natural empathy for such patients. When working with a cold, flu, or headache, I often feel I am like one of those cute little animal January 2010 SAN DIEGO PHYSICIAN . o rg

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healthcarefinancing

Healthcare costs too much in our country because we deliver too much healthcare.

We deliver too much because we demand too much. And we demand it for all the wrong reasons. signs in amusement parks that say “you must be taller than me to ride this ride,” only mine should read “you must be sicker than me to come to our emergency department.” You’d be surprised how many patients wouldn’t qualify.

At a time when we have an unprecedented obsession with health (Dr. Oz, The Doctors, Oprah and a host of daytime talk shows make the smallest issues seem like apocalyptic pandemics), we have substandard national well-

ness. This is largely because the media focus on the exotic and the sensational and ignore the mundane.

Our society has warped our perception of true risk. We are taught to fear vaccinations, mold, shark attacks, airplanes, and breast implants when we really should worry about smoking, drug abuse, obesity, cars, and basic hygiene. If you go by pharmaceutical advertisement budgets, our most critical health needs are to have sex and fall asleep.

Somehow we have developed an expectation that our health should always be perfect, and if it isn’t, there should be a pill to fix it. With every ache and sniffle we run to the doctor or purchase useless quackery such as the dietary supplement Airborne or homeopathic cures (to the tune of tens of billions of dollars a year). We demand unnecessary diagnostic testing, narcotics for bruises and sprains, antibiotics for our viruses (which do absolutely no good). And due to time constraints on physicians, fear of lawsuits, and the pressure to keep patients satisfied, we usually get them.

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Yet the great secret of medicine is that almost everything we see will get better (or worse) no matter how we treat it. Usually better.

The human body is exquisitely talented at healing. If bodies didn’t heal by themselves, we’d be up the creek. Even in an intensive care unit, with our most advanced techniques applied, all we’re really doing is optimizing the conditions under which natural healing can occur. We give oxygen and fluids in the right proportions, raise or lower the blood pressure as needed, and allow the natural healing mechanisms time to do their work. It’s as if you could put your car in the service garage, make sure you give it plenty of gas, oil, and brake fluid and that transmission should fix itself in no time.

The bottom line is that most conditions are self-limited. This doesn’t mesh well with our immediate-gratification, instant-action society. But usually that bronchitis or backache or poison ivy or stomach flu just needs time to get better. Take two aspirin and call me in the morning wasn’t your doctor being lazy in

In a single night I had patients come in to our emergency department, most brought by ambulance, for the following complaints: I smoked marijuana and got dizzy; I got stung by a bee and it hurts; I got drunk and have a hangover; I sat out in the sun and got sunburn; I ate Mexican food and threw up; I picked my nose and it bled, but now it stopped; I just had sex and want to know if I’m pregnant. the middle of the night; it was sound medical practice. As a wise pediatrician colleague of mine once told me, “Our best medicines are Tincture of Time and Elixir of Neglect.”

Taking drugs for things that go away on their own is rarely helpful and often harmful.

We’ve become a nation of hypochondriacs. Every sneeze is swine flu, every headache a tumor. And at great expense, we deliver fantastically prompt, thorough, and largely unnecessary care.

There is tremendous financial pressure on physicians to keep patients happy. But unlike business, in medicine the customer isn’t always right. Sometimes a doctor needs to show

tough love and deny patients the quick fix.

A good physician needs to have the guts to stand up to people and tell them that their baby gets ear infections because they smoke cigarettes. That it’s time to admit they are alcoholics. That they need to suck it up and deal with discomfort because narcotics will just make everything worse. That what’s really wrong with them is that they are just too damned fat. Unfortunately, this type of advice rarely leads to high patient satisfaction scores.

Modern medicine is a blessing, which improves all our lives. But until we start educating the general populace about what really

affects health and what a doctor is capable (and more importantly, incapable) of fixing, we will continue to waste a large portion of our healthcare dollar on treatments that just don’t make any difference.

{About the Author}

Dr. Doyle is a specialist in emergency medicine who practices in Sewickley, Pennsylvania.

This is an excerpt from a book he is writing called Suck It Up, America: The Tough Choices Needed for Real Healthcare Reform. Dr. Doyle can be reached at tomdoy@aol.com.

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welln 26

SAN DIEGO PHYSICIAN . or g January 2010

ness lness ˘ ˘ well·ness (wel’nis)

The condition of good physical and mental health, especially when maintained by proper diet, exercise, and habits.

January 2010 SAN DIEGO PHYSICIAN . o rg

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wellness

Integrating Integrative

Medicine By robert alan bonakdar, MD 28

SAN DIEGO PHYSICIAN . or g January 2010

e

“The doctor of the future will give no medicine, but will interest his patients in the care of the human frame, in diet, and in the cause and prevention of disease.” — Thomas Alva Edison Part I: An Overview of Integrative Medicine

What Is Integrative Medicine?

The National Institutes of Health National Center for Complementary and Alternative Medicine (NIH NCCAM, http://nccam.nih.gov) defines integrative medicine as conventional care used in combination with complementary and alternative medicine (CAM) therapies for which there is high-quality scientific evidence of safety and effectiveness, such as using acupuncture/acupressure for postoperative nausea (1). Conversely, alternative medicine is used in place of conventional medicine, such as using a special diet to treat cancer instead of undergoing surgery, radiation, or chemotherapy that has been recommended by a conventional doctor. Integrative medicine is thus more than a therapy; it is the context, rationale, and communication surrounding therapies from various perspectives.

Other definitions that expand on the theme and principles of integrative medicine have been developed by the Consortium of Academic Health Centers for Integrative Medicine (www.ahc.umn.edu/ cahcim) and the University of Arizona’s Arizona Center for Integrative Medicine (http://integrativemedicine.arizona.edu) as noted in figure 1.

How Common Is CAM?

According to a 2007 NHIS survey, approximately 38 percent of U.S. adults and 12 percent of children have used some form of CAM at least once. This represents a 2.3 percent increase from 2002 as noted in figure 2 (2, 3).

Complementary therapies are categorized into four domains: mind-body medicine, biologically based practices, manipulative/ body-based practices, and energy medicine. NCCAM also recognizes whole medical systems — such as Traditional Chinese Medicine — that incorporate the other domains.

The most common types of complementary therapies utilized by adults in the United States are natural products, deep breathing, meditation, chiropractic, and massage. Dietary supplements are the most commonly used form of CAM at 17.7 percent (see figure 3). It is important to note that the use of these therapies varies widely, with dietary supplements, for example, being used by up to approximately 70 percent of the population in a previous survey evaluating only that intervention (4).

Pain is by far the most common condition treated with CAM (see figure 4). The top 10 include headache pain as well as more common conditions, including back, neck, and joint pain. Part two of this article describes an integrative model for headache treatment.

CAM combined with conventional medicine would help. Unfortunately, several barriers often make this attempt fragmented, including financial/insurance coverage, knowledge base, discussion, and coordination of care.

The less-than-optimal level of clinician/patient discussion regarding CAM was best exemplified by the 2006 NIH/AARP report on CAM (5). Overall, 77 percent did not discuss CAM use with their doctors, with reasons given for non-discussion including: • Physicians never asked (42 percent).

• Patients didn’t know they should talk with their doctors (30 percent).

• Lack of time (19 percent).

• Don’t think doctor knows the topic (17 percent).

• Doctor would have been dismissive or told you not to do it (12 percent).

In a survey of more than 700 physicians, Corbin and colleagues confirmed that 84 percent felt uncomfortable discussing CAM with their patients. The authors noted that the physicians wanted to learn more about CAM to adequately address patient concerns and concluded that education may help alleviate the discomfort physicians have when answering patients’ questions about CAM (6).

These barriers may stand in the way of truly integrative care. As a starting point, simply bringing up the topic in an open and nonjudgmental manner can be highly effective in overcoming several of the more common reasons for nondisclosure, as well as creating a conducive environment for discussion. Additionally, several resources and evidence-based tools can be accessed to provide point-of-care answers to improve the level of comfort and discussion (see table 1).

Integrative medicine is thus more than a therapy; it is the context, rationale, and communication surrounding therapies from various perspectives.

Barriers to Implementing Integrative Medicine

It is important to point out that nearly all patients ideally wish to pursue an integrative approach to their healthcare with less than 5 percent attempting an alternative-only approach. When surveyed about the motivation for the use of CAM, the most typical response (54.9 percent) in the 2004 version of the CDC/NIH survey was that

A New Model of Healthcare

Integrative medicine is on the rise in hospitals throughout the country. In 2005, the Institute of Medicine conducted a survey and found that 25 percent of U.S. hospitals offer CAM. That represents a 17.3 percent increase since 1999. The most common complementary therapies offered by hospitals are massage, music therapy, healing touch, guided imagery, relaxation techniques, and acupuncture.

To illustrate this trend, a total of 44 highly respected academic medical centers such as Duke, Yale, Harvard, Johns Hopkins, Mayo Clinic, and Beth-Israel now belong to the Consortium of Academic Health Centers for Integrative Medicine, which is dedicated to advancing the principles and practices of integrative healthcare within academic institutions. These medical centers all have integrative medicine programs that provide a broad spectrum of integrative services to their patients.

Next Steps

It is important for physicians to have access to scientifically validated information about complementary therapies and best-practice apJanuary 2010 SAN DIEGO PHYSICIAN . o rg

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Figure 1: Integrative Medicine Definition and Principles Integrative Medicine is the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals, and disciplines to achieve optimal health and healing.

Figure 2: CAM Use by U.S. Adults and Children

— Consortium of Academic Health Centers for Integrative Medicine

Integrative Medicine is healing-oriented medicine that takes account of the whole person (body, mind, and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative.

— Arizona Center for Integrative Medicine, University of Arizona

Key Principles • Patient and practitioner are partners in the healing process.

• All factors that influence health, wellness, and disease are taken into consideration.

• Appropriate use of both conventional and alternative methods facilitates the body’s innate healing response.

• Effective interventions that are natural and less invasive should be used whenever possible.

• Integrative medicine neither rejects conventional medicine nor accepts alternative therapies uncritically.

• Good medicine is based in good science. It is inquiry-driven and open to new paradigms.

• Alongside treatment, health promotion and prevention are paramount.

• Practitioners of integrative medicine should exemplify its principles.

Source: Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Report #12. Complimentary and Alternative Medicine Use Among Adults and Children: United States, 2007. December 2008.

Table 1: Evidence-based Internet Resources for Integrative Medicine

— Arizona Center for Integrative Medicine, University of Arizona

20

15

10

5

0

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SAN DIEGO PHYSICIAN . or g January 2010

Free Access • National Institutes of Health: • National Center for Complementary and Alternative Medicine* (www.nccam.nih.gov)

• Time to Talk Program

• Topics A–Z

• Herbs at a Glance • Office of Dietary Supplements (http://ods.od.nih.gov)

• Dietary Supplement Fact Sheets

• International Bibliographic Information on Dietary Supplements Database (IBIDS)

• Computer Access to Research on Dietary Supplements Database (CARDS) • CAMline (www.camline.ca/about/about.html) • MD Anderson Cancer Center (www.mdanderson.org/ departments/CIMER/dIndex.cfm) Subscription Required • DynaMed* (www.ebscohost.com/dynamed) • Natural Medicines Comprehensive Database* (www.naturaldatabase.com) • Natural Standard* (www.naturalstandard.com) Asterisk (*) denotes AAFP-recognized source of evidence-based information.

20

15

10

Figure 3: 10 Most Common CAM Therapies Among Adults, 2007 Therapies With Significant Increases Between 2002 and 2007 Are:

2002 2007 Deep Breathing 11.6% 12.7% Meditation 7.6% 9.4% Massage 5.0% 8.3% Yoga 5.1% 6.1%

20

15

10

5

5

0

0

Source: Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Report #12. Complimentary and Alternative Medicine Use Among Adults and Children: United States, 2007. December 2008.

It is important for physicians to have access to scientifically validated information about complementary therapies and best-practice applications. plications. To that end, Scripps Center for Integrative Medicine offers several continuing medical education conferences and grand rounds lectures on integrative medicine topics designed for healthcare providers. For more information, please contact Scripps Conference Services and CME at (858) 652-5400. In addition, physicians should sample several resources from Table 1 to identify point-of-care resources appropriate for their practices.

Conclusion

Integrative medicine is a recognized model of care that offers a wholeperson approach to improving health outcomes while empowering patients as partners in the healing process. To overcome barriers to implementing integrative medicine into clinical practice, physicians need access to accurate and timely information about evidence-based approaches.

To read “Part II: Integrative Medicine in Headache Management,” please visit SDCMS.org/publications

Figure 4: Diseases/Conditions for Which CAM Is Most Frequently Used Among Adults, 2007

Source: Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Report #12. Complimentary and Alternative Medicine Use Among Adults and Children: United States, 2007. December 2008.

References: 1) Lee A, Fan LTY. Stimulation of the wrist acupuncture point P6 for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD003281.

2) Barnes PM, Bloom B, Nahin R. CDC National Health Statistics Report #12. Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007. December 2008.

3) Barnes P, Powell-Griner E, McFann K, Nahin R. CDC Advance Data Report #343. Complementary and Alternative Medicine Use Among Adults: United States, 2002. May 27, 2004.

4) Timbo BB, Ross MP, McCarthy PV, Lin CT. Dietary supplements in a national survey: Prevalence of use and reports of adverse events. J Am Diet Assoc. 2006 Dec;106(12):1966-74.

5) Complementary and Alternative Medicine: What People 50 and Older Are Using and Discussing with Their Physicians. The 2006 NIH/AARP report accessed at http://assets.aarp.org/rgcenter/health/ cam_2007.pdf.

6) Corbin W et al. Physicians want education about CAM to enhance communication with their patients. Arch Intern Med. 2002 162 (10): 1176-81.

{ Abo u t

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Dr. Bonakdar, SDCMS and CMA member since 2005, is the director of pain management at the Scripps Center for Integrative Medicine and the co-director of the Scripps Conference "Natural Supplements: An Evidence-based Update."

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wellness

Upstream

Medicine The Case for Prescriptive Health-related Behaviors

By E. Lee Rice, DO

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A

A good friend and colleague of mine who is the current secretary general of the World Council on Cardiovascular and Pulmonary Rehabilitation likes to tell the story of a young cardiologist. He was standing on the edge of a riverbank enjoying the view when he spotted a man flailing in the water, being carried down the rapids toward a 1,000-foot waterfall that would mean certain death. He immediately took his shoes off, jumped into the river, and pulled the man to safety.

As he was catching his breath back on the riverbank, he heard a scream coming from the river. Looking back, he saw another man being swept toward the edge of the great waterfall. He fearlessly dove back into the frigid water and grabbed the second man, courageously dragging him back to safety. Amazingly, within minutes the same scenario repeated itself a third time. An onlooker, seeing this incredible sequence of events, approached the heroic doctor. “My,” he exclaimed in awe, “you’ve just risked your own life to save three strangers! That was an amazing display of selfless courage and skill!

Do you mind if I give you some advice?” “Why no, not at all” said the exhausted doctor. “Well,” continued the bemused observer, “did you ever consider walking upstream to see who’s throwing them in?”

Like the young doctor, traditional “Western Medicine” is noted for practicing “downstream medicine.” Our system, which has historically focused on disease care, is undeniably the most sophisticated and technologically advanced in the world. It is also the most expensive. According to the 2004 report of the U.S. Department of Health and Human Services, we spent $1.9 trillion on healthcare, or 16 percent of our country’s GDP. That’s $6,280 per man, woman, and child.

2008 data from the Organization for Economic Cooperation and Development reveals that we spend approximately twice as much on healthcare as every other industrialized nation in terms of both percentage of our country’s GDP and dollars per capita. That would be fine if our healthcare and/or quality of life outcomes were equally notable. But that’s simply not the case.

Unfortunately, our country’s overall healthcare outcomes do not match our world dominance in either technology or spending. In fact, according to the latest statistics of the World Health Organization (WHO), the United States ranks 37th among the world’s 191 member countries for overall quality of healthcare. Although critics cite this data as flawed, it is nonetheless an

alarming statistic and should give us pause to consider what healthcare we’re providing for our patients’ medical buck. According to the 2009 CIA World Fact Book, we have slipped to 50th in the world in average predicted life expectancy. And we currently rank 24th in the world in the WHO’s data regarding “Healthy Life Expectancy” — the number of years one can expect to live in “full health.”

One thing does seem clear. The majority of our healthcare dollars are spent taking care of medical concerns that are directly related to our patients’ lifestyles. Our choices of health-related behaviors are now the biggest etiologic factors in creating premature disease, chronic medical conditions, and disability. According to the U.S. Public Library of Science, in 2005 there were eight risk factors that accounted for approximately 80 percent of all deaths in the United States: smoking, physical inactivity, excess alcohol intake, diets high in salt and low in fruits and vegetables, elevated blood pressure, high cholesterol, and being overweight. The key point here is that there are effective interventions for every one of these risk factors! So we have a wonderful opportunity to influence our patients in terms of their health-related lifestyle choices.

The question is, can our interventions really be effective? Dr. Earl Ford from the Centers for Disease Control and Prevention and his colleagues completed a study of 23,153 middle-age people, focusing on four healthy-lifestyle factors: smoking, obesity, exercise, and diet. Eight years later, as reported in the Aug. 10–24, 2009, issue of the Archives of Internal Medicine, those in the group who adhered to not smoking, having a BMI less than 30, eating a diet high in fruits, vegetables, whole grains and low in meat consumption had some astonishing statistical benefits. The hazard ratio for developing a chronic disease decreased progressively as the number of healthy factors increased. Participants with all four factors at baseline had an overall 78 percent lower risk of developing a chronic disease

A recent study at the University of Sheffield revealed that the least effective strategies in getting patients to successfully change behaviors involved instilling fear. The second least effective method was to instill guilt for past choices.

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than participants without a healthy factor (diabetes was reduced 93 percent, myocardial infarction 81 percent, stroke 50 percent, cancer 36 percent).

The truth is that most of our patients know the majority of information regarding what constitutes healthy behaviors. The problem is getting them to adhere to more healthy practices on a regular basis. I’ve personally come to the conclusion that for most patients, we cannot scare them into health. A recent study at the University of Sheffield revealed that the least effective strategies in getting patients to successfully change behaviors involved instilling fear. The second least effective method was to instill guilt for past choices. Not surprisingly, the most effective strategies consisted of education, coaching, partnering, goal setting, and establishing methods of accountability.

someone to hold them accountable. Most already feel some sense of guilt, shame, or failure around past efforts to change. The last thing they need or want is any additional feeling of perceived negative judgment. So we try to provide a safe environment where patients are surrounded by a team that truly cares about them, wants them to succeed, and celebrates their successes. We emphasize progress, not perfection. It’s a process, and the key is to not give up. Like the rocket ship to the moon, our patients are always a bit off course. But with established and mutually agreed upon goals, objective feedback regarding key indicators of success, and timely redirection, many achieve remarkable progress.

The most effective first step in a wellness program is increasing physical activity. Fewer than 25 percent of Americans get the exer-

I encourage my patients to develop a personal mission statement, clarifying what each one sees as his or her purpose in life. Then it’s not a big leap to reason that only by maximizing both health and performance can their mission be truly accomplished. And all unhealthy behaviors can be seen as personal choices that undermine the mission.

Norman Cousins, in his book Anatomy of an Illness, noted that the most important thing his doctor did for him in assisting him in his recovery from a supposedly terminal illness was to treat him as a “respected partner” in his journey back to health. I think that’s our challenge: How do we become that respected partner for our patients?

In my practice, we focus on a three-step process: education, motivation, and life restyling. We do pay attention to the readinessfor-change model with each patient, attempting to approach each patient with the most appropriate strategy based on his/her level of knowledge concerning risks and rewards and whether or not there is motivation for change around the issue involved. For some we just educate. We find that most people are truly unaware of the actual prices they are already paying for the choices that they’re making.

Once informed, many would like to change if they can be convinced that they could actually be successful and if they feel like they have someone who will respectfully guide them along the way. For others, they just need a plan. Some need motivation, and some just want

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SAN DIEGO PHYSICIAN . or g January 2010

cise they need. On average, we watch 170 minutes of television and movies, but spend less than 19 minutes a day exercising. Yet studies are clear that exercise promotes self-esteem, increases energy, assists in normalizing the balance of brain neuropeptides, improves sleep, enhances immune response, assists in stabilizing mood, lessens sarcopenia, and helps to control weight, blood pressure, serum glucose, lipids, and the metabolic syndrome. It also lessens the overall risk of chronic diseases and is one of the most potent initiators of brain neurogenesis. In the Nov. 21, 2007, issue of JAMA, a review of 26 studies was published that showed that, overall, pedometer users increased their physical activity by 26.9 percent over baseline and decreased their BMI by 0.38. The simple act of giving patients a pedometer with a suggested goal of 10,000 steps per day may well be one of the most powerful interventions possible. It’s a good example of “what gets measured gets addressed.”

My experience is that the more specific our exercise recommendations are, the more credible and influential they become to our

POLITICAL REALITY:

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MEnu We’re at the Table, Every Day …

By choosing to join the San Diego County Medical Society (SDCMS), over 3,000 practicing physicians, resident physicians, and medical students in San Diego County have given voice to our patients and to our communities in the healthcare reform discussions and in every single healthcare issue being debated locally, in Sacramento, and in Washington, DC. Ask your colleagues: “Are You a Member of SDCMS?” San Diego County Medical Society (SDCMS) | 5575 Ruffin Road, Suite 250 San Diego | 858.565.8888 | SDCMS.org January 2010 SAN DIEGO PHYSICIAN . o rg

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patients. Dr. William Foege, former director of the CDC, validated the importance of an active lifestyle thusly: “Physical activity may provide the shortcut we in public health have been seeking for the control of chronic diseases, much like immunization has facilitated progress against infectious diseases.”

Motivating patients to alter ingrained lifestyles is difficult at best. It often takes a painful or frightening experience to convince someone that it’s indeed time to pay attention to lifestyle. One of my patients referred to his wake-up call as a “cosmic goose.” Significant change rarely occurs without clear intention and purpose.

I encourage my patients to develop a personal mission statement, clarifying what each one sees as his or her purpose in life. Then it’s not a big leap to reason that only by maximizing both health and performance can their mission be truly accomplished. And all unhealthy behaviors can be seen as personal choices that undermine the mission. The next step is development of true mindfulness regarding significant choices and encouraging patients to develop a passion for rigorous honesty concerning their own truth. A well lifestyle is then developed over time much like a successful business plan evolves.

People who practice healthy lifestyles have developed a set of wellness skills that they learn to employ, self-monitor, and correct as needed over time. As demands change, they develop new compensatory skills that allow them to stay on track. The really successful ones generally have nourished relationships with other successful people who act as mentors and coaches. And here’s the best part: Patient surveys have repeatedly established that the most influential person

OF THE SAN

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REGISTRY

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Physicians

Nurse Practitioners Physician Assistants

mEDICAL SOCIET Y

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

th e

Dr. Rice, SDCMS and CMA member since 2009, is the founder and CEO of the Lifewellness Institute, specializing in preventative medicine, wellness, and health promotion. He is the Dr. Jerry C. Lee Endowed Chair at National University, charged with furthering the goals of the Center for Integrative Health, a clinical professor at Western University of Health Sciences, and an associate clinical professor at UCSD School Project4:Layout 1 9/22/08 11:22 AM Page 1 of Medicine.

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member physicians receive

advertising in this publication.

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SDCMS

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in many patient’s lives in determining whether or not they adopt healthy lifestyle choices is their physician. One such survey concluded that the single most important person in determining whether or not the involved patients began an exercise program was their primary care physician. So it was disheartening to learn that more than 80 percent of those patients also said that they had never heard their doctor mention exercise to them.

Clearly, we have our work cut out for us. We owe it to our patients to be their guidepost regarding healthy lifestyles. We have an obligation to provide for them informed consent regarding the risks and rewards of health-related behaviors. But that’s not enough. We owe them an individualized, prescriptive plan for success. The future of our nation’s health will largely depend on the developing willingness of our physicians to be effective patient advocates, educators, and mentors. And oh, by the way, in order to be credible professionals, we must, as they say in the airline business, “First put the oxygen mask on yourself. Then, you can help others!” Time to go for that walk!

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SDCMS members receive an additional 10% discount! Contact John Alexander, MD, FACS, JD, at (858) 369-5121 or at jta@ protectingdoctors.com, or visit ProtectingDoctors.com.

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

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

Technology Solutions Potential Value: $1,000!

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

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

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

Torrey Pines Bank is a “lowmaintenance” bank that meets business owners’ high expectations while requiring of them the absolute minimum of time and effort. Approved SDCMS members receive nofee lines of credit, $1,000 fee discounts on commercial real estate loans, waived monthly

maintenance fees on personal accounts for practice partners and employees up to $10/month, free first order of standard checks for personal accounts, increased deposit interest rates, waived monthly maintenance fee for business online banking and bill pay services, ATM fees waived up to $15/month, and free courier service or remote deposit service. Contact Vince Kingsley at (858) 259-5323 or at vkingsley@ torreypinesbank.com, or visit TorreyPinesBank.com.

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

Alliant Insurance Services, Inc., is California’s largest premier specialty insurance broker and ranks among the 13 largest in the nation. SDCMS members receive discounts on a comprehensive portfolio of insurance products and services, including savings of 5–10% or more off of the cost of insurance, or cash rebates related to practice size, a savings of 7–12% on long-term disability income protection, and no-cost human resources consulting.

Contact Mark Allan at (800) 654-4609 or at mallan@ alliantinsurance.com, or visit AlliantInsurance.com.

Tamper-Resistant Prescription Pads Potential Value: $300!

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

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Billing Solutions Potential Value: 10% of Net Revenue!

Coastal Healthcare Consulting Group, Inc., is a specialty consulting firm that assists clients with managed care contracting, contract negotiations, credentialing, revenue enhancement, and strategic planning. SDCMS members receive a free contracting analysis, a discount on hourly rates, and a package price on services for contract negotiations, including health plan contracts! Contact Kim Fenton, president, at (949) 481-9066 or at kimf@ healthcareconsultant.org, or visit HealthcareConsultant.org. For

consultation scheduling, contact Marisol Gonzalez, your SDCMS physician advocate, at (858) 300-2783 or at MGonzalez@ SDCMS.org.

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

Practice Performance Group (PPG) provides high-performance medical practice management services for physicians, including consulting, expert witness, workshops, speaking, and a monthly newsletter. SDCMS members receive discounted management consulting on productivity and patient flow, personnel, governance and management, market strategy and tactics, practice acquisitions,

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Collections Services Potential Value: $350–500!

TSC Accounts Receivable Solutions has provided personalized, innovative collection and total accounts management services since 1992. This local, family-owned business’ management team has combined experience of more than 50 years in the healthcare billing and collection field.

SDCMS members receive a 10% discount on monthly charges.

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

The Doctors Company (TDC) enjoys a reputation as the industry vanguard for low California rates, aggressive claims defense, expert patient safety programs, superior customer service, and exemplary member benefits. Most SDCMS members are eligible for a 5% discount on insurance premiums and a 7.5% dividend credit. Contact Janet

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

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

January 2010 SAN DIEGO PHYSICIAN . o rg

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By Nick Macchione, MS, MPH, and Wilma Wooten, MD, MPH 38

SAN DIEGO PHYSICIAN . or g January 2010

health improvement A Strategic Framework for

in San Diego County

L

The 3-4-50 Imperative

Lately, there has been much talk and action in Washington, DC, regarding healthcare reform, and, thankfully, some of the reform talk has focused on prevention and proactive intervention. While we care about healthcare coverage, which is the main thrust of the federal debate, prevention can be the key to reforming the health of the San Diego community. To see the possibilities for transforming the health of all San Diegans, one need only examine these three numbers: 3, 4, and 50.

Worldwide, three risk factors (tobacco use, poor diet, and physical inactivity) contribute to four of the most prevalent chronic diseases (cancer, cardiovascular disease, type 2 diabetes, and respiratory disease) that are responsible for more than 50 percent of all deaths.

Also, co-morbidity of these prevalent physical diseases with common mental health disorders is found across the lifespan and linked to many chronic complications.

Local San Diego health statistics indicate 57 percent of all deaths are attributed to these four chronic diseases, which are highly associated with the three behavioral risk factors. The potential impact of reducing mortality by addressing these three risk factors represents a significant opportunity to reduce the burden of disease in San Diego County and improve the health and well-being of all the members of our community.

As has been stated above, chronic diseases are common and preventable. They are also costly.

Most importantly, these medical conditions extend pain and suffering, and decrease quality of

life for tens of thousands of San Diegans each year. In San Diego County alone, a total of more than $4 billion is spent annually on healthcare costs for these four chronic diseases — excluding the treatment of lung cancer.

Physicians make health recommendations to patients that emphasize the importance of good nutrition, increased physical activity, and being smoke-free. But when patients leave the office, does the environment support these healthy choices? Are they living in “healthy environments” that include access to fresh and healthful produce, walkable and safe neighborhoods, opportunities for recreation and social connections, and decreased exposure to tobacco products?

Unfortunately for the majority of low-income patients and their families, the answer is probably “no.” Patients often face obstacles in the community to implementing the healthy choices recommended. In order to facilitate patients making healthy decisions and reducing chronic conditions, an “Ecological Model” of health promotion

Worldwide, three risk factors contribute to four of the most prevalent chronic diseases that are responsible for more than 50 percent of all deaths.

January 2010 SAN DIEGO PHYSICIAN . o rg

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3

4 

behaviors

Tobacco use poor diet no exercise

heart disease type 2 diabetes lung disease cancer

is needed to improve outcomes. This model encompasses a range of environmental approaches and policies at various levels, including individuals, families, neighborhoods, schools, businesses, faithbased institutions, and government. The approaches and policies impact multiple environments and their relationship to people at the individual, interpersonal, organizational, and community levels.

In addition to focusing on environments that support healthy choices, there must also be a focus on the impact of mental illness on physical health. Research shows that people with serious mental illnesses served by the public mental health system die on average 25 years earlier than the general population — a tremendous health dis-

In San Diego County alone, a total of more than $4 billion is spent annually on healthcare costs for these four chronic diseases — excluding the treatment of lung cancer. parity that should be unacceptable to all of us (Morbidity and Mortality in People With Serious Mental Illness, National Association of State Mental Health Program Directors, October 2006). The links between mental health and general health are significant. For example, research shows that increased physical activity can reduce depression. Risk factors for poor mental health include isolation, low self-esteem, social discrimination, and school failure. Protective factors to address these risks include a sense of belonging, attachment to social networks, social skills, and participation in school and community groups. A practical example of a strategy that focuses on the link between physical and mental wellbeing is increasing the number of children who walk to school — increasing physical activity can enhance children’s self-esteem, broaden social networks, and decrease depression and isolation, as well as promote physical health and fitness.

How can physicians and the County of San Diego Health and Human Services Agency (HHSA) partner to reduce the three behaviors and four diseases leading to more than 50 percent of the mortality in our community? Environmental strategies must be employed. HHSA and its many community partners, including the San Diego County Medical Society, are actively pursuing evidence-based strategies for making changes to the physical, economic, social, and service environments. Why? We must encourage and support healthy behaviors that then contribute to healthier outcomes for everyone and a reduc-

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SAN DIEGO PHYSICIAN . or g January 2010

50 

diseases

percent

of deaths

tion in chronic diseases. However, we cannot do this alone and need to enlist the help from our entire allied health professional community, starting with physicians.

The framework that can be used to carry out these changes in the San Diego community is laid out in the “Action Strategies Toolkit” from the Leadership for Healthy Communities, a national program of the Robert Wood Johnson Foundation. The toolkit contains best and promising practices that include evidence-based research supporting: • Transportation, planning, and community design to increase physical activity.

• Increasing availability of healthy foods in stores, and supporting local agriculture.

• Increased opportunities to walk or ride a bike from home to schools, parks, and businesses.

• Access to safe places to recreate, and increasing physical activity in underserved communities.

HHSA has integrated these concepts into its newly developed Health Strategy Agenda, which is an integral part of a larger effort to transform HHSA’s approach to addressing the total health of county residents. HHSA’s Health Strategy Goal is that by 2020, the people and communities that HHSA serves will receive cost-efficient, integrated services that improve health (defined as physical, mental, social, and spiritual wellbeing). Prevention efforts will reflect systems change, strategies that address the social determinants of health, and policies and practices that advance changes to the built environment.

We welcome you to join us in reaching beyond office walls to impact changes in San Diego’s environment. These activities will collectively create healthy environments for communities throughout San Diego County to meaningfully improve the health of our community. As a physician, build on what you are doing on an individual level with your patients to promote healthy behaviors. Also, we applaud any effort that fosters an environment in your practice setting that supports these healthy behaviors. You can also get involved with groups and organizations in the community that are advocating for healthy environments in San Diego County. Your role as a physician is respected in the community and greatly needed to help affect change!

{ Abo u t th e A u tho r s } Mr. Macchione is the director of the Health and Human Services Agency of the County of San Diego. Dr. Wooten, SDCMS and CMA member since 2006, is its public health officer.

Project Access

San Diego

Volunteerism Made Easy The heart of the program is to link low-income, uninsured adults in San Diego County with specialist volunteers who agree to see a limited number of patients per year in their office for free.

• Physician Volunteer Flexibility: Physicians set their own volunteer commitment (ideal is one patient per month). Project Access patients are seen in the private office setting so you do not have to travel far to provide care for the medically underserved.

• Enrolling Patients Based on Need: Patients are referred to us exclusively from the community clinics in the area and do not qualify for any type of public health insurance program. Specialty care is a significant challenge for the clinics, and many patients endure wait times of up to six months to see a volunteer specialist at their clinic.

• Making Appropriate Referrals: Project Access publishes referral guidelines for community clinic

use. Our Chief Medical Officer also reviews each case individually so that specialists see only the most appropriate referrals.

• 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 hospital and ancillary services to a defined pharmacy benefit.

Join over 75 specialists as a Project Access volunteer!

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 needed for our success! Please visit our website at SDCMSF.org to learn more and to sign up.

Sign up NOW at SDCMSF.org 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. You may also contact Lauren Radano, Healthcare Access Manager, at 858.565.7930.

January 2010 SAN DIEGO PHYSICIAN . o rg

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classifieds CLINICAL STUDIES CLINICAL STUDY: Dr. Timothy Bailey, boardcertified endocrinologist and ACRP-certified physician investigator, invites you to participate in a research study to determine if treating obstructive sleep apnea (OSA) may lead to improvements in diabetes control and other health benefits for people with type 2 diabetes. Tests results obtained from wearing a sleep-screening device in your home overnight may indicate whether or not you have OSA. If positive, you will be scheduled for an overnight visit to a sleep clinic and then assigned to sleep apnea therapy and lifestyle counseling or you will receive lifestyle counseling with sleep apnea therapy occurring upon completion of the study, if you would like treatment. If you are interested in this study or would like more information, please call (877) 567-2627 or email us at info@amcrinstitute.com. [731] OFFICE SPACE NORTH COUNTY THERAPIST OFFICE SPACE AVAILABLE IN THE TRI-CITY AREA: 2–3 days a week. Spacious, ocean view, fully furnished office suite. Contact Laura at (760) 967-5898. [772]

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

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

TURNKEY MULTI-MILLION OFFICE MEDICAL SUITE: Spectacular design with a history of successful medical practices in this suite. We have a multi-million dollar practice out of this 1,700ft2 facility. We have outgrown our space, and we are moving to a larger suite in the same building.

Over 150K in tenant improvements have been made. Furniture is also included at this turnkey suite. Up to four exam rooms, small procedure room, doctor’s office, elective procedure consultation room, and two waiting rooms. Office is for sale for a very reasonable rate - much less than a build-out. Rent is extremely reasonable. Furniture and improvements also included. Be ready to practice nearly instantly! Located in Mission Valley in a prime location. Contact Dr. Tony at

tpinvestor@yahoo.com or cell phone (858) 3352266. [770] PROFESSIONAL OFFICE SPACE TO SHARE OR LEASE: Part time, full time, flexible terms and incentives. Up to 1,400ft2 in a medical complex. Near Alvarado Hospital, SDSU college area.

Ample parking. High visibility street location.

Ideal for any specialty or allied medical professionals. Call (858) 243-2425. [733]

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 information, contact Ed Muna at 619-702-5655, ed@lankfordsd.com www.pinnaclemedicalplaza.com MISSION VALLEY HEIGHTS-AREA MEDICAL OFFICE SPACE AVAILABLE TO SHARE: Medical office space available to share in existing 2,700ft2 orthopedic office in Mission Valley Heights area. Newer building with excellent parttime tenant, but may consider daily or half-day rental arrangements. Willing to rent space only or can provide full-service, turnkey environment.

Contact Roger Freeman at (858) 277-9000. [768]

CARMEL VALLEY OFFICE SPACE TO SHARE: Sublease and share extra space in 4,600-sf cosmetic surgeons’ office. Surgery center and X-ray on site.

Beautiful space in very attractive, welllocated building on El Camino Real in the heart of Carmel Valley. Ideal for a surgeon, satellite office, or solo physician not needing space full time. Potential for sharing staff / overhead.

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

MULTI-SPECIALTY MEDICAL OFFICE SPACE AVAILABLE IN BANKER’S HILL AREA: Large office with view of San Diego harbor, eight fully equipped exam rooms, lab on site, and underground parking. Please contact Chris Bobritchi at (619) 233-4044 or at hivdocs@yahoo.com. [767]

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 sublease on Mondays, Wednesdays, and Thursdays beginning June 1. For more information please contact Jessica at (619) 397-2950, ext.

200. [766] SPACE AVAILABLE FOR SINGLE DOCTOR PRACTICE: Office located in the Alvarado Hospital area, near San Diego State College. Space includes a physician office and two exam rooms.

Please email cnc_case@cox.net. [765] CORONADO OFFICE SPACE AVAILABLE: New, gorgeous building with 1,100ft2 left. “Build to suit” tall ceilings, excellent location, and onsite parking. Contact Dr. Glenn Cook at (619) 7429300 or at drcook@glenncookmd.com. [764] OFFICE SPACE IN CORONADO FOR LEASE: Beautifully built-out space with all the extras, grandiose reception area, granite counter tops, extravagant lighting and artwork. One exam room still available for lease per half day, per full day, etc. Contact Dr. Glenn Cook at (619) 7429300 or at drcook@glenncookmd.com. [763] LOOKING TO RENT OFFICE SPACE IN GREATER SAN DIEGO AREA: I am a physician specializing in pain medicine. I am currently looking to rent office space from a family/general medicine doctor in the greater San Diego area, approximately once a week. I am pretty flexible in setting up the arrangement. Please contact me at guptaa3@hotmail.com or call me at (760) 285-8866. [762] 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] LA MESA OFFICE SPACE TO SHARE: Over 6,000ft2 OB/GYN office of three doctors, with space available immediately. 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]

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 $150 (100-word limit) per ad per month of insertion.

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SAN DIEGO PHYSICIAN . or g January 2010

PHYSICIAN POSITIONS AVAILABLE 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 CA and DEA licenses. Malpractice coverage provided. Bilingual: English/Spanish preferred. Forward resume to hr@vistacommunityclinic.org or fax to (760) 4143702. Visit our website at http://www.vistacommunityclinic.org. EOE/M/F/D/V [760]

MD Seeks PT/FT Position Skilled physician with extensive experience including: Radiology, Primary Care, research and teaching. Board certified in addiction medicine. Available immediately. Very flexible with terms and location.

Please contact 412-606-1681

FAMILY PRACTICE DOCTORS NEEDED: Full time and part time. Days, nights, weekends available. Fax CV to La Costa Urgent Care at (760) 603-7719. [750] NONPHYSICIAN POSITIONS AVAILABLE 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 CA license. Malpractice coverage provided. Bilingual: English/Spanish preferred. Forward resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. Visit our website at http://www.vistacommunityclinic.org. EOE/M/F/D/V [759]

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

Increase Your Referral Business San Diego Physician is the only publication that is distributed to all 8,500 practicing physicians in San Diego County.

Advertising is a cost-effective and profitable way to increase your referral business.

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

January 2010 SAN DIEGO PHYSICIAN . o rg

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readersurvey

Help Us Improve YOUR San Diego Physician Magazine One Lucky Survey Respondent Will Win a $100 Gift Certificate!

Please help SDCMS improve the content of San Diego Physician magazine by answering the following questions and faxing your responses to SDCMS at (858) 569-1334. Thank you!

1. Indicate if you would like to see the following topics covered more, less, or about the same by checking the appropriate boxes:

2. What other topics would you like to see covered more?

• Billing and Coding oMORE oLESS oSAME oNO OPINION • Bioethics oMORE oLESS oSAME oNO OPINION • Clinical Trials oMORE oLESS oSAME oNO OPINION • Collections oMORE oLESS oSAME oNO OPINION • Economic Advocacy oMORE oLESS oSAME oNO OPINION • Evidence-based Medicine oMORE oLESS oSAME oNO OPINION

3. What other topics would you like to see covered less?

• Health Information Technology oMORE oLESS oSAME oNO OPINION • Healthcare Access oMORE oLESS oSAME oNO OPINION • Healthcare Financing oMORE oLESS oSAME oNO OPINION • Healthcare Quality oMORE oLESS oSAME oNO OPINION • Healthcare Reform oMORE oLESS oSAME oNO OPINION • History of Medicine oMORE oLESS oSAME oNO OPINION • Interviews With Healthcare Leaders oMORE oLESS oSAME oNO OPINION

• Joy of Being a Doctor oMORE oLESS oSAME oNO OPINION • Leadership Skills oMORE oLESS oSAME oNO OPINION • Legal Advocacy oMORE oLESS oSAME oNO OPINION • Legislative Advocacy oMORE oLESS oSAME oNO OPINION • Medical Staff Relations oMORE oLESS oSAME oNO OPINION • Mental Health oMORE oLESS oSAME oNO OPINION • Pay-for-Performance oMORE oLESS oSAME oNO OPINION • Personnel Issues oMORE oLESS oSAME oNO OPINION • Physician Compensation oMORE oLESS oSAME oNO OPINION

4. How often do you visit SDCMS’ website — www.SDCMS.org? o Daily o Weekly o Monthly o Never

5. Are you an SDCMS member? o Yes o No 6. Are you the office manager of an SDCMS member? o Yes o No 7. Are you the office manager of an SDCMS nonmember? o Yes o No 8. If you are not a physician or an office manager, what is your position?

9. How old are you? o 20–29

o 30–39

o 40–49

o 50–59

o 60–69

o 70+

10. If you would like to be considered for our $100 gift certificate giveaway, please tell us your name and the best way to contact you:

• Physician Volunteerism oMORE oLESS oSAME oNO OPINION • Physician Workforce oMORE oLESS oSAME oNO OPINION • Practice Management oMORE oLESS oSAME oNO OPINION • Public Health oMORE oLESS oSAME oNO OPINION • Risk Management oMORE oLESS oSAME oNO OPINION • Scope of Practice oMORE oLESS oSAME oNO OPINION • SDCMS Foundation News oMORE oLESS oSAME oNO OPINION • SDCMS-CMA Member Benefits oMORE oLESS oSAME oNO OPINION

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Please Fax Completed Surveys to Sdcms at (858) 569-1334

Thank You!

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