May 2010

✖ SDCMS Celebrates Its 140th Anniversary in 2010 ✖ Reaching 8,500 Physicians Every Month

M ay 2010

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The

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ok for th lications e Ju or 38 WHERE ARE MY KEYS? UNDERSTANDING of San D ne 2010 issue iego Phy sician.

AND TREATING ALZHEIMER’S IN THE 21ST CENTURY

by Steven A. Ornish, MD, and Andrea Ladmer MA Y 20 10

24

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PH YS

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23

departments 4 Contributors This Issue’s Contributing Writers 6 SDCMS Seminars, webinars, and Events 8 Community Healthcare Calendar 10 Briefly Noted SDCMS Medical Office Managers’ Bulletin Board, and More ‌ 16 BIOETHICS CASE STUDY A 28-year-old Woman Presents in Active Labor 18 PATIENT SAFETY Illegal Trafficking of Prescription Drugs 22 HEALTH REFORM FOR 2010 27 SDCMS ENDORSED PARTNER BENEFITS Potential Value: $11,000–$18,000

44 2

S A N  D I E G O  P HY S I CI A N .or g May 2010

42 PHYSICIAN MARKETPLACE Classifieds 44 SDCMS FOUNDATION Project Access Reaches 100 Physician Volunteers!

May 2010 SAN DIEGO P HY SIC I A N. o rg

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contributors Kimberley Bell, DPT, MPT Dr. Bell is a physical therapist who specializes in vestibular rehabilitation. She is currently serving her third year as chair of the San Diego Fall Prevention Task Force and is the safe strides director at Gentiva Health Services.

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

Adam Frederic Dorin, MD, MBA Dr. Dorin, SDCMS-CMA member since 2003, is partner-shareholder of Anesthesia Service Medical Group and medical director/owner of RiverView MD Facility and Spa. Tom gehring Mr. Gehring is executive director and CEO of the San Diego County Medical Society.

Sonia Gonzales Ms. Gonzales is your SDCMS director of medical office manager support and your SDCMS office manager advocate. She can be reached at (858) 300-2782 or at SGonzales@SDCMS.org.

James S. GrisolÍa, MD Dr. Grisolía has over 20 years’ experience with driving issues. Former national chair of advocacy for the Epilepsy Foundation in Washington, DC, he has served on the Older Californian Traffic Safety Taskforce for the California Highway Patrol and currently serves as a medical advisor to the Department of Motor Vehicles on revising guidelines for the evaluation of dementia.

He has worked on legislation related to driving for CMA, Epilepsy California, and the Association of California Neurologists. The opinions expressed in “Keeping Older Drivers Safe” are solely the authors’ and do not represent official DMV, CHP, AMA, or CMA policy.

Linda L. Hill, MD Dr. Hill is clinical professor and director of preventive medicine residency in the Department

of Family and Preventive Medicine at the UC San Diego School of Medicine.

Dilip V. Jeste, MD Dr. Jeste is a distinguised professor of psychiatry and neurosciences at the UC San Diego School of Medicine, as well as Estelle and Edgar Levi Chair in Aging and director of UC San Diego’s Sam and Rose Stein Institute for Research on Aging. In addition, he is head of the division of geriatric psychiatry in the San Diego VA Healthcare System.

Rosemarie Marshall Johnson, MD Dr. Johnson, SDCMS-CMA member since 1978 and retired member since 2004, is a past president of SDCMS and the current medical community liaison for the SDCMS Foundation’s Project Access San Diego.

Andrea Ladmer Ms. Ladmer is the founder and president of Performance and Entertainment Program for Adult Care Facilities, and provides music and pet therapy programs to more than 100 long-term care facilities throughout San Diego County. Ms. Ladmer may be reached at (619) 440-4800.

Eric McDonald, MD Dr. McDonald, SDCMS-CMA member since 2010, is an emergency physician who practices at the Naval Medical Center, San Diego, and is the project coordinator for Safety Net Connect at Community Health Improvement Partners.

William A. Norcross, MD Dr. Norcross, SDCMS-CMA member since 1999, is board certified in both family medicine and geriatric medicine.

Steven A. Ornish, MD Dr. Ornish, SDCMS-CMA member since 2008, is double-board-certified in general and forensic psychiatry, has a private practice in Mission Valley, and specializes in adult, geriatric, and forensic psychiatry. He is a clinical professor (voluntary), UC San Diego School of Medicine, Department of Psychiatry, president-elect of the San Diego Psychiatric Society, and a director on SDCMS’ board of directors.

››Send your letters to the

editor to Editor@SDCMS.org 4

S A N D I E G O P HY S I CI A N .or g May 2010

Managing Editor Kyle Lewis Editorial Board Van L. 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 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. Verfolin, 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 (open) 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

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.]

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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/event or contact SDCMS at (858) 565-8888 or at SDCMS@SDCMS.org.

SDCMS Seminars / Webinars / Events Date

Day

Time

Topic

Presenter

MAY 20 MAY 22

THU

11:30am – 1:00pm

“ABCs of Workers’ Compensation Billing” (Workers’ Compensation Billing and Reimbursement Specifics Vital to Your Practice)

CHMB Solutions

x

SAT

8:00am–11:30am

Media Training

Tom Gehring, SDCMS

x

SDCMS and SDCMSF

x x

x

JUN 5

SAT

6:00pm – 11:00pm

SDCMS / SDCMSF White Coat Gala (formerly known as the SDCMS Installation Dinner and Dance, formerly known as the SDCMS Inaugural)

JUN 10

THU

11:00am – 7:30pm

EMR / EHR Trunk Show

Maxwell IT, Multiple Exhibitors

JUN 18–19

FRI–SAT

8:00am – 4:00pm

Leader’s Toolbox Seminar

Tom Gehring, SDCMS

x

JUN 24

THU

11:30am – 1:30pm

Preventing Workplace and Sexual Harassment

Strategic HR

x

The Doctors Company

x x

x

JUL 20

TUE

11:30am – 12:30pm

Risk Management (“The Employee’s Role in Decreasing Liability Risks in the Physician Office”)

JUL 21

WED

6:30pm – 7:30pm

Risk Management (“The Employee’s Role in Decreasing Liability Risks in the Physician Office”)

The Doctors Company

JUl 22

FRI

6:30pm–9:00pm

Membership Social

Rock Bottom Restaurant and Brewery, La Jolla

Aug 7

SAT

8:30am – 12:00pm

MS Outlook for Busy Docs

Tom Gehring, SDCMS

x

AUG 18

WED

11:30am – 1:00pm

OSHA Updates

Tom Gehring, SDCMS

x

x

AUG 25

WED

11:30am – 1:00pm

HIPAA Updates

David Ginsberg, PrivaPlan

x

x

SEP 11

SAT

4:00pm – 7:00pm

Young Physicians Summer Social

SDCMS

SEP 15

WED

11:30am – 12:30pm

E-town Hall (T)

Tom Gehring, SDCMS

SEP 16

THU

11:30am – 1:00pm

Palmetto / Medicare

Michele Kelly, California Medical Association

x

SEP 18

SAT

9:00am – 12:00pm

Media Training

Tom Gehring, SDCMS

x

8:00am – 4:00pm

Certified Medical Coder Course

Practice Management Institute

x

11:30am – 1:00 pm

Economic Survival

AKT CPAs

x

OCT 1–29 5 FRIDAYS OCT 7

THU

* "S" = Seminar • "W" = Webinar • "E" = Event

6

S* W* E*

S A N D I E G O P HY S I CI A N .or g May 2010

x

x x x

x

San Diego Academy of Family Physicians 53rd Annual Postgraduate Symposium

Family Medicine Update: 2010 June 25 - 27, 2010 Paradise Point Resort on Mission Bay San Diego, California

Approved for 36.75 CME Credits by AAFP Register by calling (858) 458-9439 or by going to our website at sandiegoafp.org

May 2010 SAN DIEGO P HY SIC I A N. o rg

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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.

U.S. Public Health Service Scientific and Training Symposium

San Diego Academy of Family Physicians Annual Symposium

May 24–27 • Sheraton Hotel and Marina • phscofevents.org

Jun 25–27 • Paradise Point Resort and Spa • regonline.com/sdafp10con

First Annual San Diego HIV Golf Classic

Hugh Greenway’s 27th Annual Superficial Anatomy and Cutaneous Surgery

May 25 • The Crosby at Rancho Santa Fe • sdhivgolf.com

“A Conversation About Palliative Care” May 27 • UC San Diego School of Medicine, Leichtag Auditorium • KDotson@SDCMS.org

Alzheimer’s Disease: Update on Research, Treatment, and Care May 27–28 • Omni San Diego Hotel • cme.ucsd. edu/alzheimers

California Society of Industrial Medicine and Surgery’s 25th Annual Mid-summer Seminar Jun 18–20 • Paradise Point Resort and Spa • csims.net or (900) 692-4199

UC San Diego Conference on Limb Salvage and Functional Reconstruction: Orthopedic, Vascular, and Wound Care Team Approval Jun 25–27 • Westin San Diego • cme.ucsd.edu

8

S A N D I E G O P HY S I CI A N .or g May 2010

Jul 12–16 • San Diego Marriott Del Mar • cme.ucsd.edu

Diabetes Day for Primary Care Physicians Jul 17 • Hyatt Regency La Jolla • (904) 353-7878

Critical Care Summer Session 2010 Jul 22–24 • Catamaran Hotel, San Diego • cme.ucsd.edu/criticalcare

5th Annual Frontiers of Clinical Investigation Symposium: Pain 2010 Bench to Bedside Oct 14–16 • Estancia La Jolla • cme.ucsd.edu/ b2b2010

Challenges in the Perioperative Management of OSA Patients Oct 15 • San Diego Location TBD • cme.ucsd.edu

American Society for Bioethics and Humanities 12th Annual Meeting Oct 21–24 • Hilton San Diego Bayfront Hotel • asbh.org

Cutting Edge Strategies in Diabetes Care: Making the Connection Oct 30 • San Diego Convention Center • cme.ucsd.edu

4th Annual UCSD Hands-on NOTES and Single Site Surgery Symposium Nov 11–13 • Omni San Diego Hotel • cme.ucsd.edu/notes

West Coast Geriatric Psychiatry Conference Feb 16–19, 2011 • Catamaran Resort Hotel, San Diego • cme.ucsd.edu

Topics and Advances in Internal Medicine Mar 7–13, 2011 • San Diego Marriott, La Jolla • cme.ucsd.edu

Topics and Advances in Pulmonary and Critical Care Medicine Mar 13–14, 2011 • San Diego Marriott, La Jolla • cme.ucsd.edu

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brieflynoted

SDCMS Medical Office Manager's

By Sonia Gonzales, Your Office Manager Advocate Help Us Help R! YOU With EM to Please take a few moments questions:

answer the following

from efits you are trying to get 1) Do you know what ben or No  an EMR system? Yes  o the r data will populate int 2) Do you know how you  new system? Yes  or No s in R vendors’ track record 3) Do you know the EM physician to es vic ser gy olo techn providing information  practices? Yes  or No ociated derstand all the costs ass 4) Do you know and un No  or  EMR system? Yes with the purchase of an oose and e of licenses you can ch 5) Do you know what typ  No or  es exist? Yes what kinds of warranti

of these questions, or if you If you answered “NO” to any hostabout EMRs, SDCMS will be simply want to learn more a.m.

11 m fro 0, ” on June 10, 201 ing an “EMR TRUNK SHOW ing om upc ation, see our list of to 7:30 p.m. For more inform at ” nts CMS’ “Calendar of Eve seminars on page 6, visit SD at (858) 300-2782 or at SDCMS.org, or contact me SGonzales@SDCMS.org.

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! u o Y m o r F r a e H o t We Want

ents, picons, comm ld like to ti s e u q r u d yo wou Please sen anything that you tin — gers Bulle s a a n e a ffice M tures, id O l a @ ic s d le e a r “M onz see on you to me, Sonia, at SG ceived will re — ” s il rd a a m o B ve e h . The first fi g to receive a “Lunc rg .o S M C SD in w !” ra te d into a r Advoca be entered CMS Office Manage D S With the

[SAVE THE DATES!] The Best Events and Semin ars for Medical Office Managers

✓ May 20: WORKERS’ COMP BILLING ✓ June 10: EMR TRUNK SHOW ✓ June 24: SEXUAL HARASSMENT ✓ July 20 or 21: RISK MANAGEMENT ✓ Aug. 18: OSHA ✓ Aug. 25: HIPAA 10

S AN D I E G O P HY S I CI A N . or g May 2010

Top 5 Reasons To Attend

An Sdcms Seminar:

5. Enjoy a Delicious, Catered Meal  etwork With Your Office Manager 4. N Colleagues and Exchange Experiences et the Answers to Your Questions 3. G From Experts in Their Fields 2. Learn About the Latest Practice Management Topics and Issues AKE ADVANTAGE OF YOUR FREE 1. T SDCMS BENEFITS!

Ask Your Office Manager Advocate!

Question:

Does CMA have a letter that indicat es an HMO provider is required to provid e 45 days notice prior to converting overuse of con sult codes to E&M codes?

Answer:

OCUS SPECIALllF ment Guide PECOS Enro

rvices (CMS) has re and Medicaid Se ica ed M r fo ers nt The Ce its Provider Enrollof enrollment in n tio ca rifi ve ed delay ECOS) until Jan. nership System (P Ow d an , ain ims Ch t, men edicare to reject cla rules authorize M w ne e in Th . ed 11 tifi 20 3, is NOT iden erring physician if an ordering or ref m.

S enrollment syste Medicare’s PECO

PECOS: ine If You Are in an is in How to Determ ici ys ph d out if your

ys to fin There are three wa k PECOS: 00) 786-4262 to loo embers can call (8 1. SDCMS-CMA m ot. t status on the sp up your enrollmen ntact Center at Co er id ov Pr o GBA’s 2. Contact Palmett (866) 931-3901. hs.gov/MedicareS PDF file at cms.h CM e th d eoa nl ow 3. D rderingReferringR ll. Click on the “O ro En up erS id ov Pr left-hand side. port” link on the

No. The basic rule is whether or not the change constitutes a material change in the contract. Most HMOs have contracts wit h language that ties the reimbursement into the Medicare program rates and rules. With tho se types of contracts, it’s difficult to argue a materi al change. If the HMO has other language, there ma y be a material change, but an analysis of the con tract would have to be made to determine if that is the case. There are many variables, but the majority of the contracts reviewed were tied into Medicare gui delines. For more information on contract term inations, see CMA ON-CALL documents #1055 and #1099, which discuss terminations withou t cause or for material changes.

Email your questions to SGonzales@S DCMS.org.

ysiep guide to walk ph blished a step-by-st pu o ing als in s m ha ter A de CM ocess, from ff through the pr ed as t-b ne ter cians and office sta In ssing the in PECOS to acce em m to le if they are already ab ail . This guide is av m ste sy t en llm ro PECOS en et.org/ces. bers only at CMAn

icare or re-enroll in Med cians who enroll ysi Ph : TE ctronNO ele SE in PLEA atically enrolled tem will be autom sys S s, CO ion PE est e th qu via you have any T) for payment. If anz Go l so ari M ic funds transfer (EF n advocate, ur SDCMS physicia rg. please contact yo S.o alez@SDCM 782 or at MGonz lez, at (858) 300-2

anced Attendeesedai-tCoualr BAillprinilg"28wor"Aksdvhop M May 2010 SAN DIEGO P HY SICIA N. o rg

11

brieflynoted

DynaMed Offers

Free CME For Reading Its Weekly Update Free CME credits can now be earned by readers of DynaMed’s Weekly Update, a cost-free, advertising-free e-newsletter provided as a service to the global DynaMed community.

DynaMed’s editors monitor a large volume of research information on a daily basis through systematic literature surveillance. Based on the criteria of choosing “articles most likely to change clinical practice,” DynaMed sends a concise brief about these articles to opted-in Weekly Update subscribers each week.

Readers can earn free CME credits through DynaMed’s partnership with Antidote Education Company, an ACCME-accredited provider. Look for the CME link in each issue. Create a user account in the Antidote system, a one-time process, and then log in each week after reading the new issue to obtain your free credit. You will take a simple post-test and then earn either .25 or .50 AMA credits, depending upon the nature of the articles. You can also print credit certificates and track them via the Antidote Education site.

For further information and to subscribe to DynaMed’s Weekly Update, visit ebscohost.com/dynamed. Subscribers can also use their mobile devices to listen to Weekly Update podcasts — podcast subscriptions are available via iTunes.

Did You Know About Your Auto Insurance Discount?

12

S AN D I E G O P HY S I CI A N . or g May 2010

How’s Your

Math?

Taken from Calculated Risks: How to Know When Numbers Deceive You,

by Gerd Gigerenzer:

The probability that a woman of age 40 has breast cancer is about 1 percent. If she has breast cancer, the probability that she tests positive on a screening mammogram is 90 percent. If she does not have breast cancer, the probability that she nevertheless tests positive is 9 percent.

What are the chances that a woman who tests positive actually has breast cancer?

See page 43 for the answer.

SDCMS-CMA members and their spouses receive 4.5–14 percent discounts on all lines of coverage on auto insurance with the Automobile Club of Southern California. Contact Marisol Gonzalez, your SDCMS physician advocate, at (858) 300-2783 or at MGonzalez@SDCMS.org. For a list of your other SDCMS-CMA members-only benefits, see page 35.

Get in

touch

Your SDCMS and SDCMSF Support Teams Are Here to Help!

SDCMS Contact Information 5575 Ruffin Road, Suite 250 San Diego, CA 92123 T (858) 565-8888 F (858) 569-1334 E SDCMS@SDCMS.org W SDCMS.org • SanDiegoPhysician.org CEO/Executive Director Tom Gehring at (858) 565-8597 or Gehring@SDCMS.org COO/CFO James Beaubeaux at (858) 300-2788 or 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 MGonzalez@SDCMS.org director of medical office manager support and Office Manager Advocate Sonia Gonzales at (858) 300-2782 or SGonzales@ 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 BUSINESS MANAGER Nathalia Aryani at (858) 300-2789 or NAryani@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 5575 Ruffin Road, Suite 250 San Diego, CA 92123 T (858) 565-8888 F (858) 560-0179 W SDCMSF.org Executive Director Kitty Bailey at (858) 300-2780 or KBailey@SDCMS.org Patient Care Manager Barbara Rodriguez at (858) 300-2785 or at BRodriguez@SDCMS.org project access PROGRAM DIRECTOR Brenda Salcedo at (858) 565-8161 or at BSalcedo@SDCMS.org SURGERY DAY PROGRAM MANAGER 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

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

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

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

Global: • Organizational Structure • Succession Planning • Internal Control Review and Risk Assessment 5946 Priestly Drive, Ste. 200 Carlsbad, CA 92008

CPA’s and Consultants

SDCMS Tweets!

Follow SDCMS on Twitter.com to keep abreast of H1N1 updates, the latest healthcare reform developments, SDCMS seminars, and more!

May 2010 SAN DIEGO P HY SICIA N. o rg

13

brieflynoted

Please Welcome Our New and Rejoining SDCMS-CMA Members Welcome Our New Members!

Erick H. Alayo, MD Gastroenterology Chula Vista • (619) 585-8883 Amarpal Singh Arora, MD Orthopedic Sports Medicine San Diego • (858) 934-6503 Alfonso Camberos, MD Plastic Surgery San Diego • (858) 847-0800 Ramin Hamdy Farsad, MD Family Medicine Encinitas • (760) 943-9111 Vincent John Flynn Jr., MD Urology San Diego • (619) 528-5000 Dyson Lister Hamner, MD Orthopedic Surgery San Diego • (858) 939-6504 Alshafie Mohamed Hassan, MD Internal Medicine Chula Vista • (858) 499-2261 Elan Hekier, MD Internal Medicine San Diego Jasmine Y. H. E. Ide, MD Internal Medicine San Diego • (858) 499-2261 Pourang Kamali, MD Obstetrics and Gynecology Chula Vista • (619) 216-2100 Kenneth Andrew Katz, MD Dermatology San Diego • (619) 692-8394 Lisa Cecilia Krijger, MD Internal Medicine Poway • (858) 485-6644

14

Monique Lenore Manganelli, MD Endocrinology, Diabetes and Metabolism San Diego • (619) 867-8414 Eric Clyde McDonald, MD Emergency Medicine San Diego Jill Siren Meoni, MD Diagnostic Radiology Coronado Mehran Moussavian, DO Interventional Cardiology Chula Vista • (619) 616-2100 Johnny Hoang Nguyen, MD Family Medicine San Diego • (858) 499-2705 Richard John O’Leary Jr., MD Anesthesiology Encinitas • (760) 632-6662 Anthony David Puopolo II, MD Family Medicine San Diego • (858) 499-2204 Meera P. Ravindranathan, MD Internal Medicine San Diego • (858) 939-6622 Harrison L. Robinson, MD Internal Medicine Escondido • (760) 432-6886 Benjamin Ray Saben, MD Family Medicine San Diego • (858) 499-2714 John Thomas Steele, MD Surgical Critical Care Escondido Lourdes Gomez Villaume, MD Internal Medicine Carlsbad Marcella Maria Wilson, MD Psychiatry San Diego • (619) 282-7172

S AN D I E G O P HY S I CI A N . or g May 2010

Simon Dixon Wu, MD Urology La Mesa • (619) 828-1000

Sarmistha Kumar, DO Pain Medicine Vista • (760) 806-5820

Shirley Yee, MD Family Medicine La Mesa • (619) 670-5400

Trang Dang Thu Le, MD Family Medicine Encinitas • (760) 901-5100

Amy-Elizabeth Zanotti, DO Family Medicine Chula Vista • (858) 499-2261

Binh Cam Lieu, MD Family Medicine Oceanside • (760) 901-5085

Welcome Our Rejoining Members!

Imran Ahmed, MD Family Medicine Vista • (760) 806-5600 Theresa Aquino Bartolome, MD Family Medicine Vista • (760) 806-5520 Bart Simeon Chapman, MD Ophthalmology Carlsbad Connie Hong Chen, MD Family Medicine Oceanside • (760) 901-5010 Elena Anatolie Dolgonos, MD Family Medicine Oceanside • (760) 901-5020 Vong Ngoc Huynh, MD Family Medicine Vista • (760) 806-5800 Ignacio Iturbe-Alessio, MD Hematology Chula Vista • (619) 425-2080 Howard Norman Kaye, MD Rheumatology Poway • (760) 806-5890 David Hyunin Ko, MD Internal Medicine Oceanside • (760) 901-5100

Stacey Lin, MD Family Medicine Encinitas • (760) 901-5100 Afsaneh Maghsoudy, MD Diagnostic Radiology Carlsbad • (760) 730-3536 Eileen Stack Natuzzi, MD Surgery Encintas • (760) 634-2411 Irina F. Proshkina, MD Family Medicine Vista • (760) 806-5560 Carlos Martin Quiros, MD Family Medicine Chula Vista • (619) 472-1000 Jeffrey Steven Rakoff, MD Obstetrics and Gynecology San Diego • (858) 794-6363 Kendall Radburn Roberts, MD Pediatrics La Jolla • (858) 457-2043 Reyzan E. Shali, MD Internal Medicine Oceanside • (760) 806-5500

Physicians Get Noticed!

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

Congratulations to the 2010 Combined Health Agencies

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More information at combinedhealth.org

858.636.4158

Birthday: JUNE 22

Senator Dianne Feinstein E: www.feinstein.senate.gov Capitol Office: United States Senate 331 Hart Senate Office Building Washington, DC 20510 T: (202) 224-3841 F: (202) 228-3954 TTY/TDD: (202) 224-2501 San Diego Office: 750 B Street, Suite 1030 San Diego, CA 92101 T: (619) 231-9712 F: (619) 231-1108

25%

SDCMS member physicians receive

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May 2010 SANâ&#x20AC;&#x2C6; DIEGOâ&#x20AC;&#x2C6; P HY SICIA N. o rg

15

bioethics

By Lynette Cederquist, MD

A 28-year-old Woman Presents in Active Labor

A

Bioethics Case Study

16

S AN D I E G O P HY S I CI A N . or g May 2010

A 28-year-old Somali woman, G2P1, full term, presents in active labor. After several hours of labor, the fetal monitor indicates increasing fetal distress. The obstetrician recommends Cesarean section. The patient refuses a Cesarean, stating that her first baby was delivered Cesarean because her obstetrician estimated the baby was too large to safely deliver via vaginal birth. The surgery was very traumatic for the patient, and her baby was normal weight, so she does not believe the doctors when they advise her she needs another Cesarean. She repeatedly verbalizes, “My baby will be fine. I trust God.” Her husband is present, but he defers to his wife’s wishes. She continues in active labor for another 17 hours, with the fetal monitor continuing to show evidence of severe fetal

distress.

Can the physician force the patient to have a Cesarean section in order to protect the baby?

Once a patient has refused a Cesarean section despite the physician’s best efforts to clearly explain the situation, the obstetrician has three options: 1) Respect the patient’s autonomy and not proceed, regardless of the outcome; 2) Offer the patient the option of seeking her care from a different provider (except in an emergency situation); or 3) Request the involvement of the court.

Rarely, physicians have resorted to obtaining a court order to proceed with a Cesarean section when the mother is refusing. In a landmark case, In re A.C., the D.C. Court of Appeals overturned a previous, court-ordered

authorization of Cesarean delivery, saying that if a competent pregnant woman makes an informed decision, “her wishes will control in virtually all cases.” In this case, the parents sought the appeal after their daughter, Angela Carter, died as a result of a Cesarean section mandated by court order in 1987. The courts made this determination based on the fact that medical judgment is fallible. There is no certainty in predicting a bad outcome.

Fetal monitors are fallible, and the physician cannot guarantee that performing a Cesarean will result in a good outcome with no harm to the mother.

Support for Life.

Can the physician force the patient to have a Cesarean section in order to protect the baby?

Historically, forcing a mother to have a Cesarean without her consent occurred with much greater frequency among low-income, African American patients. This lead to suspicion that decisions to force Cesareans were carried out in an unjust, biased manner. This practice became ethically and legally unacceptable.

The ethical values at conflict in this case are respect for the mother’s autonomy vs. beneficence for the fetus, as well as the value of justice, or equal treatment. Physicians must respect a patient’s right to refuse treatment regardless of how likely it is that the treatment would benefit the patient or another individual. This respect for autonomy is extended to pregnant women just as it is to any nonpregnant person. This also exemplifies the ethical value of justice, or equal and fair treatment. Physicians cannot force a treatment or procedure on one person in order to benefit another person. For example, a physician cannot force a person to be a kidney donor, even if the donation would benefit that person’s own child.

In this case, the mother was determined to have decision-making capacity. After the additional 17 hours of labor, she was very reluctantly persuaded to consent to the Cesarean section. Unfortunately, her baby did not survive.

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May 2010 SAN DIEGO P HY SICIA N. o rg

17

patientsafety

By Adam Frederic Dorin, MD, MBA

Illegal Trafficking of Prescription Drugs

More Akin to Assault or Attempted/Negligent Homicide Than Simple Theft 18

S AN D I E G O P HY S I CI A N . or g May 2010

Dr. Bryan Liang is a physician, a PhD, and a lawyer. As professor of law and executive director of the Institute of Health Law Studies at California Western School of Law here in San Diego, he has tackled many of this nation’s top health safety concerns where medicine and law meet. Over the years, at his annual spring “roundtable” conference on Harbor Island, he has brought to light the important subjects of counterfeit drugs, counterfeit biologics, healthcare safety/ security/terrorism, and the complex world of espionage and product safety as it applies to “Big Pharma.”

At this year’s March 26 6th Annual Institute of Health Law Studies Conference, the topic was the illegal trafficking of prescription drugs. In an age where healthcare costs (and the relative scarcity of health system resources) is under intense scrutiny, the scheme of prescription drug trafficking is especially interesting, telling, and concerning. The criminal activity can be complicated but often involves Medicaid and Medicare patients, local community pharmacies and supermarket pharmacy chains, drug runners, small-time “mob bosses,” drug wholesalers, and checkcashing stores.

Without the knowledge of the doctors who prescribe the drugs, stolen or “bought” merchandise — at pennies on the dollar to poor patients, or those posing as patients — or otherwise legitimate drugs are picked up at real pharmacies and then diverted and sold back to pharmaceutical outlets on the secondary market. According to the speakers at the conference, some of whom were undercover agents working for the pharmaceutical industry and state health inspectors

in Florida (the national epicenter of such illegal activity), the trafficking of prescription drugs is a multibillion-dollar industry annually in the United States. Some of the speakers and audience members were still active in law enforcement and working at the state and national levels. Not unexpectedly, the health insurance industry was represented, as it also has a stake in the fight against this underground prescription drug diversion.

In this crime syndicate, health insurers find themselves literally paying for the same item of medicine many times over.

Here’s how the scheme works: Criminals first obtain possession of the real prescription medications through various means (usually paying patients for their newly acquired prescriptions, using forged prescriptions, raiding pharmacies, or staging large-scale operations to clean out entire drug storage facilities); then, they repackage the drugs to remove any trace that the medicine has been issued to a particular patient or warehouse facility. The drugs are then relabeled through a very sophisticated process that, in the end, makes it very difficult

May 2010 SAN DIEGO P HY SICIA N. o rg

19

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20

S AN D I E G O P HY S I CI A N . or g May 2010

Many of the prescription medicines being diverted are also among the most expensive drugs on the market, ranging from antivirals to cancer drugs to insulin. to distinguish the stolen/diverted drug from the original, “real thing.” In some instances, drugs are diluted, tampered with, or even replaced with placebo-type substitutes that are not detected unless an end-user patient complains about not responding properly to their medication.

On a government and public safety level, the problem could not be more pressing.

Patients suffer from this type of despicable scheme because their medicines may be fake or impure, and lawmakers and government officials are usually ill-informed and undermotivated to ramp up efforts to stop the cycle of corruption. Some police officers speaking at the conference revealed that they were just

not trained to pick up on this unique type of crime. They related that if most cops were to stop a car filled with $2,000 worth of marijuana, they would immediately take action and know what to do. In contrast, they reported real cases of cars being stopped with $200,000 worth of stolen or repackaged prescription medicines that were unknowingly allowed to proceed without intervention by the police.

The societal problem at stake also involves the U.S. court system. In the vast majority of cases, judges need educating that this type of crime is more akin to assault or attempted/negligent homicide than simple theft.

Many of the prescription medicines being diverted are also among the most expensive

drugs on the market, ranging from anti-virals to cancer drugs to insulin. Abuse, diversion, and tampering with these medicines can be extremely dangerous and even deadly for patients.

A grand jury in Florida in 2003 brought this problem to the attention of state legislators, and stricter licensing and operating mechanisms were put into place for prescription drug wholesalers. This did make a difference in the amount of illegal, repackaged drugs making their way back to the secondary prescription drug market. To illustrate this point, the number of licensed drug wholesalers in Florida over the past seven years has dropped from 432 to 129. States like California could potentially have an even greater long-term problem with the illegal trafficking of prescription drugs, but educating the law enforcement system and courts will prove formidable, and lags far behind where it should be to optimally protect innocent patients. Hopefully, with the persistent efforts of Dr. Liang and others, creative solutions will be found to minimize healthcare theft and fraud, and save lives.

URGENT CARE ISN’T JUST FOR PATIENTS Torrey Pines Bank has been integral to my success in establishing and growing my practice into the largest independent private medical group in the North County.

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May 2010 SAN DIEGO P HY SICIA N. o rg

21

healthreform

By Tom Gehring

Health Reform T Insurance Reforms

Insurance Coverage

Medicare Prescription Drugs

Medicare Reimbursements to Physicians

The following health reform legislation changes are scheduled to be implemented in 2010.

To access a complete 2010–18 health reform timeline, along with specific requirements for physicians, for patients, for businesses, for hospitals, and for taxpayers, please visit SDCMS.org/publications or look for the June 2010 issue of San Diego Physician.

INSURANCE COVERAGE:

INSURANCE REFORMS:

• Temporary high-risk pool with subsidized premiums created for uninsured individuals with preexisting conditions who have been denied healthcare coverage.

• Temporary reinsurance program created for employers providing health insurance coverage to retirees over age 55 who are not eligible for Medicare.

• Parents allowed to continue health insurance coverage for children up to age 26.

• Catastrophic-only health insurance coverage created for those up to 30 years of age.

• Tax credits to small employers — fewer than 25 employees, average annual wages less than $50,000 — that purchase health insurance for employees.

• Group and individual health insurance plans to cover certain preventive services without cost sharing.

• Health insurance providers required to report the proportion of premium dollars spent on healthcare.

• Health insurance providers required to have adequate provider networks.

• Health insurance providers prohibited from denying children for preexisting conditions.

• Health insurance providers prohibited from rescinding coverage when a patient gets sick.

• Lifetime or annual limits on health insurance benefits prohibited.

• Health insurance providers required to implement operating rules for certain electronic transactions within specified time periods.

22

S AN D I E G O P HY S I CI A N . or g May 2010

MEDICARE REIMBURSEMENTS TO PHYSICIANS: • Payments for mental health psychotherapy services increased by 5 percent.

• Physician payments in some rural states — not California — increased.

• A national study on physician practice expenses mandated.

• Reimbursement rates for advanced imaging services reduced by changing utilization rate assumptions.

MEDICARE PRESCRIPTION DRUGS: • $250 rebate provided to Medicare beneficiaries who reach the Part D coverage gap in 2010.

• Medicare Part D coverage gap gradually eliminated by 2020.

Timeline for 2010 Comparative Effectiveness Research

Biologics

Medicare Reimbursements to Hospitals

MEDICARE REIMBURSEMENTS TO HOSPITALS: • Annual market basket updates for inpatient hospital, home health, skilled nursing facility, hospice, and other Medicare providers reduced and adjusted for productivity.

• Additional requirements on nonprofit hospitals imposed, with penalties for noncompliance.

• Regulations issued to establish a process for public notice and comment for section 1115 Medicaid waivers.

BIOLOGICS: • Biologics manufacturers granted 12 years of exclusive use before generics can be developed.

• FDA authorized to approve generic versions of biologic drugs.

Revenue Increases

Workforce

WORKFORCE:

*

• Workforce Advisory Committee established to develop a national workforce strategy.

• Workforce supply increased and training of health professionals supported through scholarships and loans.

• Teaching Health Centers established to provide Medicare payments for primary care residency programs in Federally Qualified Health Centers.

COMPARATIVE EFFECTIVENESS RESEARCH (CER): • Independent, nonprofit CER institute established to support clinical research on comparative effectiveness — board of governors with four physician representatives; use of research for coverage, payment, or policy recommendations prohibited.

REVENUE INCREASES:

Access Complete Details on Health Reform

To access a complete 2010–18 health reform timeline, along with specific requirements for physicians, for patients, for businesses, for hospitals, and for taxpayers, please visit SDCMS.org/publications or look for the June 2010 issue of San Diego Physician.

• Ten percent tax on indoor tanning services imposed.

May 2010 SAN DIEGO P HY SICIA N. o rg

23

The Senior Tsunami

Geriatrics:

By William A. Norcross, MD, and Dilip V. Jeste, MD 24

S AN D I E G O P HY S I CI A N . or g May 2010

Successful

Aging Alive and Well in San Diego!

W

When we think about treating the rapidly growing population of seniors, the first thing that may come to mind is an increase in disease and disability — a tidal wave of dementia, hip fractures, and walkers. But at the UC San Diego’s Stein Institute for Research on Aging, we focus on what goes right in the aging process — the science of successful aging. We believe that how and why people age without significant impairments is as important as how and why they become ill.

We all know that physical health and some cognitive abilities decline with age, but studies have shown that mental health and psychosocial functioning tend to improve. This “paradox of aging” is clearly evident in some of our recent studies in which we have surveyed a total of more than 3,000 seniors between the ages of 60 and 102 years from local retirement communities and those who have participated in other UC San

Diego studies. When asked to rate themselves on a scale from 1 (not successful) to 10 (extremely successful) in terms of aging, most gave themselves a score of 7 or higher, even though they had some serious health problems.

This tells us that many San Diegans believe that they are aging quite well; they tend to place more importance on cognitive, emotional, and psychosocial qualities, such as having a positive attitude or being socially engaged, than on the physical aspects of aging. Their perception of aging is “golden,” not “gray.”

Successful aging research substantiates this. For example, a study on the power of positive thinking, or “dispositional optimism,” found that men who exhibited a high level of optimism had a reduced risk of cardiovascular death compared to those with a negative attitude. A positive self-perception of aging has been reported to be associated with a nearly eight-year survival advantage.

We believe that how and why people age without significant impairments is as important as how and why they become ill.

May 2010 SAN DIEGO P HY SICIA N. o rg

25

You might think that genetics supersedes many of these factors, but a study of more than 2,700 twin pairs found that genes only have a modest (22 percent) role in age-related functional impairments.

Likewise, numerous studies have shown that social support and interactions, as well as satisfaction and engagement in life, are associated with protection against hypertension, other cardiovascular diseases, and depression; higher baseline cognitive performance; delayed onset of dementia; and lower mortality rates. Additional bio-psychosocial factors that enhance suc-

26

cessful aging include caloric restriction, physical exercise, nontoxic environments (e.g., nonsmoking), cognitive stimulation, adaptability, a sense of humor, purpose and self-control in life, self-esteem, and reduction of stress.

You might think that genetics supersedes many of these factors, but a study of more than 2,700 twin pairs found that genes only

S AN D I E G O P HY S I CI A N . or g May 2010

have a modest (22 percent) role in age-related functional impairments — our behavior and the environment in which we choose to live take the lead (78 percent).

Studies have shown that senescent mice living in a stimulating environment have better brain function and structure.

Brain research, using magnetic resonance imaging, shows that their brains compensate for any neurodegeneration; neuroplasticity allows their brains to form new neurons and synapses, even in old age. These findings apply to humans as well, indicating that our behavior and environment may impact the function and structure of our brain; successful aging will increasingly depend on our brain health.

With this evidence-based knowledge, we as physicians have the perfect opportunity to enhance the quality of life of

our patients as they enter their golden years by providing them with strategies to improve their behavior and psychosocial support, and, thus, improve their brain function and structure.

These strategies should focus on prevention and intervention, and can be traditional or nontraditional. For example, time spent on Sudoku, crossword puzzles, and reading each day could help our senior patients keep their minds sharp. Square dancing, gardening, and playing Wii, an interactive video game, could help them stay physically active.

Through patient education materials and credible websites, we can teach them about proper nutrition and “super foods,” such as blueberries, beans, and walnuts.

Additionally, we need to set an example for successful aging, as many of us have joined or will be joining our senior patients in this journey into successful aging! We need to reinforce to our patients that successful aging isn’t just something that happens on their 65th birthday — it’s a lifelong process. The things that happened to you as an infant, a child, a teenager, and a young adult, as well as the things that you do now, are predicting your health going forward. This not only applies to your health but also to your socioeconomic status and quality of life.

Having a loving and caring family is also an essential component of successful aging.

Many of our geriatric patients have children and grandchildren who come to their appointments. This is the perfect time to discuss issues like planning for retirement, long-term care, and developing a hobby or interest outside of work. Through a shared decision-making process, we can ensure that they not only understand how to treat their disease or disability, but also participate in successful aging.

No matter what age they are, it’s never too late to start!

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May 2010 SANâ&#x20AC;&#x2C6; DIEGOâ&#x20AC;&#x2C6; P HY SICIA N. o rg

27

The Senior Tsunami

Geriatrics:

fall prevention

Positively Impacting the Health and Quality of Life of Older Adult Patients

By Eric McDonald, MD, and Kimberley Bell, DPT, MPT 28

S AN D I E G O P HY S I CI A N . or g May 2010

A

Note: Visit SDCMS.org/publications to access this article with references.

According to the Centers for Disease Control and Prevention (CDC), at least one in three adults age 65 and older falls each year, and three quarters of them will fall again within six months. Based on recent census estimates, this means that nearly 122,000 older San Diegans will fall this year. Not only will 91,000 of these older adults fall again, but between 24,000 and 35,000 will suffer injuries that will make it difficult to get around or to live alone. Without preventive interventions, these figures are expected to double by 2030 as the population increases and ages in the county. It should come as no surprise that falls are already the leading injury-related cause of 911 calls, emergency department visits, hospitalizations, and deaths among older adults in San Diego. The latest available data show that falls in older San Diegans resulted in 5,606 prehospital calls in 2009, 12,535 emergency department discharges in 2008, 6,056 hospitalizations in 2006, and 186 deaths in 2008.

Falls and fall rates are higher in women than in men, and the fall rate rises with age, especially after age 85. Most older San Diegans fall at home, usually by tripping or slipping at the same level. Falls are a greater per-capita burden in the eastern and north coastal regions of the county, the areas where many older adults live. The social, emotional, and economic costs associated with fall-related injuries are significant, and the overall wellbeing of older adults is strongly undermined by falling and the fear of falling. The acute hospitalization costs after falls for older patients were reported at $207 million in the county in 2004. Nearly half (48 percent) of older patients admitted with a fall are discharged

to a long-term care setting, so the actual economic and social costs are much higher.

Although falls in older adults are a serious concern, the most recent California Health Interview Survey revealed that only 45 percent of local patients 65 years and older who fell within the previous year received professional advice about how to avoid falls, and only 28 percent indicated that a healthcare professional reviewed their medications after a fall. Few older San Diegans started physical activity, were referred to therapy, made changes to their home, or changed their routine as a result of a fall in the past year. This reflects a significant opportunity for primary care, acute care, and emergency physicians to identify individuals at high risk for falls, to fully evaluate older patients who fall, and to reduce risk through appropriate fallpreventive measures.

The American Geriatrics Society recommends that older persons be asked about falls at least

once a year, and that those who report a single fall be observed in a brief screen such as the “Get Up and Go Test.” Those who demonstrate difficulty or unsteadiness on the screen, who report more than one fall, or present for medical attention because of a fall should have a detailed fall-risk assessment. A history of fall circumstances, medication review, and examinations of vision, gait, and balance, lower limb joints, and basic neurologic and cardiovascular functions are key assessment components.

Modifiable medical fall-risk factors such as medication sideeffects, vision problems, or muscle weakness may be found in up to one-third of patients. Evidence-based interventions that have been shown to reduce fall risk include the gradual withdrawal of psychotropic medications, first eye cataract surgery, vitamin D supplementation in those with demonstrated deficiency, and pacemakers in those with carotid hypersensitivity.

Patients on anticoagulants de-

San Diego Fall Prevention Task Force Resources • Toolkit for Providers: An information resource for providers including details on the “Get Up and Go Test,” patient handouts for older adults, and an exercise guide.

• “Don’t Fall for It” Video: English and Spanish versions of videos suitable for waiting room use detailing the fall problem and simple steps to reduce fall risk.

• “Preventing Fall-related Injuries in High-risk Patients” Webinar: A continuing-education series for providers.

• Fall Prevention Resource Guide: An annually updated listing of community resources that provide fall-prevention services, such as exercise programs, home safety modification, home health services, and more.

These materials and much more are available online at sandiegofallprevention.org, or call (858) 495-5061 to arrange a presentation or to obtain paper copies and DVDs. For more information about Task Force products or to join, contact Kristen Smith at kristen.smith@sdcounty. ca.gov.

May 2010 SAN DIEGO P HY SICIA N. o rg

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An excellent local resource for providers and patients is the San Diego Fall Prevention Task Force, originated in 2004 by the County of San Diego’s Aging and Independence Services. serve directed attention for fall prevention. Physical therapists experienced in vestibular rehabilitation are a valuable referral resource for patients with dizziness, vertigo, or disequilibrium.

A major strategy to prevent falls involves exercise programs.

A 2009 Cochrane Review noted that programs for older adults that contain two or more of the

following components are effective in reducing fall rates and the number of people falling: strength, balance, flexibility, and endurance. Exercising in supervised groups, participating in tai chi, and carrying out individually prescribed exercise programs at home have all been shown to be effective in reducing falls. A wide variety of exer-

cise programs tailored for older adults is available in the county, including the free-of-charge “Feeling Fit” clubs and a new, free tai chi program through a CDC fall-prevention grant.

Interventions to improve home safety may be effective in reducing falls, particularly in high-risk patients such as those with visual impairments, and when included in a multifaceted approach to risk reduction. A typical, multifaceted approach might combine a thorough medical assessment with specific interventions such as a home modification evaluation, an exercise program, and/or a specialty referral.

Along with several recently published reviews of prevention programs by the CDC and others, an excellent local resource for providers and patients is the San Diego Fall Prevention Task Project4:Layout 1

Force, originated in 2004 by the County of San Diego’s Aging and Independence Services (AIS).

Staffed by AIS, chaired by a community agency representative, and consisting of more than 160 volunteer members from health organizations across the county, the Task Force has produced and made accessible existing bestpractice information and other local resources, some of which are listed in Table 1. Physicians can positively impact the health and quality of life of their older adult patients by utilizing these resources to reduce both the risk and fear of falling.

9/22/08

11:22 AM

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Tracy Zweig Associates A

REGISTRY

&

PLACEMENT

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Physicians

Nurse Practitioners Physician Assistants

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t z we i g @ t r a c y z we i g . c o m www. t r a c y z we i g . c o m

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S AN D I E G O P HY S I CI A N . or g May 2010

Mechanisms of Injury

Nature of Injury

Emergency Department Discharges for Adults Over 64 After a Fall, San Diego County, 2008 (N=12,535)

Emergency Department Discharges After a Fall in Adults Over 64, San Diego County, 2008 (N=12,535)

1.9%

Internal Organ

5.6%

9.4%

1.5%

Non-injury

Against Object

6.1%

Dislocation

6.2%

Stairs or Steps

Sprains and Strains

5.1%

From Other Furniture

4.5%

29.0%

From Bed

Other/Unspecified Fall

1.8%

12.0%

27.7%

Superficial/Contusion

Other/Unspecified

Other One Level to Another

43.1%

1.0%

From Ladder/Scaffolding

Same Level: Slipping or Tripping

21.7%

Open Wounds

23.5% Fracture

Source: Hospital Association of San Diego and Imperial Counties, Community Health Improvement Partners, County of San Diego Health and Human Services Agency, Public Health Services, Emergency Medical Services, Emergency Department Discharge Database, 2008.

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This private club is located in the heart of the Anza Borrego Desert State Park and is renowned for its beautiful setting and the friendliness of its membership. Come and play a single round for $75.

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May 2010 SAN DIEGO P HY SICIA N. o rg

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The Senior Tsunami

Geriatrics:

Keeping Older Drivers Safe And Out of the News Note: Visit SDCMS.org/publications to access this article with references, graphics, and a list of alternative mobility resources.

By Linda L. Hill, MD, MPH, and James S. Grisolía, MD 32

S AN D I E G O P HY S I CI A N . or g May 2010

Older adults have positive driving attributes like experience, being more likely to follow the laws and less likely to take risks; however, as a group, they have rates of death per distance driven and per population as high as teenage boys.

D Driver, 86, loses license after mistaking the gas pedal for the brake and runs over man in Costco parking lot.

74-year-old driver with health problems plows into an El Cajon Carl’s Jr., killing a man inside.

CHP Officers spend 40 minutes pursuing elderly motorist from Encinitas to University City. Driver did not notice the six squad cars and police helicopter following him the entire way.

75-year-old driver with a bad hip mistook the gas for the brake and drove off a cliff at Cabrillo National Monument, resulting in his death.

On average, men outlive their ability to drive safely by six years, and women by 10 years.

With individuals 65 years old and older the fastest growing demographic in the United States today, the problem of elder driving safety is exploding. By 2020, there will be more than 40 million licensed drivers over the age of 65 in the United States. Our challenge is to identify — before tragedies occur — when alternative transportation options should be employed.

The age at which driving becomes unsafe is variable, with many individuals continuing to drive safely into their ninth decade. Older adults have positive driving attributes like experience, being more likely to fol-

low the laws, and less likely to take risks; however, as a group, they have rates of death per distance driven and per population as high as teenage boys, due mainly to declining vision, impaired cognitive function, general frailty, and chronic diseases with their associated medications. In addition, in crashes of the same intensity, older adults have three to four times the risk of death as 20-year-olds due to decreased muscle mass and osteoporosis.

AMA has recognized the role of physicians in identifying which older adults should no longer be driving and has developed guidelines that provide tools and practice management aids, including sample letters, screening tests, management guidelines, and charting aids.

The screening tests suggested

by AMA are blunt but identify three areas of concern: vision (acuity and fields), frailty (gait speed, range of motion, and strength), and cognition (TrailMaking B and Clock Drawing).

The bluntness of these tools stems from the paucity of data linking failure (as a group) on these tests directly to the outcomes of interest: citations, crashes, injuries, and deaths.

There is, however, more than sufficient evidence on each of these tests with the relevant outcomes to support their inclusion.

In addition to the seven tests, the screening process should

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also cover targeted history to include a history of loss of consciousness, seizures, dementia [all reportable to the California Department of Motor Vehicles (DMV)], medication history to include drugs that interfere with cognition, and especially patient or family concerns about their ability to drive safely. Since driving involves rapid decisionmaking, especially under stressful conditions that cannot be duplicated in the office, family concerns remain the most effective screen.

For patients who pass all seven screens, management should focus on restricting medications to their lowest necessary doses; on strict avoidance of alcohol while driving; and counseling on safe driving. Seniors should be retested periodically or with health changes. These screening tests may identify problems as-

For patients who pass all seven screens, management should focus on restricting medications to their lowest necessary doses; on counseling on safe driving, including strict avoidance of alcohol while driving; and on retesting at regular intervals or with health changes. sociated with temporary or correctable changes in function. In those cases, referral and evaluation, with treatment, may result in enough improvement in function to resume driving.

If the vision or frailty tests are failed, assess whether the diagnosis has been made and whether there is a reversible component. If the deficit is permanent, and the patient wishes to continue driving, consultation with an occupational therapist with advanced training in driver assessment may help in deciding if this is a safe option.

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Known as Certified Driving Rehabilitation Specialists (CDRS), these health professionals can take drivers on the road and provide both safety assessments as well as rehabilitation of driving skills. Currently, CDRS programs exist at Sharp Memorial, Tri-City Hospitals and Scripps Encinitas has one in development.

The failure of the dementia testing requires further evaluation to confirm the diagnosis and determine the level of dementia. The DMV feels that some individuals with early de-

mentia are able to continue driving safely; however, they want to be aware of these individuals and conduct testing and monitoring. As with patients exhibiting frailty and impaired vision, a CDRS can be very helpful in providing guidance for patients with mild dementia.

The DMV mandates reporting of drivers with dementia, a loss of consciousness, or seizures. Reporting can be done through the Confidentiality and Morbidity Report (CMR) form or through the DMV’s DS 699: Request for Driver Reexamination. Physicians can also report drivers with other health issues — such as substance abuse, vision deficits, frailty, and medication sideeffects — that may potentially impair their driving. Physicians who report are protected from liability by Health and Safety Code 103900. Especially once

families have expressed concern, physicians who choose not to report could face potential liability in the event of an accident. Lawsuits by third parties injured in an accident would often not be covered by malpractice policies.

Once the DMV has been notified, whether by an emergency department, the treating physician, or law enforcement, a detailed medical questionnaire (Driving Medical Evaluation, or DME) is sent to the patient.

Physicians traditionally dread filling out these forms, but irrelevant sections may simply be lined out rather than completed in detail. The legal consensus is that no liability attaches to filling out the DME, unless deliberately and provably false statements are made.

The most helpful questions for the DMV hearing officer are: “In your opinion, does your

patient’s medical condition affect safe driving?” and “Do you currently advise against driving?” Physicians may hesitate to answer these questions, but no liability attaches to answering them. Our medical opinion carries great weight, but the ultimate decision and liability rests with the DMV. Patients may be reluctant to bring driving concerns to their physician’s attention. Driving is a sensitive issue for many older adults who depend on driving for independence. Driving cessation in this population has been associated with a three-fold decrease in out-of-home activity and a two-and-a-half-fold increase in depressive symptoms.

Thus, ARDDS (age-related driving disorders screening) should be conducted in a supportive environment where options for continued mobility can be given

to patients who should no longer be driving.

UC San Diego has been training professionals on ARDDS since 2004 through funding from the California Office of Traffic Safety. Our team is a unique partnership of preventive medicine physicians in the Department of Family and Preventive Medicine, led by Dr. Linda Hill, and trauma surgeons in the Division of Trauma, led by Dr. Raul Coimbra. More than 1,000 patients have been screened for ARDDS in both in- and outpatient settings. We have found both settings to be valuable: Outpatient settings capture the majority of older adults, and primary care physicians are ideally suited to screen and counsel on this issue. Inpatient settings provide access to persons whose health may have suddenly changed and where

driving is either temporarily or permanently unsafe. Screening is well accepted, and satisfaction level is high in both settings.

Addressing driving retirement requires effort on many levels.

The availability of alternative transportation methods for older adults is a problem that must be addressed by society through increasing public transportation options. SANDAG has a centralized transportation website for older adults and individuals with disabilities at: StrideSD.org/ default.asp. The government has a role through the DMV in helping to identify unsafe drivers during relicensing; however, the healthcare system must also play a crucial role as physicians screen and identify patients.

Society, older adults, and their families depend on physicians to help them through this transition.

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The Senior Tsunami

Geriatrics:

A Hospice Caregiver, Daughter, and Physician Lessons Learned

M My mother died recently after a brief terminal illness as a San Diego Hospice patient in my home. The physician, daughter, and caregiver in me harmonized finally, thanks to lessons learned from hospice professionals, family, and friends.

1. Just Be a Caregiver: Let the hospice team lead and guide you. They have tremendous experience in this, and most of us are truly beginners. You really can trust them. Their gentle, caring ways quickly convince you of this.

By Rosemarie Marshall Johnson, MD 36

2. Limit Your Time in Doctor Mode: Sometimes, a lot of the time, doctor mode helps because it controls your personal feelings so that you can do the

S ANâ&#x20AC;&#x2C6; D I E G Oâ&#x20AC;&#x2C6; P HY S I CI A N . or g May 2010

tasks necessary to provide comfort and care. But excuse yourself from that doctor responsibility we live with 24/7, retired or not.

The hospice team is in charge; ask questions, but follow orders.

3. Ethics vs. Patient Wishes: Should you give another dose of morphine? Should you call the hospice triage nurse? Just be a relative. Remember what the hospice team tells you: Call us anytime you feel the need!

They are kindly and attentively available 24/7. Every moment is precious for your loved one, and you want to make it as comfortable as possible. Ask your hospice helper about the morphine, or whatever you are considering.

But also remember this: What does your loved one want? See

everything in that context, and blend in the ethics.

4. Learn Nursing Skills: Some of us know very few valuable nursing skills, like turning and moving patients with a draw sheet, bathing, or assisting with other personal hygiene matters.

And some of us are awkward doing this, especially for Mother or Father, or maybe anyone. I found it surprisingly easy once I followed the hospice caregiverâ&#x20AC;&#x2122;s ways. Again, the love and concern you feel for the patient trumps all discomfort of the task.

5. Be Gracious: Fatigue and anxiety seep in without warning; it cannot be avoided. Just let the kind, genuinely solici-

Death does not have to be a failure. It is a passing beyond our ken, but one’s beliefs help in accepting and even rejoicing in this.

But listen to all of those who are experienced. Some of our night sitters with no medical or nursing degree but lots of experience and talent gave me very good guidelines for noticing decline.

Physicians in most fields do not sit with patients over long periods of time. Add this to the fact that there are no timetables for dying, and patients surprise us all the time. We physicians are in that area of unknown that we do not like. Just listen to the experts and go with the obvious.

tous manner of the hospice expert waft over you. There will be frustrations. We live in a canyon that is very hard to find. Even though this and directions are everywhere on Mother’s chart, a pharmacy driver or new night sitter will come from another site without directions. One prescription took four hours to arrive. Bothersome, but this was not a critical medication, and it happened early in our experience. Help them help you; anticipate these simple problems and be patient yourself. You may call them before you get frustrated.

6. The Timetable: Of course this varies greatly from patient to patient, and it is often just an educated guess that varies from one answer to the next.

7. The Hospice Team: I happened to be familiar with San Diego Hospice and Palliative Care (SDHPC), their outstanding physician leaders, all types of healthcare professionals, staff, and volunteers. I kept using the word “angel” to describe each and every one who called or came. Really. There were an amazing number of SDHPC people with whom we came in contact, and every single one was very polite and truly sympathetic. When asked, all said they loved their work. What a blessing for them and all of us who need them. You may not be familiar with the concept of a hospice team — they will explain and give you lots to read and review. It is a unique medical entity from both the professional and personal side of your experience.

8. Take Notes: Progress notes with times, dates, and doses, as well as comments, will definitely help as time goes along. A diary of help and social visits, a listing of services will be appreciated. All of these things help

you make decisions and connect to caregivers and assistance you may need. And after your family member dies, you can review the notes for comfort and reassurance that you did the right things.

9. Visitors: It is tough to say no to visitors, especially special people. What does the patient want?

What will add to the dignity, rest, and comfort the patient deserves? Of course, closure for everyone should be considered.

We asked people early on to visit, especially the toddler greatgrandchildren who loved and played and hugged with “Nanny” so much. That was possible the first week of hospice, but after that the little ones stayed home. As Mother went on a morphine drip and was sleeping most of the time, we encouraged no one to come, but agreed to individual requests.

10. Make Lists: There are many ways to check all the necessary business and personal steps as death seems to be approaching.

Lists might include all those who need a call about the patient’s current condition, and again when death comes; some people suggest a phone tree for this. The patient’s business affairs should be organized, especially while the patient can give instructions. Funeral wishes should be known. Check out the Memorial Society of San Diego, a nonprofit for 50 years that secures arrangements with many mortuaries at significant discount rates.

11. Treasures and Things: It was suggested to us that we

should close Mother’s apartment while she was with us. We did know she would not return there; she would be with us no matter how long. This gave us a chance to do what she wanted with her clothes (Rachel House), household items, and treasures.

It was wonderful going through such things as her high school yearbook, very old family pictures, a pictorial history of our hometown, her Christmas decorations.

12. Be Good to Yourself: As possibly the only medical person (or the chief one) closest to the patient, you may feel you have to be present 24/7. That does no one any good. If still practicing, your burden becomes horrendous. But even those retirees among us have other responsibilities and need breaks. Get night sitters and a baby monitor for your room. Accept help. Realize you cannot be there for every decision and event.

Enjoy this time with your loved one as much as possible.

Death does not have to be a failure. It is a passing beyond our ken, but one’s beliefs help in accepting and even rejoicing in this. My mother was ready at 89; she felt she had a great life and talked about seeing Dad, other relatives, and friends. She wanted to know everything, the truth.

This was difficult, but I told her: the diagnosis, the time estimate, the possible complications to be expected. She wanted to be comfortable, but let go. Knowing all this has helped our family since she died. We could let her go; she had graduated!

May 2010 SAN DIEGO P HY SICIA N. o rg

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The Senior Tsunami

Geriatrics:

“

”

Where Are My Keys?

T

Understanding and Treating Alzheimer’s Disease in the 21st Century

By Steven A. Ornish, MD, and Andrea Ladmer 38

S AN D I E G O P HY S I CI A N . or g May 2010

The San Diego Psychiatric Society, in partnership with the San Diego County Medical Society and the UC San Diego School of Medicine, presented a panel on Feb. 25, 2010, titled: Understanding and Treating Alzheimer’s Disease in the 21st Century.

The distinguished panel included Douglas R. Galasko, MD, Lisa Snyder, LCSW, John Daly, MD, and Dan Sewell, MD. Steven A.

Ornish, MD, served as panel moderator.

Each of the speakers was allotted 10 minutes for their presentations, followed by a question-and-answer session from a diverse audience of physicians, students, and the public.

Dr. Galasko, the first speaker, stressed the importance of proper and early diagnosis of dementia. Risk factors for Alzheimer’s

Although risk factors for Alzheimer’s include aging and genetics, and while there are no proven deterrents, Dr. Daly pointed out that following a healthy lifestyle of diet and exercise is always a good bet!

disease include aging, genetics, head injury or loss of consciousness, and atherosclerosis. Dr. Galasko made the point that memory loss is not always due to Alzheimer’s disease, since delirium, depression, anxiety, and prescription medications can all cause cognitive impairment that can mimic Alzheimer’s disease.

Although diagnosis of Alzheimer’s disease is primarily a diagno-

sis of exclusion, a PET scan can be diagnostic of Alzheimer’s.

Although there are tests and imaging studies that can provide a definitive diagnosis of Alzheimer’s disease, these are for research purposes and currently unavailable to the general public. Dr. Galasko also pointed out that the common “tip of the tongue” phenomenon is due to a problem with retrieval and not necessarily indicative of early Alzheimer’s disease.

Dr. Daly discussed how we are living longer as a population and that the fastest demographic are individuals 85 years old and older. Since age is a risk factor of Alzheimer’s disease, the prevalence of Alzheimer’s disease is increasing. Dr. Daly stressed the importance of a comprehensive history and thorough medical evaluation in patients presenting with cognitive impairment, since underlying medical problems are not uncommonly overlooked in patients presenting with dementia that can mimic or exacerbate Alzhemier’s. A work-up for Alzheimer’s disease includes a brain MRI, vitamin B12 level, a TSH, CBC, a chemistry panel, and an ESR. HIV and RPR tests should also be ordered when clinically indicated. Dr. Daly indicated that a healthy lifestyle of diet and exercise might be protective.

Dr. Sewell, an expert psychopharmacologist in treating patients with Alzheimer’s, stated that San Diego is on the cutting edge of research in Alzheimer’s and stressed the importance of

making an accurate diagnosis when evaluating patients presenting with complaints of cognitive impairment. Dr. Sewell teaches family members to use “redirection” as a tool when dealing with a distraught, agitated loved one with Alzheimer’s.

For example, should a female patient with Alzheimer’s become fearful and paranoid that her purse has been stolen (when, in fact, she cannot remember where she put it), he suggests simply distracting the patient from their fear and changing the subject (e.g., “That dress looks great on you!”).

Dr. Sewell believes that medications prescribed for Alzheimer’s, such as Aricept and Namenda, are overrated but became widely prescribed since, for the first time, physicians had a treatment. Although the benefits of these medications are modest at best, they also serve to “treat” the prescribing physician’s feeling of helplessness in the face of a chronic, deteriorating illness. Dr. Sewell emphasized that when considering acetylcholine esterase inhibitors and Namenda, one should be mindful of the Hippocratic Oath — Primum non nocere or “First, do no harm” — since the side-effects of these medications, such as insomnia, loss of appetite, diarrhea, and agitation, often outweigh their modest benefits. The goal is to optimize quality of life, and this can often be achieved through simple interventions such as ensuring that the patient’s hearing and vision are optimized.

Ms. Snyder addressed the daily challenges of living with Alzheimer’s disease for the patient and family members. She spoke about the many “hues” of the illness and the challenge of “the long goodbye” for the patient and their family as the patient declines. When working with families and patients whose propensity is to focus on the losses, Ms. Snyder reframes the condition by emphasizing the many “hellos” that concurrently exist by highlighting the remaining possibilities. Although we may see the Alzheimer’s patient as “different” than we are, in her years of working with this population, she has come to appreciate how we are far more alike than different. Ms. Snyder’s book, Speaking Our Minds: What It’s Like to Have Alzheimer’s, describes the experience of Alzheimer’s from the patient’s perspective. Ms. Snyder’s book in press, Living Your Best With Early Alzheimer’s: An Essential Guide, is a practical guide for people with early Alzheimer’s and their families.

Many questions and answers followed this esteemed panel’s presentation. Although risk factors for Alzheimer’s include aging and genetics, and while there are no proven deterrents, Dr. Daly pointed out that following a healthy lifestyle of diet and exercise is always a good bet!

May 2010 SAN DIEGO P HY SICIA N. o rg

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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.

40

S AN D I E G O P HY S I CI A N . or g May 2010

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classifieds housing needed CANADIAN SURGEON SEEKING HOUSING: Canadian surgeon moving to San Diego for a one-, possibly two-year fellowship with wife and single child. Seeking housing, preferably furnished. Any and all assistance is greatly appreciated. Please contact at nearest convenience: denniskim@rogers.com. [791] OFFICE SPACE MEDICAL OFFICE SPACE AVAILABLE PART TIME TO SHARE IN SOLANA BEACH: Excellent location off I-5 by coast. Space includes three fully equipped exam rooms, waiting room, lunchroom, two bathrooms. Available all day Thursdays and other days half-day flexible schedule.

Great opportunity for a start-up practice that can’t fill a full-time schedule. Affordable rent and flexible arrangements. Call (858) 259-9708 or email solanabeachmed@sbcglobal.net for more information. [811]

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 OFFICE SPACE IN HILLCREST: Office space available for a physician with an established primary care practice in Hillcrest, located near Scripps Mercy and UCSD. Turnkey opportunity with excellent staff, state-of-the-art office and equipment. Please send letter of interest to KLewis@sdcms.org. [810] OFFICE SPACE TO SHARE: Currently occupied by orthopaedic surgeon. Great location close to Scripps/Mercy and UCSD Hospital. Looking to share with part-time or full time physician. Fully furnished, fully equipped with fluoro machine and 4 exam rooms and staff. (NEGOTIABLE) Please contact Rowena at (619) 299-3950. [804] 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] MEDICAL OFFICE SPACE FOR RENT IN ENCINITAS: Convenient location five minutes from Scripps Encinitas Hospital. Close to 5 freeway. Features include two spacious exam rooms, private consultation/doctor’s office, lunchroom, private bathroom, and a spacious waiting room shared with one other doctor. Very affordable rent. Office located at the corner of Encinitas Blvd. and Manchester Ave. Call (858) 756-3021 or email ktagdiri@gmail.com for more information. [800] SINGLE DOCTOR PRACTICE SPACE AVAILABLE: Office located across from Sharp Chula Vista Hospital. Space includes a physician office and 2–3 exam rooms fully equipped. Share reception and a large remodel waiting room. Preferably a primary care physician or internal medicine.

Reduce your overhead by sharing space. Flexible to any arrangement proposed. Call (619) 9944366, email jeannette0038@yahoo.com, or fax letter of interest to (619) 421-3315. [796] DOWNTOWN OFFICE SPACE AVAILABLE: Family practice physician in downtown San Diego has office space available. Preferably a primary care physician, but open to any healthcare provider. If interested, please call (858) 270-7633. [735] SCRIPPS ENCINITAS CONSULTATION ROOM/ EXAM ROOMS: Available consultation room with two examination rooms on the campus of Scripps Encinitas. Will be available a total of 10 half days per week. Located next to the Surgery Center. Receptionist help provided if needed.

Contact Stephanie at (760) 753-8413. [703] CARMEL VALLEY OFFICE SPACE FOR SHARED LEASE OR SUBLEASING: 2,900 square feet located in the Scripps Medical Offices on El Camino Real and High Bluff. Busy women's health office ideal for physician seeking exposure to new patients. Convenient practice ready space ideal for a solo physician. Possibility for shared staff and/or overhead. Contact Mrs. Kim at cvwh858@gmail.com or at (858) 259-9821. [790] 1,200FT2–1,600FT2 OF OFFICE SPACE IN EAST SAN DIEGO/LA MESA AVAILABLE FOR LEASE: Ideal as a satellite clinic or administrative office, on University Ave. near 70th St. Very visible tower signage provides outstanding visibility and exposure to cars and pedestrians on University Ave. Adjacent to a pediatrics office, and with easy access from Highways 8, 94, 125, and

15, Alvarado and Grossmont College, La Mesa, El Cajon, Spring Valley, Lemon Grove, points south and north. Plenty of parking and directly across from the Joan Kroc Recreation Center (over 3,000 families visit each week). Fixed rent for three years $1.95/ft2 per month, includes lighted tower signage, and NO additional charges for common areas or services. Please contact Venk at (619) 504-5830 or by email at venk@gpeds. sdcoxmail.com. [777] SPACE AVAILABLE FOR PHYSICIAN TO SHARE: Space available for physician to share with a very busy internal medicine group near Alvarado Hospital. Established practice with five internists serving the community for more than 30 years. The “turn-key” practice is waiting for the right doctor. Great opportunity! Please call the office manager, Lydia, at (619) 229-5055. [765] PHYSICIAN POSITIONS AVAILABLE PART-TIME AND FULL-TIME OPENINGS FOR PRIMARY CARE PHYSICIANS: Board-certified family practice or internal medicine physicians wanted to join our prominent East County private medical group. One year or more experience preferred. Located on the Grossmont Hospital campus, our primary care group practices full-spectrum family medicine, including hospital care. Sharp Community Medical Group providers.

Ownership opportunities available. Interested applicants please send CV to brad.kesling@gfmg. net. For further information, visit us at www. gfmg.net. [808]

Medical Directors – MD/DO North County – San Diego, CA: Seeking candidates that are board certified or board eligible as well as previous experience in Electronic Medical Records. Occupational Medicine experience is preferred. U.S. HealthWorks is an innovative leader of industrial and outpatient physical therapy centers in the nation. We are an employee-focused organization offering outstanding compensation & a competitive benefits program!

Submit your CV with cover letter to: providerrecruitment@ushworks.com Fax: 866.357.6380. Apply online at: www.ushealthworks.com EOE Great FP Opportunity in Ramona: Immediate opening for CA-licensed physician in thriving family practice with small-town, rural atmosphere. We are flexible and friendly with

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.

42

S AN D I E G O P HY S I CI A N . or g May 2010

excellent working conditions, loyal staff, and wonderful patients. No hospital work, easy call, attractive compensation package. Email fredarsham@hotmail.com. [807] UNIQUE, PART-TIME INTERNAL MEDICINE OPPORTUNITY IN NORTH SAN DIEGO COUNTY: Tired of working too much? Want more flexibility? Then this may just what you’re looking for. Well-established internal medicine practice in North County seeking part-time, board-certified internist on a long-term basis. This is a rare chance to enjoy the rewards of private practice in a well-respected, single-specialty group setting and still have plenty of free time for other work or family commitments. If interested, call (619) 248-2324. [806] NURSE PRACTITIONER: We are looking for a nurse practitioner with at least two years experience in OB/GYN mandatory. Please call Valerie at (858) 618-1156, ext. 105 or email vrizzotto.kohatsu@yahoo.com. [805] URGENT CARE PHYSICIAN NEEDED ON A LOCUM TENENS BASIS FOR 4–5 SHIFTS PER MONTH: The location of the urgent care is in the north county coastal area of San Diego County.

Please visit our website at www.cassidymg.com for information on the group and hours of the urgent care. If interested, please send CV to judy@ cassidymg.com or fax to (760) 630-2558, attention: Judy Krueger, Executive Director. [803] PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com) is a fastgrowing group of house-call doctors. Great pay ($140–$200+K), flexible hours, choose your own days (full or part time). No weekends or inpatient duties. Transportation and personal assistant provided. Call Chris Hunt, MD, at (858) 279-1212 or email CV to hpmg11@yahoo.com. [801] FULL-TIME PHYSICIAN OR NURSE PRACTITIONER NEEDED IN NORTH SAN DIEGO COUNTY: Physician or nurse practitioner to perform housecalls in North San Diego County Monday thru Friday. Ten to 12 patients per day.

Please forward CV. Full time. Excellent time management skills required. Pager one week per month. No hospital rounds. Established patient base. Independent contractor position. Email to mobiledoctor@sbcglobal.net or fax to (760) 5919976 or mail to 1582 W. San Marcos Blvd., Suite 100, San Marcos, CA 92078-4081, Attn: Julie Humphrey, Administrator. [795] NORTH SAN DIEGO COUNTY IM, FP: We are a Joint Commission-accredited, federally qualified community health center, celebrating nearly 40 years of service, and serving more than 60,000 patients in multiple locations in North San Diego County. We have opportunities for BC/BE physicians. Compensation includes attractive base, incentive, and great benefit programs, malpractice, reimbursement for CME/licensure. This is

an opportunity to make a difference in the lives of patients who are under- or uninsured without having the expense of overhead or management concerns, and provides work-life balanced hours.

NHSC loan repay may also be available. Email cynthia.bekdache@nchs-health.org or fax to (760) 736-8740. [794] 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 VistaCommunityClinic. org. EOE/M/F/D/V [792] SEEKING BOARD-CERTIFIED PEDIATRICIAN FOR PERMANENT 3.5 DAYS PER WEEK POSITION (TO START): Private practice in La Mesa seeks pediatrician 3.5 days per week (to start) on a PARTNERSHIP track. Practice pediatrics in a modern office setting with a reputation for outstanding patient satisfaction for 14 years. Dedicated triage-pharmacy-referrals and education nurse takes routine calls off your hands, leaving you to focus on direct, quality patient care. Nine office staff provide experienced, attentive support. Clinic care is three patients per hour, 1-in-3 call is minimal, rounding at Sharp Grossmont on newborns, no high-risk delivery attendance (ALS nurse team present), all make for a very tolerable practice profile. Benefits include paid tail coverage included professional liability insurance, paid holidays/vacation/sick time off, paid practice expenses, professional dues, health and dental

insurance, uniforms, CME, disability and life insurance. Please contact Venk at (619) 504-5830 or by email at venk@gpeds.sdcoxmail.com for a July–September placement. [778] PRACTICE FOR SALE DEL MAR-AREA GENERAL PRACTICE: Prime location, huge potential for practice expansion in fast growing Carmel Valley community. Established in 1990; terms available. Inquiries call (858) 755-0510. [185] NONPHYSICIAN POSITIONS AVAILABLE NURSE PRACTIONERS 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) 414-3702. Visit our website at VistaCommunityClinic.org. EOE/M/F/D/V [793] MEDICAL EQUIPMENT FOR SALE: Exam tables and other exam furniture. Call (619) 585-0476. [798] MISCELLANEOUS MOBILE SKIN CANCER SCREENING OFFICE: 1993 Class A Winnabago Motor Home Converson. $25,000 or BO. Location: Ramona, California. For information, email happytrails1959@yahoo.com.

[809]

Reach 8,500 doctors by advertising in San Diego Physician magazine.

Contact Dari Pebdani today!

858-231-1231 or DPebdani@SDCMS.org

How’s Your Math, from page 12: Answer: 10 percent. Problem rephrased: Think of 100 women. One has breast cancer, and she will probably test positive. Of the 99 who do not have breast cancer, 9 will also test positive. Thus, a total of 10 women will test positive. How many of those who test positive actually have breast cancer?

May 2010 SAN DIEGO P HY SICIA N. o rg

43

sdcmsfoundation

By Rosemarie Marshall Johnson, MD

Project Access Reaches 100 Physician Volunteers!

Keeping Patients out of Emergency Rooms and Lowering Inpatient and Outpatient Visits

V

Volunteering for Project Access San Diego (PASD) has been beyond expectations, thanks to the generous participation of our physicians and other health professionals.

As of March 2010, PASD has enlisted more than 100 individual physician specialists, in addition to 275 anesthesiologists, radiologists, pathologists, physical therapists, and medical equipment providers, all willing to donate their services for uninsured adult patients. We also have hospitals and surgical centers and are hoping for more!

What does this mean? We have helped control or cure the health problems of more than 400 patients. With the dedication and devotion of our expert staff, not one patient appointment has been missed, and every patient visits the specialist with a complete and up-to-date chart. Another special feature of Project Access San Diego is that the patient goes to the specialist’s office. The physician does not have to interrupt a busy practice to provide care for the medically underserved in a community clinic. Like the other Project Access programs around the country, we are keeping patients out of emergency rooms and are lowering both inpatient and outpatient visits. This not only helps patients and their families but, according to available data, saves significant money, staff time, and medical equipment for the overall healthcare system.

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S AN D I E G O P HY S I CI A N . or g May 2010

This is a great San Diego beginning for a program that has been successful in more than 50 other cities in the United States. But there is no room for complacency. We need more specialists, their expertise Paul Bernstein, MD, med director of SDAMC and ical and their assistance in Project Access volunteer. prepares to perform a recruiting hospitals, and sebaceous cyst and lipo surgical centers and equipremoval on patient, Simma on. ment necessary to carry out their treatment plans for our patients. and many other health professionals who Our dedicated Foundation staff agrees that serve these patients reflects this generosity of it is a privilege to provide Project Access San spirit. Although we are providing invaluable Diego for our grateful patients. Our physihealthcare for the working uninsured and cian volunteers energize us with their desire other uninsured adults, the best aspect of to participate, which continually reminds us Project Access is the joy of volunteering! that this is what physicians love to do: help Please join us and experience it! patients. The support of medical office staff

Interested in Volunteering?

If you are interested in volunteering or donating other healthcare services, please contact Lauren Radano, SDCMS Foundation Healthcare Access Manager, at (858) 565-7930 or at LRadano@SDCMS.org. You may also page Dr. Rosemarie Marshall Johnson at (619) 290-5351 or email her at RJohnson@SDCMS.org.

POLITICAL REALITY:

YOU’RE EITHER

AT THE

TABLE OR

YOU’RE ON THE

MENU SDCMS Is at the Table!

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 May 2010 SAN DIEGO P HY SICIA N. o rg

45

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

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