December 2010

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

december 2010

official publication of the san diego county medical society

Spirituality medicine and

“ P h y s i c i a n s U n i t e d F o r A H e a l t h y S a n D i e g o ”

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

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

We are The Doctors Company.

You deserve more than a little gratitude for a career spent practicing good medicine. That’s why The Doctors Company created the Tribute Plan. This one-of-a-kind benefit provides our long-term members with a significant financial reward when they leave medicine. How significant? Think “new car.” Or maybe “vacation home.” Now that’s a fitting tribute. The San Diego County Medical Society has exclusively endorsed our medical professional liability program since 2005. To learn more about our program for SDCMS members, including the Tribute Plan, call us at (800) 328-8831, extension 4390, or visit www.thedoctors.com/tribute.

Endorsed by

B

S A N D I E G O P HY S I CI A N .or g de c em b e r 2010

ARE YOU READY FOR EHR? ARE YOU READY FOR EHR? CHMB – The Choice for EHR & Successful Adoption Improved with&CHMB—ranked the top CHMB business – The performance Choice forstarts EHR Successful among Adoption

providers in California for EHR Adoption & Implementation Services. Here’s Improved business performance starts with CHMB—ranked among the top why hundreds of physicians have selected CHMB for building and installing providers in California for EHR Adoption & Implementation Services. Here’s the Allscripts EHR application into their community practices: why hundreds of physicians have selected CHMB for building and installing the AllscriptsAND EHRLOCAL application into their community practices: NATIONAL EXPERTISE •NATIONAL Established footprint 1,000 community physicians and clinics statewide AND LOCALwith EXPERTISE

“CHMB has been our trusted partner for more than “business CHMB has been our trusted six years.partner It madeforperfect sense business more than that when It wemade decided to move six years. perfect sense forward with EHR in our practice, that when we decided to move we entrusted our implementation forward with EHR in our practice, of Allscripts to them as well. They we entrusted our implementation have been there for us of Allscripts to them asevery well. step They of the way!” have been there for us every step of the way!”

ELIZABETH SILVERMAN, MD Partner ELIZABETH SILVERMAN, MD North County OB/GYN Medical Group Partner

North County OB/GYN Medical Group

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•PROVEN Real Utilization RESULTS– 95% of physicians are at Meaningful Use with CHMB EHR Services • Real Utilization – 95% of physicians are at Meaningful Use with CHMB • EHR Superior Support – 98% client satisfaction on CHMB Clinical & IT Services Services during implementation & on-going support • Superior Support – 98% client satisfaction on CHMB Clinical & IT Services • during Outstanding ROI – 97% physicians believe CHMB’s services met all implementation & of on-going support expectations, including cost, training, implementation, and application • Outstanding ROI – 97% of physicians believe CHMB’s services met all optimization expectations, including cost, training, implementation, and application Asoptimization your business partner, let us navigate your entire EHR project As your business partner, let us and create the right solution to fit navigate your entire EHR project your practice. Count on us to train and create the right solution to fit you to use the EHR at its optimal your practice. Count on us to train level. It’s time to trade up to you to use the EHR at its optimal EHR and discover level. It’s time to trade up to Meaningful Use with CHMB. EHR and discover Meaningful Use with CHMB.

San Diego County — 1121 East Washington Ave., Escondido, CA 92025 Orange County — 7700 Irvine Center Drive, Ste 290, Irvine, CA 92618 San Diego County — 1121 East Washington Ave., Escondido, CA 92025 760.520.1400 • 800.727.5662 • www.chmbsolutions.com Orange County — 7700 Irvine Center Drive, Ste 290, Irvine, CA 92618 760.520.1400 • 800.727.5662 • www.chmbsolutions.com

CHMB DELIVERS THE HIGHEST LEVEL OF SERVICE AND EXPERTISE TO ENSURE A SWIFT, SMOOTH AND SUCCESSFUL EHR COMPLETION.

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

CHMB DELIVERS THE HIGHEST LEVEL OF SERVICE AND EXPERTISE TO ENSURE A SWIFT, SMOOTH AND SUCCESSFUL EHR COMPLETION.

1

thismonth Volume 97, Number 12

features Spirituality and Medicine

14 Accessing Spiritual Care in the Medical Treatment of Patients: Physician Considerations

by Gerald J. Swanson 18 Knock Knock … Who’s There?

Incorporating Patient-centered Spirituality Into Ethics Consultations

by Daniel J. Bressler, MD

22 Faith-full Service: Approaching Spirituality With Permission, Respect, and Sensitivity

by David Stevens, MD, MA

Past President (AMA Alternate Delegate) Lisa S. Miller, MD President-elect (CMA District 1 Trustee) Robert E. Wailes, MD Secretary (SDCMS At-large Director) Robert E. Peters, PhD, MD

geographic and geographic alternate Directors East County William T. Tseng, MD, Heywood “Woody” Zeidman,

26 Poetic Wisdom: Reclaiming a Powerful Method for Spiritual-Mental Health

by John (Jack) Webb

28 Hands Held Tightly: Softening Toward Spirituality

by Katherine Morrison, MD

30 Instrument and Purpose: I Am but One Small Part in a Great Drama

by George Delgado, MD

14

SDCMS Board of Directors Officers President Susan Kaweski, MD

Treasurer Sherry L. Franklin, MD

24 Spiritual Care: A Catalyst for End-of-life Palliative Care

by Dorothy Crockett, MA, M/Div

Cover Photo: Sunrise over Mono Lake tufas, taken in May

by Tom Gehring, SDCMS CEO.

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

32 Just Sit With Me for a While …

Caring for the Spirit

by John Tastad 36 The Healing Arts: A Higher Calling

by Wayne R. Freiberg

MD (A: Venu Prabaker, MD) Hillcrest Niren Angle, MD, Steven A. Ornish, MD Kearny Mesa John G. Lane, MD (A: Jason P. Lujan, MD) La Jolla J. Steven Poceta, MD, Wynnshang “Wayne” Sun, MD (A: Matt H. Hom, MD) North County James H. Schultz, MD, Doug Fenton, MD (A: Steven A. Green, MD) South Bay Vimal I. Nanavati, MD, Mike H. Verdolin, MD (A: Andres Smith, MD) At-large and At-large alternate Directors Jeffrey O. Leach, MD, Bing S. Pao, MD, Kosala Samarasinghe, MD, David E.J. Bazzo, MD, Mark W. Sornson, MD, Mihir Y. Parikh, MD (A: Carol L. Young, MD (sdcms foundation president), Thomas V. McAfee, MD, Ben Medina, MD, James E. Bush, MD, Alan A. Schoengold, MD) other board members Communications Chair Theodore M. Mazer, MD Young Physician Director Van L. Cheng, MD Alternate Young Physician Director Kimberly M. Lovett, MD Resident Physician Director Katherine M. Whipple, MD

departments

Alternate Resident Physician Director Steve H. Koh, MD

6

Retired Physician Director Rosemarie M. Johnson, MD Alternate Retired Physician Director Mitsuo Tomita, MD Medical Student Director Adi J. Price CMA Speaker of the House James T. Hay, MD

ex-officio, nonvoting board members

4 SDCMS Seminars, Webinars, and Events

CMA Past Presidents Robert E. Hertzka, MD, Ralph R. Ocampo, MD

4 Community Healthcare Calendar

CMA district I Trustees Sherry L. Franklin, MD, Albert Ray, MD,

Robert E. Wailes, MD

6 Briefly Noted SDCMS Medical Office Manager Bulletin Board, and More …

CMA Trustee (other) Catherine D. Moore, MD, CMA Solo and Small-group Practice Forum Delegates

Michael T. Couris, MD, James W. Ochi, MD Alternate CMA Solo and Small-group Practice

10 Sdcms Foundation: Making a Difference in Our Community

Forum Delegate Dan I. Giurgiu, MD AMA Delegates James T. Hay, MD, Robert E. Hertzka, MD Alternate AMA Delegates Lisa S. Miller, MD, Albert Ray, MD

12 Happy Holidays From SDCMS! 34 Physician Marketplace

Classifieds

Erratum: In the Nov. 2010 issue, Joe W. Craver’s name was misspelled on page 30.

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S A N D I E G O P HY S I CI A N .or g dec em b e r 2010

10 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.]

P PHYSICIANS HYSICIANS M MEDICAL EDICAL C CENTER ENTER OF OF S SAN AN D DIEGO IEGO SSALUTES ALUTES O OUR UR “T “TOP OP D DOCTORS OCTORS” ”

Congratulations to our Congratulations to our physician-tenants who have physician-tenants who have been recognized by their peers been recognized by their peers for providing exceptional service* for providing exceptional service* Sam Baradarian, M.D. Sam Baradarian, M.D. Walter P. Dembitsky, M.D. Walter P. Dembitsky, M.D. Cardiac, Vascular, Thoracic & Cardiac, Vascular, Thoracic & Transplant Surgery Transplant Surgery Eyla G. Boies, M.D. Eyla G. Boies, M.D. Bretten Drake Pickering, M.D. Bretten Drake Pickering, M.D. Martin Terry Stein, M.D. Martin Terry Stein, M.D. UCSD Pediatric & Adolescent Medicine UCSD Pediatric & Adolescent Medicine William E. Bowman, M.D. William E. Bowman, M.D. Richard F. Santore, M.D. Richard F. Santore, M.D. Orthopedic Medical Group Orthopedic Medical Group Lynne Michelle Champagne, M.D. Lynne Michelle Champagne, M.D. Internal Medicine Internal Medicine Raymond Chinn, M.D. Raymond Chinn, M.D. Metro Infectious Disease Metro Infectious Disease Keith E. Kortman, M.D. Keith E. Kortman, M.D. James W. Lyon, M.D. James W. Lyon, M.D. San Diego Imaging San Diego Imaging Ada Maria Marin, M.D. Ada Maria Marin, M.D. Metro Family Physicians Metro Family Physicians Robert Edwin Peters, Ph.D. M.D. Robert Edwin Peters, Ph.D. M.D. Family Medicine Family Medicine *Through the San Diego County Medical Society / *Through San Diego County Medical Society / San Diegothe Magazine’s Annual “Top Doctors” San Diego Magazine’s recognition program. Annual “Top Doctors” recognition program.

Managed By Cambridge Healthcare Properties Managed By Cambridge Healthcare Properties 2010/2011 Outstanding Medical Building of the Year (San Diego Building Owners and Managers Association) 2010/2011 Outstanding Medical Building of the Year (San Diego Building Owners and Managers Association) Leasing Inquiries: Nancy Clayton-Ross (858) 277-9999 Leasing Inquiries: Nancy Clayton-Ross (858) 277-9999

calendar

sdcms Seminars / Webinars / Events Free to member physicians and their staff.

For further information, contact Sonia Gonzales at (858) 300-2782 or at SGonzales@SDCMS.org, or visit SDCMS.org. Look to our January issue of San Diego Physician for a complete listing of SDCMS seminars, webinars, and events in 2011!

“Collection Procedures” (seminar/webinar) Thurs., Jan. 13, 11:30am–1:00pm “Palmetto GBA/Medicare Provider Enrollment” (seminar/webinar) Thurs., Jan. 20, 11:30am–1:00pm Office Manager Focus Group Wed., Jan. 26, 11:00am–1:00pm “Simple Approaches to Informed Consent and Informed Refusal” (risk management webinars) Wed., Jan. 26, 6:30pm–7:30pm • Thurs., Jan. 27, 11:30am–12:30pm SDCMS Membership Social Sun., Jan. 30, 4:00pm–7:00pm “Treating Patients Right” (practice management seminar/webinar) Thurs., Feb. 3, 11:30am–1:00pm Certified Medical Insurance Specialist Course Four Fridays: Feb. 4, 11, 18, 25, 8:00am–4:00pm “Contract Negotiations” (legal seminar/webinar) Thurs., Feb. 10, 11:30am–1:00pm “Identity Theft” (practice management seminar/ webinar) Thurs., Feb. 24, 11:30am–1:00pm

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S A N D I E G O P HY S I CI A N .or g dec em b e r 2010

community Healthcare Calendar “Cross-cultural Considerations in End-of-life Care” (CME Monograph) Until Feb. 28 • cme.ucsd.edu/crosscultural “Infection Prevention for Hospital Epidemiology” Jan. 3–Mar. 27 • Meets the Requirements of SB158 • CMEs Available • $195 • extension.ucsd.edu “Brain Tumors: First Annual Collaborative Care Conferences” Jan. 15 • 7:30am • $25–$65 • UC San Diego Moores Cancer Center Goldberg Auditorium • cme.ucsd.edu/braintumors/ index2.html

West Coast Geriatric Psychiatry Conference Feb. 16–19 • Catamaran Resort Hotel, San Diego • cme.ucsd.edu Topics and Advances in Internal Medicine Mar. 7–13 • San Diego Marriott, La Jolla • cme.ucsd.edu Topics and Advances in Pulmonary and Critical Care Medicine Mar. 13–14 • San Diego Marriott, La Jolla • cme.ucsd.edu Annual San Diego Science Festival Mar. 19–26 • Petco Park • sdsciencefestival.com/host-an-event. html

To submit a physician-focused, San Diego County healthcare event for possible publication, email KLewis@SDCMS.org.

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

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brieflynoted

SDCMS Medical Office Manager

By Sonia Gonzales, Your Off ice Manager Advocate

Ask Your Officete!

Manager Advoca an office and does If a patient comes into or time of the visit, can he not pay the copay at the h no wit , ire amount of the bill she be liable for the ent en? contractual write-off tak

Question:

— providers can only The short answer is no co-insuror her copayment or charge the patient his t who don’t have to see a patien ance amount. Providers see them, ent amount, but if you doesn’t pay the copaym with the ct tra con terms of your you need to abide by the m the fro t also dismiss a patien health plan. You can er three npayment, usually aft practice for repeated no lth plan, contracted with the hea times. If you are NOT visit. The ment at the time of the you can ask for full pay lth plans hea document with the patient does not sign a the time pay their copayments at agreeing that they will tes they ent the patient signs sta of the visit — the docum expectnsibilities that they are HAVE copayment respo rtion po ir nonpayment of the ed to pay, and repeated vary ces ces. These consequen could result in consequen of their practice to cancellation from dismissal from the most extreme situations. health plan policy in the

Answer:

6

CODING CORNER

by Michelle Pena , CPC, CHMB Solutions

Question: What CPT do I assign when billing for the flu shot, since it contains H1N1? answer: The CPT code 90658 is the appropriate cod e for billing the annual flu vaccine.

This year’s seasonal vaccin e labeled Fluzone contains H3N2, Infl uenza B, and 2009’s H1N1 . If the patient is 65 years old or old er, Medicare will cover the Fluzone High Dose (CPT 90662), wh ich contains an additional ant igen.

The current Medicare fee sch edule for Southern California allows $11.37 for 90658 and $29.21 for 90662. As with all vaccin ations, remember to bill for the adm inistration via CPT 90471 for the first vaccination and 90472 for each additional vaccination.

The correct HCPCS code for billing the vaccination to Medicare is G0008 with an allowable of $21.24.

References: • CDC: cdc.gov/flu/protect/v accine/qa_fluzone.htm • Palmetto GBA: palmetto gba.com/palmetto/providers.n sf • FDA: fda.gov/BiologicsBlood Vaccines/Vaccines/Approv edProducts/ucm112854.htm

[SAVE THE DATES!] ✓ JAN 16: “Collection Procedures” ✓ JAN 20: “Palmetto GBA/Medicare

Provider Enrollment” ✓ JAN 26 & 27: “Simple Approaches to Informed Consent and Informed Refusal” ✓ FEB 3: “Treating Patients Right” ✓ FEB 4, 11, 18, 25 (4 Fridays): Certified Medical Insurance Specialist Course S A N D I E G O P HY S I CI A N .or g dec em b e r 2010

P hysicians Get Noticed!

Wish Your Legislato a Happy Birthday!rs

Physicians: Let your legislators know tha t you’re paying attention and that you vote by wish ing them a happy birthd ay!

Birthday: DECE MBER 7 U.S. Rep. Duncan D. Hunter

E: (via website) ww w.hunter.house.g ov Capitol Office: T: (202) 225-5672 • F: (202) 225-0235 District Office: 1870 Cordell Cour t, Suite 206 El Cajon, CA 9202 0 T: (619) 448-5201 • F: (619) 449-2251

ENEFIT MEMBER B HT: SPOTLIGan agers!!!

Attention Office M

ow where ing and don’t kn • Need some train s CMS.org/webinar to go? Log on to SD rs na r recorded webi and view any of ou Our e! tim mputer at any right from your co an m hu m pics range fro webinar library to t nerac nt co to PAA updates resources and HI regulaanges to Medicare gotiations and ch ed your ne ll wi u Yo ! e a few tions, just to nam ation to ager login inform SDCMS office man zaon — email me at SG view the webinars for assistance. les@SDCMS.org e latest pharmacy list? Th d • Need an update bers. em m S le for SDCM version is availab S.org.

M DC @S SGonzales Please email me at

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 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 project access PROGRAM DIRECTOR Brenda Salcedo at (858) 565-8161 or at BSalcedo@SDCMS.org Healthcare Access Manager Lauren Radano at (858) 565-7930 or at LRadano@SDCMS.org Patient Care Manager Rebecca Valenzuela at (858) 300-2785 or at Rebecca.Valenzuela@SDCMS.org Patient Care Manager Elizabeth Terrazas at (858) 565-8156 or at Elizabeth.Terrazas@SDCMS.org

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

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brieflynoted es Its San Sdcms Announucts g Office in d n ta O ty n ou C o g ie D se Manager for 2010: Sue Ro

!

Congratulations, Sue

er nominating his office Dr. David J. Bodkin’s lett Diego County Medical manager, Sue Rose, for San r, 2010: Office Manager of the Yea Dear Ms. Gonzales,

her lead, and we have s built a practice that ha the ability to treat even those with limited or no Dr. David J. Bodkin and Sue Rose health insurance. Her tireless efforts have endrugs abled us to obtain free st desperate. mo se tho for es vic and ser s have gotten involved Many of our employee y events — screeniet in American Cancer Soc aisers — and do so with ings, walks, runs, fund-r

stically nominate Susan I would like to enthusia manages our group, Rose for this honor. She Medical Group, at the Cancer Center Oncology nter in La Mesa.

Grossmont Cancer Ce man with vast Sue is an exceptional wo her career as a lab techexperience. She began managed an oncology nologist and ultimately I (coincidentally, where practice on Long Island rs ago). did residency over 20 yea to San Diego over a ved mo d She married an her husband’s car wash decade ago to manage cology is her first love. business. However, on we were having A couple of years ago, p in our office. We had problems with leadershi hospital-run to a true transitioned from being g space at the cancer “private practice,” leasin center. panied a relative to At this time, Sue accom of her past experience our office. She told me get “back into it.” I told and how she wanted to you!” her, “Have I got a job for ere she used to work in wh rs cto do the led I cal Th s. ey indicated that the New York for reference their practice was when worst day in the life of course, their best day she left 15 years ago. Of m 10 years earlier. was when she joined the ctice has done nothSue joined us, and our pra she herself is a cancer ing but thrive! You see, stands “the other side.” survivor. She truly under te for patients and She has been an advoca nce plans, medical deals daily with insura ies, fighting for pan groups, and drug com She is such a great d. nee ts what cancer patien t many have followed example to the staff tha

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S A N D I E G O P HY S I CI A N .or g dec em b e r 2010

great gusto. practice on many Sue has enhanced our strong, effective depart levels. She has created d an , acy arm ph , ing, lab ments for billing/collect ves lea d an ly ear es in day treatment. She com I can tell how rewardile. sm a h wit ays alw late, is to her. ing she feels this “job” ff that includes a carsta a She has gathered I have not encountered ing, loving group that ool 30 years ago. since I began medical sch ned our relationship Ms. Rose has strengthe k, experiences in New Yor with the hospital. Her ed aid , cer can ast bre t to particularly with respec tal recently, as we were spi Ho t on ssm Gro rp Sha certification as a center successful in obtaining tional Association of of excellence by the Na American College of Breast Programs, of the Surgeons. lab from scratch and She also built our office olades from COLA and enabled us to obtain acc CLIA. asion, I have seen her On more than one occ out an employee in p go out of her way to hel hip. Sue aids her staff, times of personal hards d ily on a regular basis, an treating them like fam dem She . e or acclaim does so without fanfar cern for each individual con al son onstrates per y fit into our “cancer and makes sure that the center family.”

Over the past year, Sue has had to deal with personal hardships: the death of her beloved mother, as well as her mother-in-law, from cancer. These personal experiences have given her new insight into dealing with cancer patients AND their families. She has effectively communicated this to our employees, and I can see their performance improvements, with even more sensitivity and compassion expressed.

Sue understands that many of our employees suffer the emotional strain of dealing with very ill cancer patients and addressing end-of-life issues.

Therefore, she organizes regular social gatherings, happy hours, and events to “decompress.”

In these harsh economic times, she realizes the benefit of making sure the employees at least have a good lunch, and arranges lunch meetings and talks, tirelessly working with pharmaceutical representatives and medical device vendors. She makes sure, though, that it is not a “free lunch,” as the employees are encouraged to sit and listen to the talks, hoping the education provided can translate into better patient care.

I could go on and on and provide countless vignettes, and will do so if necessary for Susan Rose to win this deserving award. To Sue, her job is her passion, and it reflects on all of us on a daily basis as we try to make the lot of those afflicted with cancer a little better.

Simply put, Sue Rose is the best!

Sincerely, David J. Bodkin, MD Sue received an iPod Touch and a $250 Nordstrom gift card for winning our second annual “San Diego County Outstanding Medical Office Manager of the Year” contest. Congratulations, Sue! You so deserve it! — Sonia Gonzales, SDCMS Office Manger Advocate

Let us take care of the paperwork so you can take care of your patients. ¹96 µ6C764E ¸@=FE:@?### /Z dZ` SLaP ^_LNV^ ZQ TY^`]LYNP L[[WTNL_TZY^ LYO NZY_]LN_^ _Z ]PaTPb LYO NZX[WP_P* ,]P _SP PYOWP^^ OPLOWTYP^ LYO OZN`XPY_L_TZY []P[L]L_TZY N]PP[TYR TY_Z [L_TPY_ _TXP* ,_ ,XLOZ] ;Sd^TNTLY >P]aTNP^! Z`] XT^^TZY T^ _Z PL^P _SP M`]OPY ZQ SPLW_SNL]P [L[P]" bZ]V QZ] LOXTYT^_]L_Z]^! ZQ£NP XLYLRP]^! LYO [Sd^TNTLY^ LWTVP ^Z dZ` NLY RP_ MLNV _Z _SP M`^TYP^^ ZQ XPOTNTYP# 4Y^`]LYNP NZY_]LN_TYR NLY MP L_ MP^_! N`XMP]^ZXP LYO L_ bZ]^_! L YTRS_XL]P# ,XLOZ] ;Sd^TNTLY >P]aTNP^ T^ _SP [P]QPN_ LY^bP] _Z dZ`] NZY_]LN_TYR LYO N]POPY_TLWTYR YPPO^# BP `YOP]^_LYO _SL_ dZ`] _TXP T^ MP__P] ^[PY_ NL]TYR QZ] dZ`] [L_TPY_^# ,;> PL^P^ _SP M`]OPY ZQ _SP WZZXTYR ^_LNV^ ZQ NZY_]LN_TYR! N]POPY_TLWTYR! LYO PY]ZWWXPY_ QZ]X^ Md _LVTYR ZY _SZ^P _L^V^ QZ] dZ`# BT_S õü dPL]^ Pc[P]TPYNP bZ]VTYR bT_S _SP >LY /TPRZ XPOTNLW NZXX`YT_d bP L]P bPWW ^`T_PO _Z L^^T^_ dZ`] []LN_TNP LYO PL^P dZ`] bZ]VWZLO# o =PRT^_P]PO TY _SP ;0.:> ^d^_PX* o :[PYTYR L YPb []LN_TNP* o 8ZaTYR* o ,OOTYR L [Sd^TNTLY* o 4YNZ][Z]L_TYR* o 4Y`YOL_PO bT_S N]POPY_TLWTYR LYO ]PN]POPY_TLWTYR L[[WTNL_TZY^* o ;]ZMWPX^ bT_S 8POTNL]P LYO 8POT".LW PY]ZWWXPY_*

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T: 925.249.9510 • info@amadorphysicianservices.com

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Follow SDCMS on Twitter to keep abreast of the latest in health reform changes, regulatory news, scope of practice issues, practice management tips, and more!

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

9

sdcmsfoundation

The SDCMS Foundation Is Making a Difference in Our Community!

Project Access San Diego We have helped more than 500 patients achieve health, getting them back to work and caring for their families.

“As one patient wrote in a note, ‘Thank you doctor — now I don’t hurt anymore.’ It doesn’t get any better than that.”

— Dr. Paul Neustein, Project Access San Diego Volunteer

“I’m enjoying my new eyes and seeing the world again in living color. Words are not enough to express my thanks and gratitude to Project Access San Diego — may you have more power to help more people like me.”

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13

Spirituality and Medicine

Accessing Spiritual Care in the Medical Treatment of Patients Physician C onsiderations

By Gerald J. Swanson

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S AN  D I E G O  P HY S I CI A N . or g de c em b e r 2010

Note: To read this article with complete notes, please visit SDCMS.org.

Victor Frankl wrote of his experience as a prisoner in a Nazi concentration camp: “Man is not destroyed by suffering; he is destroyed by suffering without meaning.” Spiritual care in the healthcare setting is that discipline that brings meaning, hope, and healing aspects to persons in pain and suffering.

This article addresses the connection between spirituality and health, the distinctiveness of spiritual care in the healthcare setting, and identifies some of the spiritual care services available to physicians in the treatment of their patients.

The Growing Connection Between Spirituality and Health Research on the relationship between spirituality and health has seen a sharp increase in recent years.

A summary of published studies from 1996 to 2006 with spirituality as the focus found fewer than five studies done in 1996 and more than 180 studies done in 2006.

In a health crisis, spiritual issues commonly become of increased importance to the patient and are found to have a strong influence on patient health outcomes. One study found that spiritual struggle is a strong predictor of declining physical and mental health. Spirituality is also correlated with positive outcomes in a growing number of specific areas of patient health. A research study of patients undergoing disability rehabilitation reported that those who have a resilient, intrinsic, spiritually based concept of self were found to have better health outcomes. Other studies have found that spiritual wellbeing is an important factor in coping with terminal illness. In cancer patients, spiritual wellbeing has been found to offer protection against end-of-life despair in those for whom death is imminent. One research study looked at the merits of spirituality as a coping mechanism for patients with cancer. Positive religious coping was correlated with less pain severity, depression, anxiety, and a greater sense of overall physical wellbeing.

Negative religious coping correlated with more pain frequency and severity, more depression, anxiety and pain, and poorer overall physical wellbeing.

Knowing the inner life and spiritual dynamics of a patient can bring an increased opportunity for compassionate care, add to their trust in physicians and staff, assist them to have a better hospital experience overall, and contribute to a patient’s future, ongoing quality of life.

The Distinction Between Spiritual and Religious Care There are many definitions of spirituality currently in use today. Definitions tend to focus on questions of meaning, hope, and purpose in living. Spiritual care is often thought of as being in the context of religion or religious expression. However, it is important to realize that spirituality is increasingly viewed by the public as something expressed outside of a religious framework. Therefore, it is important to make a disdecember 2010 SAN DIEGO P HY SICIA N. o rg

15

Spiritual care providers are full members of the interdisciplinary medical team and are available to provide specialized services to contribute to the total health and spiritual well-being of patients, staff, and families.

tinction between spirituality and religion.

In the healthcare setting, the term “spiritual care” has come to be preferred over “religious care” or “pastoral care.” Hospitals are not parishes and so do not represent any one religion. An individual joins a particular religion because of his or her common, shared beliefs in a faith tradition. Religion is practiced in a chosen set of religious beliefs, most notably expressed within the structure of a formal religion, or denomination of religious expression. Americans are identifying less with religion. A May 2010 Gallup poll found that in 1958, 82 percent of Americans believed religion had the answers. Today, fewer than six in 10 believe they can turn to religion for answers, and nearly three in 10 feel religion is old-fashioned.

This trend is further observed when a patient will often refer to her or himself as “spiritual.” This has been widely noted by chaplains when they often hear a patient say: “I’m not religious, but I am spiritual.”

Earlier this year a website called “Spiritual But Not Religious” (dubbed SBNR) states: “SBNR.org is dedicated to serving the millions of people worldwide who walk a spiritual path outside traditional religion ….”

Institutional spiritual care departments are so named in order to avoid confusion with any one religion and effectively meet the spiritual needs of persons from all faiths or non-faith beliefs.

The traditional designation for a spiritual care provider in an institutional setting is “chaplain.” It derives from the story of St. Martin of Tours, a compassionate, fourth-century soldier who encountered a shivering beggar on a cold winter night. Having no money, the soldier took off his cloak and slashed it with his sword to give half of it to the beggar. St. Martin’s cloak or “capella” came to refer eventually to the persons, the “capellani,” who attended to the king’s religious needs. From this office of the king was derived the term “chaplain.” The depository for the cloak became the “chapel,” the place of worship.

National Recognition of Spiritual Care for Hospital Accreditation The Joint Council for Accreditation of Healthcare Organizations (JCAHO) has recognized the significance of spirituality on hospital patients by requiring a hospital chaplain or access to pastoral services in the standards for accreditation of all hospitals.

JCAHO specifies that a spiritual assessment should be performed on every patient, identifying, “at a minimum,” the patient’s denomination, beliefs, and spiritual practices. Other specifics related to spiritual care are referred to in the “Patient Rights and Organizational Ethics” section. One example from this section of JCAHO standards concerning end of life states: “respecting the patient’s values, religion, and philosophy, involving the patient and where appropriate the family in all aspects of care, and respond-

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S AN D I E G O P HY S I CI A N . or g de c em b e r 2010

ing to the psychological, social, emotional, spiritual, and cultural concerns of the patient and family.”

Board-certified chaplains are trained to deliver best-practice spiritual care exceeding JCAHO standards. Board-certified chaplains must have theological training, professional ministry experience, and one year of clinical pastoral education that includes 1,200 hours of directed supervisory training. A chaplain is supervised while actually doing spiritual care for 30 hours a week. After 2,000 additional hours of professional practice, chaplains may apply for certification through such agencies as the National Association of Jewish Chaplains (NAJC), the Association of Professional Chaplains (APC), the Association for Clinical Pastoral Education (ACPE), the National Association of Catholic Chaplains (NACC), and the Canadian Association for Pastoral Practice and Education (CAPPE).

The Advantages of Understanding a Patient’s Spirituality A cancer patient was describing his experience with his illness and concluded by saying: “God is trying to teach me a lesson.” When the patient was asked what God was trying to teach him, he stated: “I don’t know.” The patient was then asked if he really believed that God would give him cancer to teach him a lesson and then not tell him the lesson. In discussing this further, the patient expressed deep inner pain sourced from longstanding, unresolved regrets in his life, chief of which was not having a relationship with his two grown sons. In the ensuing spiritual work of reconciliation, one of his two sons came to see his father in the hospital. This was a great comfort to this patient and added significantly to his effective coping with cancer.

This chaplain was referred to a patient who was described as “unsettled, agitated, and increasingly noncompliant.” In listening to this patient, she expressed sadness and fearfulness. Eventually this patient got the courage to name her fear and said, “My mother died in this hospital six months ago.”

Assisting with her acute grief from the recent death of her mother helped to understand the specific needs of this patient and how to best care for her.

Knowing the inner life and spiritual dynamics of a patient can bring an increased opportunity for compassionate care, add to their trust in physicians and staff, assist them to have a better hospital experience overall, and contribute to a patient’s future, ongoing quality of life.

Specific Spiritual Care Services Available A chaplain service offers a number of services available to physicians for patient care. Some of them are: • Physician Referrals to Spiritual Care

Spiritual care providers are full members of the interdisciplinary medical team and are available to provide specialized services to contribute to the total health and spiritual wellbeing of patients, staff, and families.

About the Author: Jerry Swanson is presently a chaplain in the Spiritual Care Department of Scripps Mercy Hospital. As an ordained minister, he has been in pastoral care ministries for over 33 years. A board-certified chaplain for six years, he has served churches in Fullerton, Ventura, and San Diego. Jerry completed degrees from Biola University (BA), Talbot Theological Seminary (MDiv), and from Bethel Seminary San Diego (DMin).

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• Spiritual Care Assessment: Chaplains are required to enter each patient visit in the medical record. Included in that entry are the chaplain’s notes for a specific patient, identified spiritual needs, and what services were offered.

• Advance Directive for Healthcare: Chaplains provide assistance with advance directives for healthcare.

• A Terminal Diagnosis: Give support to a patient and/or a family member.

• Dying, Death: Assist with contacting family; be present for comfort and support. Contact community clergy to meet religious-specific needs, assist with release of remains documentation, mortuary selection, and arrange in-hospital memorial services when needed.

• Withdrawal of Life Sustaining Treatment, End-of-life Care: Provide a listening presence, give spiritual care, contact community clergy to provide any religious-specific sacraments, rites, or rituals, and communicate with life sharing.

• Religious, Moral, and/or Ethical Consult: In the course of healthcare and healthcare decisions, matters of conscience sometimes are raised within patients and their families. Chaplains are a listening presence to assist persons to clarify matters of conscience and identify resources that directly address their concerns.

• Inter-disciplinary Representation to Consults, Ethics Committees, and Development of Plans of Care

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december 2010 SAN DIEGO P HY SICIA N. o rg

17

Spirituality and Medicine

Knock Knock …

Who’s There?

Incorporating Patient-centered Spirituality Into Ethics C onsultations

By Daniel J. Bressler, MD

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S AN D I E G O P HY S I CI A N . or g de c em b e r 2010

“

W

ho is the person at the center of this medical process?” This question inevitably arises when I am called to assist the treatment team in handling a “biomedical-ethics” dilemma.

The “what” of the person is well-documented in the chart: the H&P, the consultants’ reports, the lab and imaging results, and the pretty pictures of ugly diseases from the pathology department. The so-called “social history,” as recorded in the initial interview, usually lists such things as health habits (smoking, drinking, and drug use), marital status, and possibly present or pre-retirement occupation. The patient’s religion may be listed, along with the basic demographic information, just under their Social Security number and home address. “CTHLC” means Catholic, “JWSH” means Jewish, “PRTNST” Protestant, “MSLM” Muslim, etc., just as “DR” means drive and “CA” California. All this seems to answer the “what” questions but — at least from the perspective of a bioethical consultation — adds only the smallest amount to the “who” questions.

Who a person is can often best be answered by understanding his or her spirituality. I am using this overworked term — spirituality — to represent the realm of human identity that addresses itself to questions that are beyond the reach of quantitative agreement. It is about beliefs and thus, by this definition, about things that cannot be proven by facts. It is the source of the questions that are addressed by the founders and adherents of religion, philosophers, and also by writers, poets, filmmakers, and singers when they dive deep. The questions are, and always will be: Where did I come from? Where do I go after I die?

What constitutes a good life? What constitutes a good death? One could call these questions “existential” or “philosophical,” but I think “spiritual” is both more specific and, in most contexts, less intimidating. Thus spirituality is the door on which we have to knock to find out who is there.

The answers to these questions end up being more useful to the demands of an ethics dilemma than do the typical denominational labels. Being a “religious Baptist” may indicate where a person spends his Sunday mornings, but not necessarily whether he wants to be defibrillated a third time. Knowing that that woman is a “practicing Hindu” often tells us little about whether or not she will choose to have her husband taken off pressors in light of a grim prognosis.

Sometimes I hear complaints that the treatment team delves insufficiently into the deeper aspects of a person’s spirituality. In their concern for the details of the technical and biological, the doctors, nurses, and ancillary personnel are said to give short shrift to the spiritual dimensions. To me, in the absence of a crisis that triggers such deeper investigation, this focus on the biological and technical facts seems

perfectly appropriate. When the goals of therapy are clear, when everyone is in agreement as to what should and should not be done, when progress is being made and “everyone is on the same page,” there seems to be no need to dig down to spiritual layers. It must also be said, however, that such straightforward circumstances rarely elicit the need for an ethics consultation.

Most consultations involve some stage of the dying process. And because, as Hamlet noted, death is that “undiscovered country from whose bourn no traveler returns,” we are, all of us, forced onto our spirituality for an answer as to what it means to be dead, i.e., “where we go after our final discharge.” Here is where we must start to dig down to the patient’s core beliefs for a way of taking into account one key factor (but obviously not the only factor) in guiding decisions.

We must turn to beliefs in part because death sends us no reliable dispatches. We also know from this side of the divide (the land of the living) that dying, whatever our faith, is an almost universally frightening prospect. As one philosopher notes, the gap between being and nonbeing is infinite; the fear, for almost all of us, is the possibility of oblivion. And even for the most devout there is the sadness of not seeing those they love again in this life.

The sheer number of permutations of bioethical conflicts is an outgrowth of the multicultural nature of American society. There is no single or unifying spiritual foundation as one goes around the circle of the stakeholders: patient, patient’s family, treatment team members, clergy, and ancillary personnel. The conflict that triggered the consult may be as much from inside the family as elsewhere. It’s not much of a confabulation to recount the story of the atheist patient struggling to decide on code status between his bouts of septicemic delirium while his Evangelical Christian twin sister and estranged Catholic wife exchange angry glances in the ICU waiting room, each presenting their perspective to the Vietnamese Buddhist senior resident and Jewish ICU Attending.

An ethics consult can also be called when there seems to be too few voices rather than too many. This is particularly true when a patient is both unable to communicate and there is no reasonable person who can speak for him. The so-called “unrepresented” or “unbefriended” patient has no durable power of attorney for healthcare, no family, no one who knows him well enough to express his wishes, and, usually, no advance directives. The treatment team may be at the crossroads of a big decision. For both legal and ethical reasons, they do not want to get caught in the trap of just talking among themselves. The ethics committee can, among other entities, speak on behalf of the patient, discerning what they can about both what he would want, given the circumstances,

Such is the challenge of an ethics consult: forming a meaningful conversational bridge between the “spiritual/ philosophical who” and the “factual/ statistical what.”

december 2010 SAN DIEGO P HY SICIA N. o rg

19

In the final analysis, the ethics consultation is best seen not as a narrowly defined problem to be solved but as a messy process to be guided.

and what are ethically acceptable clinical pathways, given the medical facts.

Ethics consults are triggered by the realization of one or more fundamental tensions between the principal players in the clinical drama. One common scenario is a conflict as to whether treatment should be directed at cure or palliation. Although it is always our intention as physicians to relieve suffering, sometimes our treatments actually cause acute pain, presumably in service to a higher good.

We drain an abscess, amputate a numb but infected diabetic limb, cardiovert asymptomatic atrial fibrillation, and intubate a patient in pleasant hypercapneic narcosis all with the therapeutic justification of short-term pain for long-term cure. When the possibility of long-term cure becomes less and less likely, the pain-for-gain tradeoff starts to look ambivalent at best, and inhumane at worst.

The concept of hope often emerges in these medical dramas. Hope can be empowering when it, for example, allows a patient and her family to look beyond the grimness of current circumstances to see a way toward healing. Hope can be a distraction if it becomes a placeholder for denial or delusion. While it’s true that one should never take away someone’s hope, one role we play in ethics consults is to clarify the object of that hope. What, in fact, are the goals

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S AN D I E G O P HY S I CI A N . or g de c em b e r 2010

of the therapy at this point? Pulling on that string leads us, again, to address such patient-centered spirituality questions as: What constitutes a good life and a good death? Hope is sometimes a fuzzy concept kept, deliberately or not, in a realm separate from measurability and likelihoods. How do statistical chances of survival mix with hope? How do you combine the conflicting results of a nuclear brain scan and EEG with the conflicting spiritual beliefs about eternity of a patient and his spouse?

Such is the challenge of an ethics consult: forming a meaningful conversational bridge between the “spiritual/philosophical who” and the “factual/statistical what.”

There are usually two undiscussed “elephants in the room” when dealing with an ethics consultation. The first “elephant” is the fear of legal repercussions. There is always a chance that an action or inaction by the treatment team (when in conflict with the wishes of someone else — patient, spouse, friend, a disgruntled treatment team member, etc., etc.) will lead to the subpoena of records and the entire disturbing process known as a malpractice lawsuit. The second “elephant” is that of justification of resource allocation — i.e., how do we deal with the fact that there are always more critically ill patients than there are ICU beds, more patients with bleed-

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ing and coagulopathy than there are units of fresh, frozen plasma in the blood bank, and more sick people than there are dollars to pay for their care? In some sense we are always robbing Peter to pay Paul.

As Donald Berwick, Obama’s new head of the Centers for Medicare and Medicaid Services, along with many others, has pointed out, we are already and always rationing but simply calling it by another name. My own experience at Scripps Mercy has been that, in conversation with families and physicians, nurses and lawyers, the direct appeal to law and money is not useful. Instead, returning to the spiritual themes allows a tacit and unthreatening way of weaving these themes into a conversation.

“Do you think of your dad as a generous person?”

“What are your sister’s beliefs about the afterlife?”

“How did Mom look on other peoples’ children?”

Such conversations do not eradicate these unruly elephants but can render them more docile.

What constitutes a “successful” ethics consultation? Is it (pick as many as you like): 1. a peaceful death?

2. an agreed decision to continue pressors, ventilatory support, transfusions, triple antibiotic therapy, dialysis, and proceed with the additional amputation?

3. the absence of a lawsuit?

4. the opportunity for the estranged son to come say his last farewells?

As you might guess, the variety of possible clinical outcomes is wide. Rather than a specific technical outcome (death, weaning from vent, transfer to a long-term acute facility, etc.), the outcomes are better characterized using emotional and social terms.

I would say, whenever possible, we seek to create the opportunity for there to be some element of closure and acceptance among all the stakeholders in those cases when the patient dies in the hospital. We also seek to promote a vision on the part of the treatment team of being “of service.” Sometimes there are storybook endings worthy of a Hollywood movie; sometimes there are endings filled with bitterness and frustration, worthy of a bad soap opera. In the final analysis, the ethics consultation is best seen not as a narrowly defined problem to be solved but as a messy process to be guided. At the center of that process is the spirituality of the patient, the layers of beliefs and identities that exist on the other side of the door labeled “Who’s there?”

About the Author: Dr. Bressler, SDCMS-CMA member since 1988, is chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and longtime contributing writer to San Diego Physician.

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Spirituality and Medicine

Faith-full

Service Approaching Spirituality With Permission, Respect, and Sensitivity

By David Stevens, MD, MA

Left: Doña Anita and her husband as we sent them to the hospital for a life-saving amputation.

Right: A small child with a skin lesion. One of the 400 patients seen each day on the Global Health Outreach team Dr. Stevens led to the slums of Nairobi.

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S AN D I E G O P HY S I CI A N . or g de c em b e r 2010

A

s I entered the door, I saw Doña Anita lying on her couch waiting to die a painful and needless death. I was shocked to see the morbid sight of her casket propped against the wall in the dimly lit living room, paid for and awaiting her remains. As they had for days, her family surrounded her, keeping vigil, awaiting her passing.

Our Global Health Outreach (GHO) team had seen more than a thousand patients that week using the local school as our exam rooms in Jesus de Otoro, Honduras, but this afternoon I had sent small teams into the town to see those too sick to attend the clinic.

Doña Anita’s problem was not a difficult diagnosis.

You could smell it. Her foot was black and weeping. She had gangrene. I examined her and quickly concluded there was still time to amputate to save her life. I talked to her family, who admitted they were too poor to afford bus fare to the nearest hospital miles away or to pay for an operation. I prayed with them, assured her that the team would cover the cost, and left to arrange transport.

This week I was reminded of what transpired nine years ago when I received an email from the young lady who served as my translator. Esperanza wrote, “Doña Anita, the lady who had the leg amputation, is still living near my house. She is so grateful, and every time she sees me, she remembers the time when you came. She says thanks!”

I try to go on a GHO team every year — not just because of what it does for people like Doña Anita, but for what it does for me. It recharges my emotional and spiritual batteries as I serve others, not concerned about being paid and not worried about being sued.

As I experience the heartfelt thanks of suffering people and apply my skills to bring hope where there is no hope, my spirit is refreshed. It reminds me why I went into medicine in the first place: Giving of yourself unselfishly brings real happiness!

I’m a family practice doctor and the CEO of the Christian Medical and Dental Associations (CMDA), the parent organization of GHO. Doing medical missions is not a new thing for me. I spent 11 years in Kenya when I finished my training. I was the third doctor at Tenwek Hospital, the only facility for 300,000 people. My first year, we averaged 180 percent occupancy in our 125 beds and only had six nurses with any formal training.

Challenging? Yes. Long hours? Of course! Gratifying? Immensely — not only in saving many lives but in starting a nursing school, a community health program, expanding the hospital to 300 beds, teaching men how to make money through community development, and much more. Today, Tenwek is a tertiary care hospital that trains national interns and residents.

There I learned not only the joy of sacrificial service, but how to incorporate spirituality into healthcare. Ev-

ery patient thinks about life, death, and eternity when they are seriously ill, but for many years spirituality has been the elephant in the exam and hospital rooms that doctors often ignored as they focused only on psychological, social, and physical issues.

That began to change through the groundbreaking research of Dr. David Larsen in the ’90s and continues today through researchers like Dr. Farr Curlin, both CMDA members. The data show that there are better illness prevention, coping, recovery from surgery, and improved treatment outcomes when spiritual issues are addressed. Spirituality in healthcare went mainstream, and more than half the medical schools in the United States now have faith and health courses.

Doctors don’t address patient spirituality due to a perceived lack of time and because they don’t know how, but just a few small changes in your practice habits can make a great difference. CMDA has trained more than 10,000 healthcare professionals at conferences about the integration of faith and health and many more via our small group video series in this country and around the world.

Just as you deal with other issues with patients, approach spirituality with permission, respect, and sensitivity, respecting the patient’s autonomy and privacy. Learn how to take a spiritual history as part of your routine H&P. There are many good screening questionnaires in

the literature. I like: H: Sources of hope, comfort, love, strength, and peace?

O: Role of organized religion?

P: Personal spirituality or practices?

E: Effects on medical care or end-of-life decisions?1 Let patients know that you are interested in and willing to address faith topics, build a referral network for issues you may not have the expertise to address, and, if you are comfortable doing it, offer to pray with patients when appropriate. My mom still talks about her surgeon who prayed with her before her mastectomy!

Don’t forget, 90 percent of patients believe in God, two-thirds desire their doctors to talk to them about their spiritual beliefs, and as many wish their doctor would pray with them if asked.

Maybe a short-term medical team experience will help you focus on more holistic healthcare, including addressing spirituality. For you and your patients’ sake, it is worth the investment.

If you would like to know more about spirituality and health or short-term mission team opportunities, go to www.cmda.org.

It recharges my emotional and spiritual batteries as I serve others, not concerned about being paid and not worried about being sued.

About the Author: Dr. Stevens is CEO of the Christian Medical and Dental Associations.

1. Am Fam Physician 2001;63(1):81-89.

Are You Getting Your Reimbursement Issues Resolved?

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

Let your office manager and staff know that they have a full-time office manager advocate at SDCMS ready to help them with any questions they may have, free of charge. Contact Sonia Gonzales at (858) 300-2782 or at SGonzales@SDCMS.org.

december 2010 SAN DIEGO P HY SICIA N. o rg

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Spirituality and Medicine

Spiritual Care A C atalyst for End-of-life Palliative C are

By Dorothy Crockett, MA, M/Div

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S AN  D I E G O  P HY S I CI A N . or g de c em b e r 2010

T

his article is written to serve as an illustration of how spiritual care is an integral factor in holistic end-of-life care practice. This is an example of how spiritual care adds to the interdisciplinary mission of palliative care.

In an unscheduled visit, I was called to Stan’s home.

His diagnosis was COPD. With our clinical care nurse there, he requested my presence, saying he needed to talk to me. He was declining, and he knew it.

Upon entering, I spoke to Anne, Stan’s partner, who was saying goodbye to her two grandsons.

Anne’s eyes were anxious as she told me, “I want to help Stan, but ….” Her voice trailed off, urging me to go see Stan. She remained in the living room, alone.

Alone, Stan sat in his wheelchair. Stating that he felt he didn’t have much time left, Stan openly expressed himself. He spoke of his fear of dying, of his concern for Anne, and his thoughts about his faith.

As this was my fourth visit, I knew Stan was a Christian, by faith, and that prayers gave him comfort. (As an interfaith spiritual counselor, I serve a diversity of faith beliefs). We prayed, and Stan repeated his belief in life’s eternity, even while he was afraid of dying. Then he spoke of Anne and his hopes.

Stan hoped that I could help him tell Anne of his worry about her after he died, worrying how she would be, without him. He told me he wanted to tell her his precious thoughts for her. However, he wanted me to talk to her first. He asked if I could do this, and then for us to return to his room. I agreed.

When I spoke with Anne, she echoed a similar message, in a heartfelt manner. Anne openly voiced her fear too, stating her desire to be honest. While affirming her love for Stan and the value of his love and friendship to her, she felt a conflict.

As his caregiver, she was experiencing burnout.

Her hope was to retain Stan’s love and friendship, even as she expressed to him her inability to continue to be his caregiver.

In preparing Anne to speak to Stan, I shared the “four things that matter most,” found in Dr. Ira Byock’s book of the same name. They are: “Please forgive me. I forgive you. Thank you. I love you.”

Together, we said a prayer, and Anne nodded her head affirmatively. She was ready to hear what Stan had to say.

With the three of us only half a foot apart, I began with a prayer, asking God to bless this time together.

As I looked directly into Stan’s eyes, I encouraged him to express what he wanted Anne to know.

“I love you, Anne. I always will.”

“Thank you for all your love and caring for me.”

“I want to spend more time with you and the boys, in the living room.”

“I’m afraid for you, when I go, Anne. I’d like to talk with you about it.”

She heard what he said. With his indication that his messages to Anne were complete, I thanked him and turned to Anne. Slowly, I turned my head toward Anne, and softly I repeated Stan’s words, focusing only on her.

Making eye contact with Anne, I invited her to tell me what she wanted to tell Stan.

“Stan, I love you. I’m thankful that you love me.”

“Your friendship means everything to me. I hope you can forgive me. I have to tell you, and it’s breaking my heart … that I can’t, I just can’t take care of you …. This is so hard for me. But I know I need to let you go ….”

Then I thanked her and turned toward Stan. He heard what she said. I made eye contact with Stan and, in a whisper, echoed what Anne said to him.

These messages were too painful to say face to face, for these two to say and hear; however, as a “bridge” between them, they were able to do so through me.

During this process we were holding hands, and each of us was weeping. My arms were covered with goose bumps. When it was silent, we gave each other hugs, and we expressed a prayer of gratitude. They both sighed in relief. In my heart, I sensed that this was, indeed, a sacred moment.

Two days later, Stan was taken to the ER and hospitalized. A day later, he returned home. The next day, Stan died.

Upon reflection, I think this experience served as a catalyst to create peace, comfort, and the courage for both Stan and Anne to let go and speak their truth to each other. Without advance planning, this described experience unfolded. I believe it was divinely orchestrated, and I was but a “bridge.” This spiritual catalyst served to palliate Stan’s spiritual pain of relatedness.

Stan’s spiritual pain is one of the four (the others are: life’s meaning, forgiveness, and hope) as presented in Richard Groves and Henriette Anne Klauser’s book, The American Book of Living and Dying: Lessons in Healing Spiritual Pain, which presents a summary of spiritual pain.

This case is told with the purpose of further informing the wider medical community in regard to spiritual care practices within palliative care. Names are changed to protect confidentiality.

During this process we were holding hands, and each of us was weeping.

My arms were covered with goose bumps.

When it was silent, we gave each other hugs, and we expressed a prayer of gratitude. They both sighed in relief. In my heart, I sensed that this was, indeed, a sacred moment.

About the Author: Ms. Crockett is a spiritual counselor at the Southeast Branch, Olive/Chestnut, of the San Diego Hospice and The Institute for Palliative Medicine. december 2010 SAN DIEGO P HY SICIA N. o rg

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Spirituality and Medicine

Note: To read this article with its notes, as well as the second part of Mr. Webb’s article, where he expands on poetic wisdom and mental health, please visit SDCMS.org.

P

Poetic Wisdom

Reclaiming a Powerful Method for Spiritual-Mental Health

By John (Jack) Webb

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S AN D I E G O P HY S I CI A N . or g de c em b e r 2010

eople who cut religion out of their lives sometimes report a sense of profound loss, as if they had performed a spiritual-intellectual lobotomy on themselves. Fortunately, this dreadful desensitization can easily be avoided, even if one chooses not to believe in God. The key is learning various methods for engaging what I think of as the “third dimension” of our interior realities. To put it most directly, the third dimension of our experience can be apprehended only by the least understood of our intellectual resources: the racial apprehension of “poetic wisdom,” as first clearly perceived by the groundbreaking, 17th-century philosopher Giambattista Vico.

Organized religion — as I hope to demonstrate here — is only one of several possible methods for assessing poetic wisdom and spiritual-mental health, but it is the method whose positive effects are most fully documented. My own contribution to this dialogue derives from my experience as a patient whose brain was stunned into near-oblivion by lack of oxygen during a series of heart operations. My recovery was due in part to the ministrations of my wonderful doctors. However, at least as much is owed to certain spiritual-intellectual resources and practices that I gathered in the six years following the operations, as I haltingly but determinedly attempted to resurrect my avocations as published poet, educator, and semiretired journalist.

Explaining all this in a way that will prove useful for health professionals is going to be difficult, given the limit on space imposed by the format of this medical magazine. However, the challenge is intriguing for a poet-editor. Let us begin with two key insights, both derived from Vico, who perceived, with the clarity of a prophet, that modern society is dominated by the “barbarism of the intellect,” i.e., the belief that reason can solve the mysteries of the universe. People who hold this view fail to realize that: 1. All things knowable, from math to government to history, are constructs of the human mind. They are valuable only because they enable us to think.

In the human mind (for example) two plus two equals four. But “two” as an abstract figure does not exist in the outside world, only in the human mind. As Plato put the same insight: We live in a

“cave,” seeing shadows on the wall (dim reflections of exterior reality) and construct sometimes-useful theories based on those shadows. But the power of reason — the power used to construct those simulacrums of reality — is a blunt and often misleading tool.

2. Reality can be perceived directly — not by reason, but by poetic wisdom. Our ancestors, many ages ago, knew this. As a result, they venerated Homer and others whose cadences and insights enabled them to construct governments and ethics. In those great old poems, the gods were the embodiment, voice, and representation of poetic wisdom — the wisdom of the race.

Religion, including prayer and the sacred-poetic texts, is one way to engage poetic wisdom. Nowadays, with the decline of poetry in our schools, it is the most widely used methodology. By connecting the individual to reality, the key religious praxes engender a soothing sense of grounding that promotes physical, mental, and spiritual health. This grounding is at least as important, I believe, as other speculative reasons offered for the health benefits of religion (one intriguing and persuasive suggestion is that most of the 10 Commandments, for example, can be seen as prescriptions for healthful moderation that might have been offered by a wise doctor).

Unfortunately, an increasing number of people admit they are unable to avail themselves of religion, citing philosophical or cultural difficulties. Fewer still have the tools to locate other access points to poetic wisdom. My own practice, developed for purely medical reasons, has the virtue of practicality. It has two salient features: 1) It is easy for anyone to imitate; and 2) It leads easily and directly to an engagement in poetic wisdom, grounded in the rhythms of the individual’s own life. Here is the method: 1. Daily meditations in the form of a diary. I originally started this diary so that I would not forget my life. A few years after I started, I discovered that another amateur diarist kept a journal for the same reason. Nota bene: If and when you start keeping a diary, you’ll soon realize that forgetfulness is a big part of everyone’s lives and that a diary is the only reliable remedy. To my great delight, I eventually became aware of a second and extremely valuable set of benefits to keeping a diary: healing, plus intellectual and spiritual growth.

2. There are types of music that are conducive to meditation. These include some, but not all, of

Mozart (a good example is Mozart’s Serenade No. 13 for strings in G major, K. 525 — also known as A Little Night Music / Eine Kleine Nachtmusik). Even better for meditation are certain forms of New Age music, especially the phenomenal work of Australian composer Ken Davis. Davis constructs his lovely pieces in consultation with tai chi masters.

3. Also useful for the person who desires spirituality without organized religion are various prayers, lightly edited. My own favorite is the first five lines of the Lord’s Prayer, just before it starts asking favors from the deity: Our Father, who art in heaven, hallowed be thy name.

Thy Kingdom come, thy will be done, on earth as it is in heaven The prayer and the music are most helpful if deployed just as one goes to sleep. The music also has excellent results even without prayer all through the day, at those times when one is writing or meditating.

For those fastidiously opposed to any allusion to God, the prayer can be further edited by substituting the phrase “poetic wisdom” for “Our Father.”

One last note, and then I shall surely be at the end of allotted space: Two other things are helpful preparation for engaging wisdom: rest and … the writing of poetry! On the wall above my computer, I have two pertinent quotes. The first is a Spanish proverb, funny and wise: “How beautiful it is to do nothing, and to rest afterward.” The second talisman is posted on the section of wall where I keep my own works-in-progress. It offers insight into one way that wisdom enters the world … through love, defined in a special way: She wanted to know, “What’s love for you?”

Love is the wedding of world and song in the human heart. In the presence of the beloved, the melody rises, and images of all we’d ever dreamed appear before us.

By connecting the individual to reality, the key religious praxes engender a soothing sense of grounding that promotes physical, mental, and spiritual health.

We become young again.

About the Author: Mr. Webb is a retired newspaper editor and prize-winning journalist who is also founder-director of the Border Voices Poetry Project (bordervoices.com), which places poets in hundreds of K–12 classrooms throughout San Diego County and flies in world-famous poets to work with schoolchildren and appear on Border Voices TV shows. december 2010 SAN DIEGO P HY SICIA N. o rg

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Spirituality and Medicine

I

Hands Held Tightly Softening Toward Spirituality

By Katherine Morrison, MD

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S AN D I E G O P HY S I CI A N . or g de c em b e r 2010

was in my internship year at Shadyside Hospital in Pittsburgh seeing a patient with Dr. B, whom I had asked to work with because of his kindness toward patients and the house staff. The patient was a thin, elderly, African-American woman with multiple medical problems, including end-stage renal disease — her prognosis was poor. At the end of the visit, Dr. B asked the patient if she would like to pray with us, and before I could react, my hands were trapped in his and his nurse’s as they took the patient’s hands. My eyes shifted downward. They murmured words that I didn’t hear. Inside, I was stunned and mortified. The next day I asked to be transferred to a different office, telling my supervisor, with scorn, that I couldn’t believe that a doctor would coerce a patient into praying with him.

I was 28 years old then, and I firmly believed that religion (which I did not differentiate from spirituality) had no place in medicine. It felt both manipulative and intrusive to me, and I worried that a vulnerable patient might agree to pray just to please a doctor and to ensure good care. It didn’t occur to me that this patient might, in fact, have chosen Dr. B because he shared her faith. I held those beliefs for the next 10 years — I was not taught to do otherwise in either medical school or residency — and so I never asked a patient about religion or spirituality, feeling it a private matter having no relationship with being a good doctor. I didn’t find it ironic that I would take a detailed sexual history but found asking about religion too intimate.

Fifteen years later, I hold quite a different view about spirituality and medicine, and I worry about what I may have missed. My biases began at an early age with my first exposure to religion being through my Easter-Christmas Catholic parents. My mom held a bit of a grudge against the Catholic Church for not annulling my father’s previous marriage, but she sent me to Catholic school in the seventh grade when the California school system began to feel the stress of Proposition 13. Perhaps because of my parent’s ambivalence toward the church, I felt most aligned with the Bible’s “doubting Thomas,”

thinking that he had gotten a bad rap. I had a lot of questions that my Catholic teachers had no patience for, and I always felt defensive about my disbelief and lack of faith.

My mom developed hepatocellular carcinoma around the time I turned 16. I remember her distress during and after the many visits paid by my brotherin-law’s relatives, who felt the need to discuss their belief that my mother would go to hell unless she converted to their religion. My mom, anorexic, weak, and fragile, was too polite to ask them to leave, so they stayed for hours. She died two months after she was diagnosed. My anger toward those relatives who had stolen some of her precious last hours collided with my anger about her death, and I rebelled.

I stopped going to church, stopped believing in God, and in my mind vilified anything religious.

I might have continued in my judgment of all things religious were it not for a beloved niece who “came out” to me that she had been “born again” eight years previously. I have great admiration for this niece, who lives and works in one of the most violent neighborhoods in Philadelphia with a group of people who believe passionately in social and environmental reform. They practice what they preach, live below the poverty level, waste nothing, and are kind to everyone. It saddened me that she felt she couldn’t tell me about something so important to her. I realized that my own dogmatism about spirituality erected barriers between others and myself.

I began exploring the difference between religion and spirituality, realizing that one doesn’t have to be dogmatic to be spiritual. The less judgmental I was, the more friends and family felt comfortable discussing this important aspect of their lives with me. With practice I also realized that I could maintain my own boundaries around people who felt a strong desire for me to adopt their faith. Now, I usually can feel compassionate about their fervency rather than uneasy.

My softening toward spirituality did not find its way into my medical practice until I started working on the inpatient palliative care service at St. Joseph’s

Hospital in Denver. There, palliative care is a team sport and the chaplain a key player. I was told that the chaplains were trained to reach out to people of every spiritual leaning, but I watched them closely and with suspicion for the first few weeks. I wasn’t sure what role the chaplain had on a medical team.

One day as I struggled to find words of comfort for the 80-year-old man who was losing his “young bride” of 60, I suddenly understood. Where I fumbled and felt completely powerless to help this man, the chaplain deftly picked up the conversation and comforted him. I watched as they sat together with his God and his suffering. He allowed her to help him unload some of his sadness and his loneliness onto his higher power. Since then there have been many occasions where I have seen people open up and trust our team only after the chaplain has made inquiries about their belief system. I remain an atheist but have became a believer in that some patients feel more cared for if we understand the importance of their spiritual practice in their lives.

My palliative care team is seeing a Spanish-speaking, 46-year-old mother of three young children and her husband. We have been consulted because the patient wants to know how to tell her children she is dying and has only months to live. This couple, obvious in their love for each other, tells many stories. Her husband teases her about needing to get a storage facility for the many toys she has bought her children over the years, and they both laugh. They cry when the social worker says it’s important to tell the children that it isn’t their fault that their mother is dying. Both of them talk about how their faith sustains them and gives them strength. The patient’s husband asks if we can say a prayer together.

They reach out and I give them my hands, shift my leaky eyes downward. “Padre nuestro que estás en los cielos, santificado sea tu nombre ….” I listen.

Where I fumbled and felt completely powerless to help this man, the chaplain deftly picked up the conversation and comforted him.

About the Author: Dr. Morrison, SDCMSCMA member since 2010, is a palliative medicine fellow at San Diego Hospice and The Institute for Palliative Medicine. december 2010 SAN DIEGO P HY SICIA N. o rg

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Spirituality and Medicine

Instrument and Purpose I Am but One Small Part in a Great Drama

By George Delgado, MD

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S AN D I E G O P HY S I CI A N . or g de c em b e r 2010

B

efore I more deeply committed myself to Christ, I tended to compartmentalize my life.

In one bin was my faith; in another was an equally important pillar, my family. Medicine was an expandable bin, like a gas that fills any container it is granted. These bins were separate and not always equal, and they rarely shared the richness of their experiences with each other.

After embracing all of the truths of my Catholic faith, I stopped choosing and picking like a diner going through a cafeteria line. With faith and reason, I chose to unconditionally follow Jesus and His Church.

This acceptance, this “giving it all up” if you will, while at first blush seemingly a loss of autonomy, actually brought me great freedom and more control over my life than I could have ever imagined. At last I had a real glimpse of “the big picture,” not just the here and now. The meaning and the purpose of life is what propels me to new adventures and blessings.

Practicing in Northern California at the time, I changed my office policies to reflect my beliefs. Now this did not mean I would be proselytizing in the office; no, it meant I would let patients know what I would and would not be willing to do as a physician.

As physicians, we have a professional autonomy that balances the duty we have to serve patients.

A family I met a few months ago clearly illustrated to me how we, as individuals, can make positive and life-saving changes in people’s lives if we just give the hand of God a chance to work through us. I am changing the names and some of the details to protect confidentiality, and I have the patient’s permission to share the story.

Rhonda and Gary were both 18, in love, and in college. Like many in our society, they did not think that having sex prior to marriage carried any consequences or could hurt them in any way. Although they used contraception, they conceived a child. Suddenly, all the plans for college and a bright future were in disarray. They were confused and frightened and did not know where to turn.

Rhonda decided she should have an abortion as that seemed to be the best “solution” to her “problem.” Gary did not agree with her, but he felt he should not try to dissuade her.

They both sought the counsel of Rhonda’s mother, who tried to convince her to choose life and not abort her baby. After several discussions, debates, and arguments, Rhonda’s mother wearied and agreed to help her have the abortion.

Since she was less than seven weeks along, Rhonda chose to take mifepristone, or RU-486. After she took the abortifacient pill, her mother had an almost immediate sense of regret that she had facilitated the abortion of her own grandchild.

She went to see a priest who offered to speak to

Rhonda. Although initially she refused to meet the priest, later that day she had a change of heart and asked to speak to him. After discussing the situation with him, she began to question her decision.

The priest put her in contact with me, and she asked to meet with me. On that Saturday I met her in the office, with an assistant, to explain how mifepristone works and what her possible options were. I first wanted to do an ultrasound to see if the baby was still alive.

When Rhonda, her mother, and Gary saw the embryo in her uterus with a beating heart, they began to cry. These were tears of joy that the baby was still alive but also tears of remorse, for each of them, individually, regretted the decisions they had made.

They wanted to know what they could do to reverse the mifepristone. I explained to Rhonda the risks of the situation and offered her progesterone therapy since mifepristone functions as a progesterone antagonist. She agreed to proceed, hoping and praying for the best.

As we journeyed together through the first trimester, at each visit I saw a transformation in Rhonda, Gary, and Rhonda’s mother. I could see a beautiful love, joy, and peace developing within them and among them. They had recommitted themselves to their faith and were now trusting that God would guide them every step of the way.

By the end of the first trimester, I referred Rhonda to an obstetrician. She is now nearing the midpoint of her pregnancy, and all of her ultrasounds indicate that all is well with her baby and her. Rhonda feels blessed to have been given a second chance; a second chance she feels was by the grace of God. When I think of Rhonda and Gary, I think that they are, on one hand, extraordinary, but, on the other hand, ordinary like you and me. They initially acted out of fear, but through their near-death experience they learned the power of trust, faith, and purpose.

They and many others whom I have been blessed to serve as a physician have humbled me and made me realize that I am but one small part in a great drama, the drama of life and salvation. I can often make a natural difference, and sometimes I can be an instrument of a supernatural difference in people’s lives. Let the adventure of life continue.

About the Author: Dr. Delgado, SDCMSCMA member since 2005, practices family medicine in San Diego County and also works part time as a hospice physician. He is certified by the American Board of Family Medicine and is board-eligible in hospice and palliative medicine. Dr. Delgado is a voluntary associate clinical professor in the Department of Family and Preventive Medicine at the UC San Diego School of Medicine.

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This acceptance, this “giving it all up” if you will, while at first blush seemingly a loss of autonomy, actually brought me great freedom and more control over my life than I could have ever imagined.

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31

Spirituality and Medicine

Just Sit with Me for a While …

C aring for the Spirit

By John Tastad

W “Just two weeks ago my dad said something to me that he hadn’t said since I was a child … I will always cherish those words …

‘I love you.’”

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illiam had been a professor at a prestigious university for years. He lapped up life like a thirsty beagle slurping water after a romp in the field. Extensive travel, fast sports cars, exquisite foods, classical music, meaningful relationships — fulfilling components of an adventure-filled way of being. And, to be sure, he did some damage along the way. As chronic illness crept in, William’s pace along the path of life slowed, but he still enjoyed a cigar on the back deck while Strauss’ The Blue Danube soothed.

Chronic illness gave way to terminal illness, as metastatic cancer was diagnosed, and, following aggressive treatment for cure, aggressive treatment for comfort was recommended by his oncologist. A body worn by disease progression and the hard-hitting curative efforts of chemo- and radiation therapy was occupied by a once-vibrant spirit that still flickered, but was fading.

“What the hell is a spiritual care counselor? Are you going to try and force some sort of dogma or doctrine down my throat or something? If so, I’m not interested.”

S AN D I E G O P HY S I CI A N . or g de c em b e r 2010

William asked a great question. What is a spiritual care counselor? Most hospice brochures say something like: Spiritual care providers, sometimes called chaplains, are men and women who are professionally trained and specialize in theology and pastoral counseling, with a focus on end-of-life issues. They work within all religions or spiritual belief systems and also assist those without a religious preference. When confronted by a serious illness, some come face to face with human limitations and mortality. Often, patients find comfort in speaking with a spiritual care counselor. Counselors are available to help you and your family deal with spiritual challenges brought on by your illness, and to find meaning and purpose as you continue the life you are living now. Spiritual care, from a broad spectrum of religious and spiritual traditions, is a core hospice service and available to all patients and their loved ones. Some people express their spirituality through religion, others do not. You may request that your spiritual care counselor officiate at any funeral rites that you choose. Your wishes dictate which spiritual support services you will receive.

“No William, I am not here to force dogma or doctrine down your throat,” I said. “Spiritual care is sometimes more care of the spirit than it is religious care.

Some people just like to have someone to talk with about what they are thinking and feeling.” William had me roll him out onto the deck in his wheel chair.

He began with some memories from his childhood, and the stories flowed on. “So that’s what a spiritual care counselor does. He sits with an old man and lets him tell his stories,” William said with a slight grin.

In subsequent visits, William addressed some thoughts and feelings related to his impending death, and he said that he viewed his passing as “the next adventure in life.” On one visit, as the smoke from his cigar encircled his head, I sat with him, listened to him, cared about him, and enjoyed him. At the conclusion of the visit, I gently challenged William to say what he needed to say to those closest to him prior to his death, and offered to assist as needed. William shrugged me off.

Following William’s death, I was honored to officiate at his memorial service. I was touched as his son shared the eulogy, and, through tears, stated, “Just two weeks ago my dad said something to me that he hadn’t said since I was a child … I will always cherish those words … ‘I love you.’”

Spiritual care in hospice is care of the spirit and often involves sitting with people as they share their stories.

About the Author: Mr. Tastad is a spiritual care counselor currently serving as the program coordinator for the Transitions — Advance Care Planning Program at Sharp HospiceCare.

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classifieds office space MEDICAL OFFICE SPACE FOR LEASE, ALL OR PART: Up to 1,100ft2. Owner may also be willing to sell. Great location in medical/dental complex in Poway, next to Pomerado Hospital (borders Rancho Bernardo). Open treatment areas and private treatment rooms, two bathrooms, waiting room/lobby, front office. Second floor. Elevator/stair access. Beautiful view of the hills. Ideal for medical, physical therapy, chiropractic, acupuncture, complementary/alternative medicine, massage/body work, etc. Patients/clients from Poway, Rancho Bernardo, Carmel Mountain, 4-S Ranch, Scripps Ranch, Escondido, Ramona, etc.

Contact Debbie Summers at (858) 382-8127 or at debjsummers1@yahoo.com.

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 AVAILABLE CONSULTATION ROOM ON THE CAMPUS OF SCRIPPS ENCINITAS, CLOSE TO 5 FREEWAY: Private entry to wheelchair accessible unit with soundproof walls, spacious waiting room shared with one doctor, BR with shower, reserved parking. Flexible sublease terms. To view the property (available January 1, 2011), please contact Beverly at (760) 944-9263 or email sdvi. office@gmail.com. [868] SHARE OFFICE SPACE IN LA MESA JUST OFF OF LA MESA BLVD: 2 exam rooms and one minor OR room with potential to share other exam rooms in building. Medicare certified ambulatory surgery center next door. Minutes from Sharp Grossmont Hospital. Very reasonable rent.

Please email KLewis@sdcms.org for more information. [867] PROFESSIONAL OFFICE SPACE TO SHARE OR LEASE: Part time, full time, flexible terms and incentives. Up to 1,400ft2 in a medical complex.

Near Alvarado Hospital, SDSU college area. Ample parking. High visibility street location. Ideal for any specialty or allied medical professionals.

Call (858) 243-2425. [733] OFFICE SPACE TO SHARE: In Eastlake Area.

Currently occupied by owner, family physician.

Great location close to Sharp Chula Vista Hospital. Beautiful, new building. Procedure and exam

room available. If interested please call Norma (office manager) at (619) 946-4073. [864] OFFICE SPACE IN UTC: Full-time office in 8th floor suite with established psychologists, marriage and family therapist, and psychiatrist in Class A office building. Features include private entrance, staff room with kitchen facilities, active professional collegiality and informal consultation, private restroom, spacious penthouse exercise gym, storage closet with private lock in each office, soundproofing, common waiting room, and abundant parking. Contact Christine Saroian, MD, at (619) 682-6912. [862] MEDICAL OFFICE OWNER/USER OPPORTUNITY — ADJACENT TO SCRIPPS MERCY HOSPITAL: Two-story medical building for sale, located on the corner of Lewis St. and 3rd Ave. at 233 Lewis Street, adjacent to Scripps Mercy Hospital. Property has tremendous foot traffic, a flexible floor plan, 10 off-street parking spaces, and is elevatorserved. Take advantage of this exclusive opportunity to own on-campus via SBA Financing (with as little as 10% down) for effectively less than renting in Hillcrest’s dense medical office submarket. For more information or to schedule a property tour, contact Nic Lyon or Evan Kovac at (858) 373-3100 or email Nic.Lyon@MarcusMillichap.com. [859] NEW SPACE TO SHARE IN KEARNY MESA: Located directly across from Sharp Memorial Hospital in a Class A medical office building. The 2400ft2 space is perfect for a part-time or fulltime, shared office arrangement. The reception area was designed to comfortably accommodate those with disabilities. Dual windows facilitate easy check-in. There are ample, built-in staff work stations. Staff also enjoy a private lounge.

A furnished office and dedicated exam room are available for the physician. The office suite also includes a leaded room for minor procedures.

Terms negotiable. Please contact carla.young@ clyoungmdinc.com for more information. [857] MEDICAL OFFICE SPACE FOR RENT IN ENCINITAS: Convenient location five minutes from Scripps Encinitas Hospital. Close to 5 freeway.

The 800ft2 space includes two spacious exam rooms, private consultation/doctor’s office, private bathroom, lunchroom, 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 (760) 519-0102 or email ktagdiri@gmail.com for more information. [855] SCRIPPS RANCH OFFICE SPACE TO SHARE: Located at 10672 Wexford St. in San Diego with easy access to I-15. 4,000ft2 office with nine exam rooms (four available) and digital X-ray suite in a class A medical building. Office is currently occupied by an orthopedic surgeon looking to share space. Options available for space sublease or cost sharing of staff, X-rays, and office equipment. Practice currently uses CCHIT certified eClincalWorks EMR with e-prescribing. For more information, please contact Ian at (858) 5369500 or email at info@mcclurgmd.com. [852]

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] 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] PHYSICIAN POSITIONS AVAILABLE 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 excellent working conditions, loyal staff, and wonderful patients. No hospital work, easy call, attractive compensation package. Email fredarsham@hotmail.com. [807] PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com) is a fast-growing group of house-call doctors. Great pay ($140–$200+K), flexible hours, choose your own days (full or part time). No ER call or inpatient duties required. Transportation and personal assistant provided. Call Chris Hunt, MD, at (858) 279-1212 or email CV to hpmg11@yahoo. com. [801] SEEKING A FULL-TIME FAMILY PRACTICE PHYSICIAN FOR AMBULATORY CLINIC: Southern Indian Health Council is made up of board-certified physicians who are experts in primary care and health management. Working closely with a well-trained support staff, our medical providers have established a solid reputation of delivering quality outpatient care and a broad scope of services to individuals of all ages. We are seeking a full-time, board-certified family practice physician, Monday–Friday, 8:00am–4:30pm. Must have current CA and DEA licenses; computer skills. Malpractice coverage provided. Forward resume to jobs@sihc. org or fax to (619) 445-7976 or visit our website at www.sihc.org. Contact jobs@sihc.org or HR phone at (619) 445-1188, ext. 291, or HR fax at (619) 445-7976. [866] INTERNAL MEDICINE, PART-TIME POSITION, PRIVATE PRACTICE, WONDERFUL JOB OPPORTUNITY!:Outstanding opportunity to work part time or more in a mature, premiere private practice setting in North San Diego County, outpatient only. This unique position blends the rewards of private practice and tradi-

To submit a classified ad, email Kyle Lewis at KLewis@SDCMS.org. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $150 (100-word limit) per ad per month of insertion.

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tional continuity of care with scheduling flexibility. Perfect for any physician who wants to transition from the demands of a full-time position, or who wants to maximize job satisfaction in an extremely high quality work environment while still working part time. Contact (619) 248-2324 for more information. [861] MEDICAL DIRECTOR: Licensed physician for busy outpatient substance abuse program.

Treatment for opiate/opioid addiction — MAT format — Methadone and Suboxone. 32 hours a week. San Diego and El Cajon locations. Contact Dennis Whitmyer at DWhitmyer@crchealth.com or at (619) 718-9890. [854] INTERNAL MEDICINE PHYSICIAN: Internal medicine physician to join a well-established turnkey practice located near Alvarado Hospital.

New physician will take over existing practice, weekend call one in five weekends. Full laboratory, dexa machine, 2D echos, and vascular studies done in the office. Traditional in- and out-patient practice. Benefits and salary leading to partnership. Interested candidates should contact Lydia Gormish at (619) 229-5055 and submit curriculum vitae to lydiagormish@cox.net. [853] PROFIL INSTITUTE FOR CLINICAL RESEARCH SEEKING CONTRACT PHYSICIAN: At Profil, we combine the careful and critical attitude of academic science with the professionalism of the bio-pharmaceutical industry. Located in Chula Vista, Profil Institute for Clinical Research is currently accepting applications for a highly qualified contract physician. Reports to medical director. Main purpose of job: Ensure the safety and wellbeing of human subjects; ensure integrity of study data; provide medical leadership and supervision for human clinical trials within PICR. Work side by side with a highly committed team proud of its contribution to diabetes and obesity research. Profil offers a competitive salary, excellent benefits, and career opportunities in a dynamic, quality-focused environment.

For further information, visit SDCMS.org/classifieds/physician-positions-available. Forward resumes to hrpicr@profil-research.com. No faxes or phone calls, please. [851] PHYSICIANS NEEDED: Full-time, part-time, and per-diem opportunities available for family medicine, pediatric, and OB/GYN physicians. Vista Community Clinic is a private, nonprofit outpatient clinic serving the communities of North San Diego County. Must have current Calif. and DEA licenses. Malpractice coverage provided.

Bilingual: English/Spanish preferred. Forward resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. Visit our website at www. vistacommunityclinic.org. EOE/M/F/D/V [846] INTERNAL MEDICINE PHYSICIANS: SHARP Rees-Stealy Medical Group, a 350+ physician multi-specialty group in San Diego, is seeking full-time BC/BE internal medicine physicians to join our staff. We offer a first year competitive compensation guarantee, excellent benefits package, and shareholder opportunity after two years. Please send CV to SRSMG, Physician Services, 2001 Fourth Avenue, San Diego, CA 92101. Fax: (619) 233-4730. Email: Lori.Miller@ sharp.com. [842]

NONPHYSICIAN POSITIONS AVAILABLE SEEKING PHYSICIAN ASSISTANT TO WORK WITH BUSY SAN DIEGO NEUROSURGEON: Responsibilities include: clinic, inpatient and surgical assisting. Will consider all candidates though experience preferred. Compensation and benefits commensurate with experience. Please contact ania@drtungonline.com. [865] PROVIDER PRACTICE MANAGER: About Us: San Diego Hospice and The Institute for Palliative Medicine (SDHIPM) is one of the 10 largest community-owned, not-for-profit hospice programs in the nation, caring for the 1,000 patients daily in their homes or other facilities in San Diego County. Our mission is to prevent and relieve suffering and to promote quality of life, at every state of life, through patient and family care, education, research, and advocacy. Position Description: The provider practice manager oversees all medical staff support, including administration, planning, budgeting, financial management, provider scheduling, and credentialing. Working in conjunction with the practice director, the provider practice manager ensures full and effective administrative and compliance support for the provider practice group. Works with IT, finance, and health information on documentation, billing, electronic medical record activities, and other activities of, and supports for, the provider practice group. Participates as appropriate in strategic and planning discussions related to provider and patient care services operating models and supports integration of direction. Education: Requires a bachelor’s degree, preferably in health administration or business administration. Experience: Must have at least three years of experience in managing the operations a physician practice group. Prior experience in a home health or hospice setting is preferred. Experience with electronic health records ideal. Must demonstrate ability to not only use computer systems effectively but also to employ them to improve processes. Familiarity with hospital and/or hospice regulations required. Position is full time, Monday through Friday. Shift is 8:00am to 5:00pm. sdhospice.org/careers [858] LOOKING FOR A LICENSED PNPC: With two years experience for a pediatric office in Clairmont area. Part/full time. Call (858) 268-0702.

Fax (858) 268-0374. [856] WANTED CALIFORNIA-LICENSED CLS GENERALIST: For lead technologist for busy group practice. Must excel at multitasking and be able to supervise lab assistants and other CLS while performing patient testing. Will oversee dayto-day operations, including quality control, lab workflow, and troubleshooting. Instrumentation includes Dimension Expand and Cell-Dyn. Strong technical background required. Two years plus experience preferred. Reports to lab director and technical consultant. Excellent benefits package.

Salary commensurate with qualifications. Contact Lydia at (619) 229-5055. [845] PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: We have an opening for a licensed midlevel practitioner (physician assistant or nurse practitioner) in our specialty practice.

The successful candidate must be able to make focused patient assessments and have experience in clinical decision-making appropriate to a

midlevel provider. We provide an environment of strong clinical support and access to supervising physician. We’re willing to make an investment in training the right candidate. The qualified candidate must be: graduate of an accredited program; current DEA certificate; Calif. license; Spanish speaking a plus; 2+ years of clinical experience. Please email cover letter, CV, and salary requirements to office@pacificsouthwestpain. com. [844] LOOKING FOR A MATURE, EXPERIENCED MEDICAL PRACTICE MANAGER: Twenty-hourper-week position. Established nephrology practice with two physicians and a third physician in the office in another specialty. Duties: The manager must have computer practice management and EHR experience. The manager must be familiar with all state and federal regulations pertaining to medical office management. The manager has to be able to evaluate and direct the office staff. The manager must be able to communicate and work with the four physicians in the office (there is a locum physician). The manage must be able to hire and fire people in a legal and professional way. The office is currently re-tooling with Allscripts; this is our software company as we move toward meaningful use. Dr. Ramenofsky’s wife is his account manager and works remotely. She is in charge of working with Allscripts to evaluate and re-tool the office to quality for the stimulus. The office manager will have to interact with her on a limited basis and then direct the office staff. Mrs. Ramenofsky also manages the hardware in the office, so that is one less duty the office manager has to perform. The entire office will re-train with the Allscripts academy onsite, the new manager will participate in this training for practice management and EHR. The manager will need to hold weekly or bi-weekly meeting with the staff to communicate and maintain high quality moral and work in the office. Contact Lauren Ramenofsky via her email: Buffmom1@ aol.com. [843] Practice for sale

RANCHO BERNARDO MEDICAL WEIGHT LOSS PRACTICE FOR SALE $75,000: Practice uses OPTIFAST and counseling programs-can add other programs. Bariatric specialty not requiredOPTIFAST offers physician training. Patients see doctor or MA once week, get product, do labs, and attend lifestyle modification with counselors. Take over with no start-up issues, payments are cash/credit card – no insurance. Doctor’s other practice expanding, forcing sale. Great freeway access and parking. Easy transition with fully equipped office space, low rent, expert staff, website, etc.

Call Diane 760-580-4423 or diane@healthfirstclinics.com MEDICAL EQUIPMENT SACRIFICE SALE: Slightly used, full-size hip and spine HOLOGIC Bone Densitometer. Price negotiable. Call (760) 703-0691. [755]

december 2010 SAN DIEGO P HY SICIA N. o rg

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spiritualityandmedicine

By Wayne R. Freiberg

Note: The following benediction was delivered at the opening of the 2010 interim meeting of the AMA House of Delegates, held in San Diego Nov. 6–9, 2010.

Dear Most Gracious Lord,

The Healing Arts A Higher Calling

In such an august body as this, I know each and every one of us has seen some type of event that defies scientific reason. In the recesses of our heart, we quietly cried for the loss of someone we were powerless to help. Through the agency of human compassion, we want to do good and often do, but there are times where our training, knowledge, and skill just aren’t enough. Which of us still carries the memory of holding someone’s hand as they passed from this life to the next, knowing this experience has changed us forever?

For this reason, we each have a higher calling because there is much at stake.

Such is the burden we all share who deal in the healing arts.

Such is life in war and in peace for those of us who are there to help those struggling with physical, emotional, and spiritual turmoil. Whether here at home or abroad on a battlefield.

Remind us that our vocation is not only a personal responsibility, it is our duty and holy calling.

For these reasons, Lord, we ask and pray for the following: • Give us passion for what we do so that many may be encouraged and we may be a blessing to others.

• Grant unto us the ability to see the extraordinary in ordinary things so that we always have a sense of wonder and purpose under Heaven.

• Help us to know that to whom much is given, much is expected.

Lastly, we need to be reminded that you are the author and finisher of life, death, and everlasting life. Let us be tools in your hands as we serve your lambs. Renew us with your strength and give us the peace that passes all understanding as only you can do. Amen

About the Author: Chaplain Freiberg was in Iraq as the 3rd Marine Air Wing (forward) chaplain and has helped many Marines suffering with PTSD with spiritual counseling. His doctoral dissertation researches the spiritual component of mental health and combat-caused PTSD with the United States Navy SEALs. He is currently the command chaplain at Naval Base San Diego.

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FAST. COMFORTABLE. ACCURATE. THAT’S HOW CANCER TREATMENT SHOULD BE. At San Diego Radiosurgery, we offer treatment using the Novalis Tx platform for image-guided radiosurgery.

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Novalis Tx is optimized to deliver radiosurgery in the shortest possible time, averaging 15 minutes, preventing errors due to minor movements during long treatments.

Call or visit our website for more information.

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$5.95 | www.SANDIEGOPHYSICIAN.org PRSRT STD U.S. POSTAGE PAID DENVER, CO PERMIT NO. 5377

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S AN D I E G O P HY S I CI A N . or g august de c em b e2010 r 2010