June 2012 by San Diego Physician

official publication of the san diego county medical society june 2012

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s c i h t 16 SDCMS’ Bioethics Commission 18 The Surrogate Who Demands ‘Everything Be Done’ 22 Informed Consent and Patient Autonomy 24 A Test of Autonomy 26 Global Health Ethics 30 The Integration Model Trifecta

“Physicians United For A Healthy San Diego”

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S A N D I E G O P HY S I CI A N . or g O c tob e r 2011

Octo ber 2011 SAN DIEGO P HY SIC I A N. o rg

this month Volume 99, Number 6

o i B

s c i h t e features

SDCMS Board of Directors Officers President Robert E. Wailes, MD (CMA Trustee) President-elect Sherry L. Franklin, MD (CMA Trustee) Treasurer Robert E. Peters, PhD, MD Secretary J. Steven Poceta, MD Immediate Past President Susan Kaweski, MD geographic and geographic alternate Directors

16 The SDCMS Bioethics Commission: A Brief History by Paula Goodman-Crews, LCSW, and Mitsuo Tomita, MD

18 The Surrogate Who Demands ‘Everything Be Done’ Counter to the Patient’s Prior Wishes: Ethics Case by Lynette C. Cederquist, MD

MD, Kimberly M. Lovett, MD (A:Venu Prabaker, MD) Hillcrest Theodore S. Thomas, MD, Steven A. Ornish, MD, Jason P. Lujan, MD (A:Gregory M. Balourdas, MD) Kearny Mesa John G. Lane, MD (A:Marvalyn E. DeCambre, MD, Sergio R. Flores, MD) La Jolla Gregory I. Ostrow, MD, Wynnshang “Wayne” Sun, MD (A: Matt H. Hom, MD) North County James H. Schultz, MD, Douglas Fenton, MD, Niren Angle, MD (A: Steven A. Green, MD) South Bay Vimal I. Nanavati, MD, Mike H. Verdolin, MD (A: Andres Smith, MD)

by Nancy L. Vaughan, Esq.

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, Peter O. Raudaskoski, MD, Mihir Y. Parikh, MD, Suman Sinha, MD (A: Carol L. Young, MD, Thomas V. McAfee, MD, Ben Medina, MD, James E. Bush, MD, Samuel H. Wood, MD, Elaine J. Watkins, DO, Carl A. Powell, DO, Theresa L. Currier, MD)

24 A Test of Autonomy: The Dax Cowart Case

Communications Chair Theodore M. Mazer, MD (CMA Vice Speaker)

22 Informed Consent and Patient Autonomy: Giving the Patient the Opportunity to Be an Informed Participant in Healthcare Decisions

other voting members Young Physician Director Van L. Cheng, MD

by Marilyn Mitchell, RN, BSN, MAS

26 Global Health Ethics: A Response to ‘Total Pain’ by Katherine Irene Pettus, PhD

departments

Editorial Board Van L. Cheng, MD, Adam F. Dorin, MD, Kimberly M. Lovett, MD, Theodore M. Mazer, MD, Robert E. Peters, PhD, MD, David M. Priver, MD, Roderick C. Rapier, MD Marketing & Production Manager Jennifer Rohr Sales Director Dari Pebdani Art Director Lisa Williams Copy Editor Adam Elder

East County William T-C Tseng, MD, Heywood “Woody” Zeidman,

Bioethics

Managing Editor Kyle Lewis

30 The Integration Model Trifecta: Good Medicine, Good Bioethics, and Good Palliative Care by London Carrasca, MPH, RN

Resident Physician Director Steve H. Koh, MD Retired Physician Director Rosemarie M. Johnson, MD Medical Student Director Beth P. Griffiths

OTHER NONVOTING MEMBERS Young Physician Alternate Director Renjit A. Sundharadas, MD Resident Physician Alternate Director Christina Pagano, MD Retired Physician Alternate Director Mitsuo Tomita, MD CMA President James T. Hay, MD CMA Past Presidents Robert E. Hertzka, MD (Legislative Committee Chair), Ralph R. Ocampo, MD CMA Trustee Albert Ray, MD CMA Trustee (OTHER) Catherine D. Moore, MD CMA SSGPF Delegates James W. Ochi, MD, Ritvik Prakash Mehta, MD CMA SSGPF Alternate Delegates Dan I. Giurgiu MD, Ashish K. Wadhwa, MD

4 Briefly Noted Calendar • Election Results • Advocacy Success Story 8 E-prescribing Malpractice Risks by The Doctors Company

10 Physicians Need Drug Rehab Before We Can Lead Our Nation Into Recovery by Roneet Lev, MD, FACEP

34 Physician Marketplace Classifieds

36 In Memoriam: John A. Bishop, MD, FAAP by David L. Collins, MD, FAAP, FRCS, and H. Glenn Kellogg, MD, FAAP

2 SAN DIEGO PHYSICIAN.org j u n e 2012

Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org. All advertising inquiries can be sent to DPebdani@SDCMS.org. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

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j u n e 2012 SAN DIEGO PHYSICIAN .org 3

brieflynoted election results

calendar SDCMS Seminars, Webinars & Events SDCMS.org/event

For further information or to register for any of the following SDCMS seminars, webinars, and events, visit SDCMS.org/event or contact Rhonda Weckback at (858) 300-2779 or at Rhonda. Weckback@SDCMS.org. Are Your Contracts Healthy? (seminar/webinar) JUN 14 • 11:30am–1:00pm Business Law 101 for New Physicians (seminar/webinar) JUN 20 • 11:30am–1:00pm Financial and Legal Life Skills (workshop) JUN 23 • 8:30am–11:30am Microsoft Outlook for Busy Docs (workshop) JUL 7 • 8:30am–11:30am Communicating Adverse Outcomes (webinar) JUL 11 • 6:30pm–7:30pm Communicating Adverse Outcomes (webinar) JUL 12 • 11:30am–12:30pm EHR Incentives (seminar/webinar) AUG 9 • 11:30am–1:00pm Buying, Selling, Leasing Office Space (seminar/webinar) AUG 23 • 11:30am–1:00pm

Cma Webinars

CMAnet.org/events

CMA and the Courts: Accessing CMA’s Legal Library JUN 13 • 12:15pm–1:15pm

Coding for Medical Necessity AUG 1 • 12:15pm–1:15pm Program Integrity in Medicare and Medi-Cal: The Physician’s Role AUG 15 • 12:15pm–1:15pm California Workers’ Compensation E-bill Part 1: Are You Ready? AUG 16 • 12:15pm–1:15pm California Workers’ Compensation E-bill Part 2: Implementation AUG 23 • 12:15pm–1:15pm California Workers’ Compensation E-bill Part 3: Understanding Remittance Advice Rules AUG 30 • 12:15pm–1:15pm

Community Healthcare Calendar To submit a community healthcare event for possible publication, email KLewis@SDCMS.org. Events should be physician-focused and should take place in or near San Diego County. California Society of Industrial Medicine and Surgery’s Midsummer Seminar: Are You on the Right Track? JUN 14–16 • www.csims.net 55th Annual San Diego Academy of Family Physicians’ Family Medicine Update: 2012 JUN 22–24 • Paradise Point Hotel, Mission Bay • www. sandiegoafp.org

Results of SDCMS’ 2012 Board of Directors Elections SDCMS’ Elections Committee, chaired by retired SDCMS-CMA member Ralph R. Ocampo, MD, has approved the results of the 2012 election, which are as follows: • President-elect: Robert E. Peters, PhD, MD • Treasurer: J. Steven Poceta, MD • Secretary: William T-C Tseng, MD, MPH • At-large Director #2: Karrar H. Ali, MD • At-large Director #4: David E. Bazzo, MD • Alternate At-large Director #3: Holly B. Yang, MD • Resident Physician Director: Christina R. Pagano, MD • Young Physician Director: Van Le Cheng, MD • Alternate Young Physician Director: Renjit Sundharadas, MD • East County Geographic Director #1: Venu Prabaker, MD • East County Geographic Director #2: Alexandra E. Page, MD • Hillcrest Geographic Director #1: Theodore S. Thomas, MD • Alternate Hillcrest Geographic Director: Gregory M. Balourdas, MD • La Jolla Geographic Director #1: Geva E. Mannor, MD • North County Geographic Director #1: James H. Schultz, MD • North County Geographic Director #3: Niren Angle, MD • Alternate North County Geographic Director: Anthony H. Sacks, MD • South County Geographic Director #2: Michael H. Verdolin, MD • AMA Delegate #1: James T. Hay, MD • AMA Delegate #2: Robert E. Hertzka, MD And the president for 2012 — the president-elect from 2011 —is Sherry L. Franklin, MD. Congratulations to one and all!

featured member

Become an SDCMS

Featured Member!

13th Annual Science and Clinical Application of Integrative Holistic Medicine NOV 2 • Hilton San Diego Resort

Writing Effective Appeals JUN 20 • 12:15pm–1:15pm 2012 Legislative Update JUL 11 • 12:15pm–1:15pm Preparing for a Medicare and/ or Medi-Cal Audit JUL 18 • 12:15pm–1:15pm

4 SAN DIEGO PHYSICIAN.org j u n e 2012

you co heruld app e ne e xt! ar

SDCMS would like to feature some of our member physicians for their noteworthy accomplishments in these pages and on SDCMS.org! If you would like to be considered for our next “Featured Member” spotlight, please email Editor@SDCMS.org. Thank you, and thank you for your membership in SDCMS and CMA!

you take care of the san diego communit y ’s health. we take care of san diego’s

healthcare communit y.

get in touch

3 income Tax Planning 3 Wealth Management

Your SDCMS and SDCMSF Support Teams Are Here to Help!

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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 James.Beaubeaux@SDCMS.org DIRECTOR OF ENGAGEMENT Jennipher Ohmstede at (858) 300-2781 or JOhmstede@SDCMS.org DATABASE ADMINISTRATOR Janet Lockett at (858) 300-2778 or Janet.Lockett@SDCMS.org DIRECTOR OF MEMBERSHIP SUPPORT • PHYSICIAN ADVOCATE Marisol Gonzalez at (858) 300-2783 or MGonzalez@SDCMS.org DIRECTOR OF BUSINESS DEVELOPMENT Naeiry Vartevan at (858) 300-2782 or at Vartevan@SDCMS.org DIRECTOR OF COMMUNICATIONS AND MARKETING • MANAGING EDITOR Kyle Lewis at (858) 300-2784 or KLewis@SDCMS.org OFFICE MANAGER • DIRECTOR OF FIRST IMPRESSIONS Betty Matthews at (858) 565-8888 or Betty.Matthews@SDCMS.org MEMBERSHIP ADMINISTRATIVE ASSISTANT Rhonda Weckback at (858) 300-2779 or Rhonda.Weckback@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) 300-2777 F (858) 560-0179 (general) W SDCMSF.org EXECUTIVE DIRECTOR Barbara Mandel at (858) 300-2780 or Barbara.Mandel@SDCMS.org project access PROGRAM DIRECTOR Francesca Mueller, MPH, at (858) 565-8161 or Francesca.Mueller@SDCMS.org Patient Care Manager Rebecca Valenzuela at (858) 300-2785 or Rebecca.Valenzuela@SDCMS.org Patient Care Manager Elizabeth Terrazas at (858) 565-8156 or Elizabeth.Terrazas@SDCMS.org IT PROJECT MANAGER Rob Yeates at (858) 300-2791 or Rob.Yeates@SDCMS.org IT PROJECT MANAGER Victor Bloomberg at (619) 252-6716 or Victor. Bloomberg@SDCMS.org

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brieflynoted An SDCMS Physician Advocacy Success Story

The following is one example of how SDCMS’ physician advocate, Marisol Gonzalez, helps SDCMS member physicians solve problems on a daily basis. Dr. Jonathan Worsey, SDCMSCMA member since 2006, contacted Marisol regarding an issue he was having with United HealthCare. Following are the steps Marisol took to solve Dr. Worsey’s problem:

1. Dr. JonathanWorsey contacted Marisol in March of this year after receiving a letter from United HealthCare (UHC) attempting to recoup monies for a patient he had seen in January of 2011 — the attempted recoupment went beyond the 365 days allowed by law. According to CMA’s CMA ON-CALL document #0135, “Plan Requests for Refunds from Physicians”: Licensed Knox-Keene plans and insurers are precluded from pursuing overpayments more than 365 days after the original payment, unless the overpayment was caused in whole or in part by provider fraud or misrepresentation. 2. After having Dr. Worsey sign a CMA business associates agreement, Marisol sent the relevant EOBs and other paperwork to CMA’s Cen-

legislator birthdays

ter for Economic Services, which escalated the case with their contact at UHC. According to CMA, the only instances where this may not get reversed are if the patient is covered by an $1,500 ERISA/self-funded plan Saved! that leases the UHC network. In these cases, ERISA/self-funded plans 4. Dr. Worsey emailed Mariare covered by federal law sol, “I appreciate your help and do not follow the stricter in getting to the right person California standards. ERISA/ and, with the backing of the self-funded plans allow recounty and state medical fund requests up to four years societies, they agreed with for contracted physicians and me.” two years for noncontracted physicians. SDCMS member physicians are encouraged to contact 3. In April, Dr. Worsey Marisol directly at (858) received a letter from UHC 300-2783 or at MGonzalez@ stating that since UHC was SDCMS.org should you need beyond the 365-day limit assistance with any political, from the date of service, it legal, or economic advocacy would overturn the requests issue you’re facing. for recoupment.

One way to let your legislators know that you’re paying attention and that you vote is by wishing them a happy birthday!

BIRTHDAY: JUNE 20

BIRTHDAY: JUNE 22

BIRTHDAY: JUNE 28

State Assemblywoman Diane Harkey (District 73) E: (via website) arc.asm.ca.gov/member/73 E: assemblymember.harkey@assembly.ca.gov Sacramento Office: State Assembly, Sacramento, CA 95814 T: (916) 319-2073 • F: (916) 319-2173 Oceanside Office: 300 N. Coast Highway, Oceanside, CA 92054 T: (760) 757-8084 • F: (760) 757-8087

U.S. Senator Dianne Feinstein E: (via website) feinstein.senate.gov Washington, DC, Office: T: (202) 224-3841 • F: (202) 228-3954 San Diego Office: 750 B St., Ste. 1030, San Diego, CA 92101 T: (619) 231-9712 • F: (619) 231-1108

State Assemblyman Marty Block (District 78) E: (via website) asmdc.org/members/a78 E: assemblymember.block@assembly.ca.gov Sacramento Office: State Assembly, PO Box 942849, Sacramento, CA 94249-0078 T: (916) 319-2078 • F: (916) 319-2178 Lemon Grove Office: Lemon Grove Plaza, 7144 Broadway, 2nd Floor, Lemon Grove, CA 91945 T: (619) 462-7878 • F: (619) 462-0078

6 SAN DIEGO PHYSICIAN.org j u n e 2012

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Risk Management

E-prescribing Malpractice Risks Contributed by SDCMS-endorsed The Doctors Company. For more information about e-risk and how to protect your practice, please visit www.thedoctors.com.

Driven by electronic health record (EHR) adoption and federal incentives, approximately 35% of physician office practices currently use e-prescribing to send prescriptions directly to pharmacies. These systems allow quick access to drug formulary and eligibility information and to the patient’s prescription history. They also reduce costs by flagging generic and “on-formulary” drugs. The systems may help with compliance problems, as approximately 20–30% of patients never pick up their prescriptions. Adding to these potential benefits is what ought to be the physician’s best friend: flagging drug-drug interactions before they occur. However, there are always unanticipated consequences when new technologies are adopted — and the EHR is no exception. Real and potential liability risks are beginning to be recognized, and it is important for physicians to become familiar with them. Consider the following: • Doctors have access to data through e-prescribing community medication histories, which can expose the 8 SAN DIEGO PHYSICIAN.org j u n e 2012

physician to potential interactions with drugs prescribed by others. For example, Dr. A renews a medication, and his e-prescribing program sends an alert advising him that the medication could interact with another drug the patient is taking. He has not prescribed that drug, so his office staff will have to contact the patient to identify who has prescribed it, and then Dr. A will have to contact Dr. X to “negotiate” which drug will be discontinued or changed. If failure to take action results in patient injury from a drug-drug interaction, Dr. A may be liable. • Doctors are responsible for clinical information they can reasonably access. There is increased access to e-health data from outside the practice through the practice EHR or website, or through a health information exchange (hospital charts, consultant reports, and laboratory and radiology reports). • Meaningful use requires that EHRs provide e-prescribing drug information and clinical decision support. Clinicians

should know the source of this information because it may conflict with their specialty’s clinical standards of care or practice guidelines — and with information in FDA-approved drug labels and drug alerts (boxed warnings). • Drug-drug interaction lists are often so comprehensive and generate alerts with such frequency that they can become disruptive and annoying. Doctors may develop “alert fatigue” and ignore, override, or disable them. However, if it is shown that following an alert would have prevented an adverse patient event, the physician may be found liable for failing to follow it. Expert consensus lists or optimized, clinically meaningful drug-drug interaction lists focused on a smaller set of interactions most frequently associated with harm may address this problem. However, EHR vendors may resist eliminating the lowrisk warnings, fearing that doing so may increase their liability. The PDR Alert Network is a free service that electronically delivers FDA alerts (including FDA label changes and boxed warnings) to physicians and other prescribers. This alert network improves physician access to important and timely medication information, thereby improving patient safety and reducing medical liability. The PDR Alert Network resulted from a multiyear effort engaging AMA, medical specialty and state medical societies, professional liability insurance carriers, patient safety groups, manufacturers, and the FDA. It is governed by the iHealth Alliance, a nonprofit board consisting of leaders from medical societies (including AMA), university medical centers, the National Patient Safety Foundation, and professional liability carriers. It is dedicated to protecting the interests and privacy of patients and providers. In collaboration with the FDA’s Safe Use Initiative, PDR Network and medical professional liability carriers launched a national Know the Label campaign early in 2011. The campaign allows physicians to earn free continuing medical education (CME) credits by reviewing the FDA-approved labeling for the drugs they most commonly prescribe, then taking a short online test on the label’s content. PDR Network hosts the CME programs, and The Doctors Company provides the CME credits to all U.S. physicians at no charge.

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Public Health

Step

The Decade of Pain Control and Research

Let’s understand how we got to this predicament. You have been trained and pushed to treat pain. You are criticized if you don’t. • 1997: The American Academy of Pain Medicine and the American Pain Society teamed up to develop guidelines for opioid use in chronic pain. • 2001: The 10 years beginning Jan. 1, 2001, was declared the Decade of Pain Control and Research by Congress and President Clinton, and the Joint Commission presented pain management standards. • 2002: California passed AB 487, establishing a task force that developed guidelines for all patients with pain. • 2005: California eliminated triplicate prescriptions and created a change to tamper-resistant forms. This is when we started writing for Percocet; before, we couldn’t do so without a triplicate.

Physicians Need Drug Rehab

Before We Can Lead Our Nation Into Recovery by Roneet Lev, MD, FACEP

re you ever fatigued by your patients demands’ for drugs? Patient: “I need OxyContin 80mg 100 tablets”; “My previous doctor always gave this to me”; “My prescription was stolen”; “I dropped some tablets, and that’s why I am out early.” You: “OK, 60 tablets, my final offer, but no more refills for 30 days.” Sometimes, after a long and expensive work-up — labs, CTs, X-rays — you find out the real reason the patient came in was for the Percocet prescription. “Oh Doc, can you make that Percocet? Vicodins don’t work for me.” This aspect of medicine is exhausting and unsatisfying, and it seems that there are more and more such patients. In fact, there are more patients like this. The CDC has declared the prescription drug abuse problem an epidemic. Sadly, we — the physicians and medical community — contribute to the epidemic. We helped create it, and now we need to get some drug rehab before we can lead our nation to recovery. First say: “I am a doctor, and I have contributed to the epidemic of prescription drug abuse.” Now let’s go through the 12-step program for recovery. 10 SAN DIEGO PHYSICIAN.org j u n e 2012

Step

The Number of Pills out There

The CDC quotes a 10-fold increase in the number of opioid prescriptions in the past 10 years. The Decade of Pain Control and Research is followed by a decade of prescription addiction. • From 1997 to 2007, the mg per person of opioids increased 402%, from 74 to 369. • In 2009 retail pharmacies sold 257 million prescriptions for opioids, compared to 174 million in 2000 — a 48% increase. • California sold 6.2kg of prescription pain killers per 10,000 people in 2011 — a statistic that’s highest in Florida (12.6) and lowest in Illinois (3.7). • Americans are 4.6% of the world population and consume 80% of the global opioid supply, 99% of the hydrocodone supply, and two-thirds of the world’s illegal drugs.

Step

The Misuse and Abuse of Pills

We demanded more pain management, and with that came more pills and more abuse. Who needs cocaine and heroin when you can get oxycodone? • Prescription medications are the second most abused drug, after marijuana.

• In 2009 more than 16 million Americans reported using prescription medications such as painkillers, tranquilizers, or stimulants for nonmedical purposes. • One-third of people age 12 and older who use drugs illegally began with prescription drugs for nonmedical use. • 2.7% of 8th graders, 7.7% of 10th graders, and 8% of 12th graders have abused Vicodin for nonmedical purposes in the past year. The numbers are slightly less for OxyContin.

Step

The ED Visits

“All the world’s a stage,” and those in the ED have a front seat. Society’s problems are reflected in our patient population. • In 2009 there were 2.1 million ED visits attributed to drug misuse and abuse, according to the DAWN Report (Drug Abuse Warning Network). • Prescription painkiller misuse and abuse resulted in 475,000 ED visits in 2009, a number that has doubled in the past five years.

Step

Deaths

When you are writing a prescription for Vicodin or Percocet for the chronic or addicted pain patient, ask yourself if you are contributing to the epidemic of prescription drug abuse. Have any of your prescriptions resulted in someone’s untimely demise? • Opioid overdose is now the second leading cause of unintentional deaths in the United States, second only to motor vehicle collisions. • In San Diego the number of deaths from all overdoses exceeds the number of deaths from motor vehicle collisions and is second only to heart disease. • 2008 data reflects 36,450 drug overdoses nationwide, with 14,800 from opioid pain relievers and 20,044 from other prescriptions. • There are 100 drug overdose deaths a day nationwide, a number that has tripled since 1990. • Deaths related to opioid analgesics are 1.93 times more than that of cocaine and 5.38 times the number for heroin. • California had 10.4 drug overdose deaths per 100,000 in 2008 — a statistic that was highest in New Mexico (27) and

lowest in Nebraska (5.5). • For every death there are 32 ED visits, 130 people who abuse or are dependent, and 825 people who are nonmedical users.

Step

Pills Come From Doctors

Your patient does not always use the prescriptions you write. Some pills get shared or sold. When a patient comes back for refills, make sure that your patient did not run out before the appropriate time. Don’t forget that Motrin and Tylenol are good analgesics, especially for people who have not developed a narcotic tolerance. You should develop a pain contract for your patients in chronic pain. They should not be going to other clinics or to the ED for refills. If you suspect a patient has an addiction, refer them to drug counseling. San Diego has several programs. • Most prescribers of pain medications are primary care physicians, followed by internists, dentists, and orthopedic surgeons. • For those aged 10–19, dentists write for the most narcotics, followed by primary care and emergency physicians. • People who abuse prescription drugs say they get them from their friends (55%) or from their doctor (17.3%), purchase them from friends or relatives (11.4%), steal them (4.8%), or buy them from strangers (4.4%).

Step

Recognize Patients at Risk

Always do your full history and physical, and don’t cut corners in your medical decision making. Don’t jump to conclusions and label someone a drug seeker before having your facts straight and ruling out objective disease. We all know about the case of the repeat back pain patient who ends up having an epidural abscess or the headache patient who has a bleed. However, after doing your medical assessment, you can recognize patients who are at risk for addiction and abuse. The CDC lists them as: 1. The Doctor Shopper: The patient who is getting multiple prescriptions from multiple providers. 2. The High Dose User and Multiple Drug User 3. Low Income and Rural Area: In a study in Washington State, 45% of deaths

from prescription drugs were people on Medicaid. Rural counties have twice as many deaths as big cities. 4. More men than women die from overdoses, and more middle-aged adults. 5. American Indians and Alaskan Natives have the highest death rate at 1:10 compared to Whites at 1:20 and Blacks at 1:30. The California DEA website identifies the following red flags for suspicion of drug abuse and fraud: 1. Patient requesting specific controlled substances 2. Repeatedly running out of medication early 3. Unscheduled refills requested 4. Unwillingness to try nonopioid treatments 5. Engaging in doctor shopping activities 6. Complaining of medical condition with lack of pathology

Step

Government Response

Step

Understanding Chronic Pain Treatment

With a declaration of an epidemic, the Drug Enforcement Agency and Health and Human Services department have developed a coordinated federal plan to deal with the growing problem of prescription drug abuse, and recognized that physician prescribing is part of the problem. The CDC lists five recommendations: 1. Prescription drug monitoring programs 2. Patient review and restriction programs 3. Healthcare provider accountability 4. Law to prevent prescription drug abuse and diversion 5. Better access to substance abuse treatment

According to the American Pain Society, opioids alone are rarely effective in the treatment of chronic pain. Opioids can be ineffective and unsafe, and may lead to addiction or abuse. Treatment of chronic pain requires a multidisciplinary approach including a combination of medications, stress management, relaxation, exercise, physical therapy, massage, and other modalities. It is also rare to obtain more than 50% reduction of chronic pain j u n e 2012 SAN DIEGO PHYSICIAN.org 11

Public Health with narcotics. It is likely that the patient in the ED with chronic pain is violating their pain contract with their doctor or clinic.

Step

California Response

California has developed its own prescription drug-monitoring program called CURES (Controlled Substance Utilization Review and Evaluation System). It was under threat for loss of funding, but it is up and running in 2012. When you complete an application, you’re only a few clicks away from seeing prescription patterns for your patients. Look at the different names of providers, and the number and dates of prescriptions. Sometimes you will find different listed addresses. It makes it very easy to spot the doctor shopper or a dishonest patient. Ask your patient: “When did you get your last prescription?” If they tell you not for many months, but indeed had one filled a week ago, they are committing a federal crime. You are not the police, but you can fight crime by documenting in your medical record a good medication history and time the patient said they received their most recent prescription. CURES is not perfect. It does not include VA patients or government patients. It also lags in time, so at best you will see prescriptions within the last two weeks. However, it is a tool to be used for optimal prescribing judgment. If a DEA agent calls you about a patient you saw, do not be alarmed. You do not need to call your lawyer or malpractice carrier. You are not under investigation. You are being called as a witness or victim for a patient who may have tricked you into writing a prescription used for abuse. It will take five or 10 minutes of your time to say, “Yes, I wrote this prescription,” and “No, I would not have written it if I knew that he already had five other prescriptions recently,” or “Yes, that was a legitimate indication for that prescription.” Be helpful to these agents. The people they arrest or fine are forced into drug treatment programs, and many are thankful in the long run.

Step

Regional Efforts

There have been communitywide efforts in limiting prescription drug abuse from emergency departments. The Cherry Hill Emergency Department in Seattle developed “The 12 SAN DIEGO PHYSICIAN.org j u n e 2012

Americans are 4.6% of the world population and consume 80% of the global opioid supply, 99% of the hydrocodone supply, and twothirds of the world’s illegal drugs.

Oxy Free ED.” Its physicians do not prescribe Schedule II controlled substances to any patient with a chronic pain condition. They require a government issued photo ID or photograph all patients who receive narcotic prescriptions. In San Diego, the SDCMS Emergency Medicine Oversight Commission (EMOC) has developed a different Narcotic Prescription Guideline. It has been distributed to each ED and is posted on their websites. The guideline also includes a phone contact and email to the local DEA agent if narcotic fraud is suspected. The San Diego DEA agency has presented informative lectures about the prescription drug problem with a local perspective. These guidelines state the following: 1. Patients who have established chronic pain conditions and have a medical home should not receive narcotic prescriptions from the emergency department, and are encouraged to obtain new prescriptions or refills by their physician or clinic. 2. Patients who received a recent prescription for narcotics as determined by the hospital’s medical records, health plan records, or CURES database should not receive repeat narcotic prescriptions from the emergency department for the same medical condition. Repeat prescriptions should be obtained by their medical follow-up physicians or clinic.

Step

Individual Effort — Learn to Say No

It is not easy to say no to patients. It is much easier and much faster to say, “Here are your 20 Vicodins,” and move on to the next patient. If you do this, you are called the “Candy Man.” Patients learn who you are and seek you out. “Is Dr. Jones working today?” Emergency departments that prescribe this way while the hospital next door develops a narcotics guideline policy are known as “Candy Land.” Learning how to say no or having a seri-

ous discussion with your patients does not come naturally to us. This is the toughest part of physician rehab. But you can do it. Learn some of the following sentences. • “When you have a chronic pain condition, your prescriptions need to be regulated and coordinated by a single clinic or doctor. You are not due for more prescriptions, but we are certainly able to help your pain today.” • “I reviewed your CURES report and see that you have broken our pain agreement. I cannot give you any further prescriptions, but I will give you referrals for addiction treatment.” • “It is not good medical care to have your condition treated by different doctors and clinics.” • “The DEA tracks all narcotic prescriptions. I can get in trouble for writing such prescriptions.” • “I see that you were just given prescription for (name medication) on (state all dates). The DEA regulates these medications. Unfortunately, I cannot write any further narcotic prescriptions.” • If you find yourself getting into a big confrontation with a patient regarding a prescription you do not feel is indicated, just give in and write for five tablets. You can then phone or email your local DEA office and report possible prescription fraud. They will take it from there. Now you can join your proud colleagues who can say they are one month clean and sober from untimely prescription refills for chronic pain. Dr. Lev, SDCMS-CMA member since 1996, is the current director of operations for the Scripps Mercy Hospital Emergency Department, current chair of the SDCMS Emergency Medicine Oversight Commission (EMOC), and past president of the California chapter of the American College of Emergency Physicians (CAL/ACEP). References: • San Diego SDCMS EMOC: www.sdcms. org/san-diego-county-emergency-medicaloversight-commission/san-diego-countyemergency-medical-oversight • Physician Scripting for Narcotic Prescriptions: Contact CAL/ACEP • National Institute on Drug Abuse: www. drugabuse.gov • Centers for Disease Control: www.cdc.gov/ homeandrecreationalsafety/rxbrief

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t e o i B 14 SAN DIEGO PHYSICIAN.org j u n e 2012

s c i h t Merriam-Webster: The discipline dealing with the ethical implications of biological research and applications, especially in medicine. Oxford English Dictionary: The discipline dealing with ethical issues relating to the practice of medicine and biology or arising from advances in these subjects. Also: the ethical issues themselves. • 1970: Van R. Potter in Perspectives Med. & Biol. 14 128. I propose the term ‘bioethics’ in order to emphasize the two most important ingredients in achieving the new wisdom that is so desperately needed: biological knowledge and human values.

• 1977: Ann. Royal College Physicians & Surgeons of Canada 10 130/1. Because of its strong component of moral and religious values, bioethics is a delicate and difficult subject. • 1978: Observer 30 July 9/3. The first successful completion of a pregnancy begun in the laboratory does raise some interesting issues. They fall into that area of debate which the Americans call … ‘bio-ethics’. • 1989: Mod. Maturity Aug.–Sept. 74/1. The doctrine of informed consent is well established in law and bio-ethics. • 2005: R. J. Sawyer Mindscan xxix. 210. Drawing the line between personhood and nonpersonhood has represented one of the greatest challenges in bioethics.

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Bioethics

The San Diego County Medical Society Bioethics Commission

16 SAN DIEGO PHYSICIAN.org j u n e 2012

A Brief History By Paula Goodman-Crews, LCSW, and Mitsuo Tomita, MD

e looked at the familiar faces around the packed room during our quarterly SDCMS Bioethics Commission meeting on April 25 and felt heartened as we listened to their passionate and respectful dialogue. The subject matter — “Ethical Issues Related to Praying With Patients” — evoked a diversity of reactions and opinions framed through an ethical lens. Is physicianinitiated prayer an ethically defensible practice? What should be done with patients’ requests for prayer if the provider does not believe in prayer at all? If patients are given the option of prayer with a provider, will those who reject prayer be likely to wonder how this will affect the rest of their care? Could this be construed as a form of coercion? How can physicians promote the spiritual good of the patient, in general?

These ethical questions and others are addressed on a regular basis by the members of SDCMS’ Bioethics Commission. The Commission’s open membership boasts representatives interested in bioethics from all of the major San Diego County hospitals, including Children’s, Balboa Naval, VA, UCSD, Kaiser Permanente, Palomar, Sharp, Grossmont, Scripps Mercy, Scripps Green, Scripps La Jolla, and Edgemoor. Representatives from the hospices in San Diego County and other longterm facilities, bioethics scholars, nursing and medical students from surrounding schools all attend. The group is multidisciplinary, and — in addition to physicians — nurses, social workers, psychologists, lawyers, and chaplains are in attendance. In short, any professional interested in the practice of bioethics is invited to attend these meetings. In 2007, Lynette Cederquist, MD, SDCMS-CMA member since 2005, and Paula Goodman-Crews co-founded the SDCMS Bioethics Commission under the gracious auspices of the San Diego County Medical Society, recognizing the need to coalesce a “moral community.” As defined by the Markkula Center for Applied Ethics, “Moral community refers to the network of those to whom we recognize an ethical connection through the demands of justice, the bonds of compassion, or a sense of obligation.” The primary “end of medicine” is to promote the good of the patient. Ethical conflict, uncertainty, or distress can occur when “the good of the patient” is defined differently, and when there are seemingly equal but competing ethical obligations. Professionals who work within medical domains such as end-of-life and beginningof-life care are faced with ethical questions on a daily basis — many of which have limited or no substantive norms and variable standards of practice. After Dr. Cederquist and Ms. Goodman-Crews conducted a survey of hospital bioethics committee chairs, it became evident that our healthcare providers were seeking community. Thus, our SDCMS Bioethics Commission charter goals were straightforward. We endeavored to create a forum for San Diego County physicians and allied health professionals for: • the discussion of bioethics issues

• the sharing of bioethics best practices • the development of nonbinding bioethics standards for San Diego County • communications to, for, and from physicians and allied health professionals in matters of bioethics • the education on bioethics matters Since its inception, the SDCMS Bioethics Commission, in addition to sponsoring quarterly meetings, created a model draft nonbeneficial treatment policy, a reflection of a San Diego County community standard of practice. This model policy has been shared in most local hospitals and was used as one of several model policies by the California Medical Association in the creation last summer of its model policy, “Responding to Requests for Nonbeneficial Treatment.” In addition, the SDCMS Bioethics Commission was awarded two twoyear POLST Community Coalition Grants by the California Health Care Foundation under the auspices of the Coalition for Compassionate Care of California. Members of the SDCMS Bioethics Commission have proffered tremendous time and energy offering advance care planning/POLST outreach, and engagement, training, and educational seminars to hospitals, skilled nursing facilities, hospices, long-term care custodial facilities, assisted-living and retirement homes. After serving three years as physician co-chair, Dr. Cederquist passed the leadership helm to Mitsuo Tomita, MD, retired SDCMS-CMA member physician, who remains passionate about the good of the patient. Under Dr. Tomita’s leadership, we are seeking increased engagement with the community at large about ethical issues like organ donation, pandemic planning, and advance-care planning. Any physician interested in attending an SDCMS Bioethics Commission meeting is welcomed. Please direct requests to Kyle Lewis at the San Diego County Medical Society at KLewis@SDCMS.org. Ms. Goodman-Crews is bioethics director at Kaiser Permanente, and co-chair of the SDCMS Bioethics Commission. Dr. Tomita, retired SDCMS-CMA member, is board-certified in family medicine and co-chair of the SDCMS Bioethics Commission.

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Bioethics

18 SAN DIEGO PHYSICIAN.org j u n e 2012

The Surrogate Who Demands ‘Everything Be Done’ Counter to THE Patient’s Prior Wishes Ethics Case

By Lynette C. Cederquist, MD

63-year-old man with a history of multiple medical problems, including early dementia, seizure disorder, hypothyroidism, and alcoholism, is admitted to the hospital with acute respiratory failure requiring intubation in the field by paramedics. He has now been in the ICU on the ventilator for eight days with the diagnosis of MRSA pneumonia. On previous hospital admissions, he had been deemed DNAR/DNI per his stated wishes. »

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The patient’s baseline mental status is that he is alert to self and conversant. Upon this admission, the admitting team was informed that the patient’s sister, who is acting as his surrogate, had “made him” a “full code/full care” once he returned to the SNF. There was no completed advance directive designating her as DPOA for healthcare, but she is his only remaining family member. The social worker at the SNF reported that she, the social worker, did not feel the patient had sufficient decisional capacity to complete a POLST (Physician’s Orders for Life Sustaining Treatment) form. She also reported that the patient’s sister never visited him at the SNF. One of the treating physicians who had cared for the patient during his previous admission reported that he had informed her (the physician) that he wished to be DNAR because he hated being in hospitals and did not wish to have his life extended if his heart stopped. Upon this admission, the admitting physician had contacted the patient’s sister by phone, at which time the sister again insisted that the patient continue to be “full code full treatment.”

Subsequently, the treating team had tried repeatedly to contact the patient’s sister, but she did not return calls, and she never visited him in the hospital. The treating team felt they were treating him overaggressively, going against his previously stated wishes. An ethics consultation was requested. This Case Involved Several Ethically Challenging Components 1. If the patient now lacks decision-making capacity but previously refused aggressive life-sustaining treatment, on what basis would the physicians now proceed with life-sustaining treatment? If the patient previously had decision-making capacity and had consistently refused treatment, then, as long as the circumstances are not significantly different, the patient’s prior wishes should still be honored. 2. What if the patient now lacks decisionmaking capacity but is refusing treatment? Ethical and legal guidelines are generally lacking. When treating such a patient, one must weigh risk of treatment vs. the risks of not treating. In general, if a treatment

is a one-time event (such as surgical repair of a fracture), and risks are low, with a high probability of benefit, one could ethically justify proceeding with treatment despite the patient’s refusal. Treatment that is ongoing and requires patient cooperation (such as a prolonged course of chemotherapy, radiation treatments, or dialysis), while still perhaps ethically defensible, is often not feasible if such treatment requires physically restraining a patient. This potentially exposes the patient and the treating staff to risk of harm, and starts to look more like battery. In these cases, it is important to involve the ethics consult service and perhaps risk management. 3. If the sister does not make herself available for discussions regarding the patient’s treatment, does she still qualify to act as his surrogate, or is he now an unrepresented patient? Physicians often feel trapped when a family member initially insists that “everything be done,” then disappears or avoids any further discussions with the physicians. Ethically and legally, part of the definition of acting as DPOA or surrogate includes the stipulation that

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the person must be willing and reasonably available to provide substituted judgment (1). In this case, since the patient’s sister did not make herself available to meet with the doctors, she should no longer have been considered to be his surrogate. This patient would then be considered an unrepresented or “unbefriended” patient. Treatment of the unrepresented patient is not addressed in California healthcare law. The California Hospital Association has a model policy after which many hospitals model their own policies (2). This policy designates the treating team, in conjunction with the ethics consultant, to act as surrogate decision maker for nonemergent treatment. Treatment decisions should be made according to the best interest standards — any treatment that would be deemed to be in the best interest of the patient and in accordance with the patient’s wishes and values, to the extent that they are known. In this particular case, the patient’s previously stated wishes and values were known. 4. On what basis is the sister in this case making decisions regarding the patient’s

treatment, and is she representing his best wishes and values? Family members or surrogates are not supposed to make decisions based on what they want; they are supposed to act in substituted judgment representing what the patient would want done. We often don’t know with certainty the basis for family members’ requests for overly aggressive treatment, even when the physician believes continued treatment is nonbeneficial or futile. In many cases, the family member is acting out of feelings of guilt or grief. Occasionally, there can be secondary gains, such as the patient’s pension or other financial gain. In this case, the sister never relayed having any conversations with her brother that led her to believe he would want aggressive treatment, and she did not appear to have a very close relationship with him, so her motives for demanding such treatment were unknown. Physicians frequently make the mistake of asking a surrogate, “What do you want us to do?” Alternatively, they should be asking, “If your loved one could talk to us now, what do you believe he/she would tell us?” This can often result in a differ-

ent response. Reframing the conversation in this way can also reduce the amount of guilt such decisions can provoke, as nobody wants to feel like they were the one to say they wanted to limit or stop treatment. In this case, the ethics consultant also tried unsuccessfully to contact the sister. The treating physicians were advised that they should proceed with treating this patient as an unrepresented patient. They subsequently did change his code status to “DNAR” based on his previously documented statements. Fortunately, the patient was successfully extubated and transferred back to his skilled nursing facility. Dr. Cederquist, SDCMS-CMA member since 2005, has been a full-time faculty member at UCSD Internal Medicine since 1994, with a focus in chronic pain management and palliative care. She is also chair of UCSD’s Ethics Committee and director of the ethics consult service. References: 1. CA Probate Code 4711-4717 2. California Hospital Association Model Policy for Acute Care Hospitals. Health Care Decisions for Unrepresented Patients.

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Bioethics

Informed Consent and Patient Autonomy Giving the Patient the Opportunity to Be an Informed Participant in Healthcare Decisions By Nancy L. Vaughan, Esq.

n 1847, the American Medical Association’s (AMA) Canons of Ethics warned that physicians should not deliver bad news to patients. It was believed that telling a patient about a bad prognosis might appear to magnify the doctor’s role in caring for the patient. A physician was the “minister of hope and comfort to the sick,” and his role was to “smooth the bed of death, revive expiring life, and counteract the depressing influences of those maladies …” (1).

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Today the AMA’s Canons of Ethics instruct that physicians “shall” respect the rights of patients, “safeguard their confidences and privacy,” … and make relevant information available to patients. This reflects the change in attitude by Western society toward patient autonomy from a traditionally paternalistic practice of medicine (2). One of the earliest legal decisions to set forth the principle of patient autonomy was written in 1914 by Justice Benjamin Cardozo, in Schloendorff v. Society of New York Hospital. Justice Cardozo wrote, “Every human being of adult years and sound mind has a right to determine what shall be done with his own body …” (3). This principle of patient autonomy was not widely respected, however, because of an ongoing belief (now referred to as benevolent deception) that patients would make decisions contrary to their own best interest if they were informed of possible outcomes and complications associated with a particular treatment. This philosophy is reflected in the 1957 case of Salgo v. Leland Stanford Jr. University Board of Trustees, in which the phrase “informed consent” was first used. This California Court of Appeals decision found that a physician could be held liable for failing to provide facts sufficient to allow a patient to make an informed decision about proposed treatment. The court suggested, however, that in order to protect a patient’s well-being, the physician must exercise discretion when deciding what risks to disclose, to keep from alarming an already apprehensive patient who may as a result refuse to undergo surgery (4).

In 1972, the California Supreme Court rendered a decision in Cobbs V. Grant, perhaps the most important case in California regarding the right of a person to make an informed decision to consent to or refuse proposed medical treatment. In this case, the patient was told about the general nature of an operation he was about to undergo, but was not told of any of the risks associated with the procedure. Following surgery, the patient suffered serious complications, requiring multiple hospitalizations and several major surgeries. Dr. Grant was sued by the patient; his own testimony at trial established that he had not disclosed any of the inherent risks of the surgery and that this was consistent with the community standard. The court held that a physician has “a duty of reasonable disclosure of the available choices with respect to proposed therapy and of the dangers inherently and potentially involved in each” (5). As a result of Cobbs V. Grant, California law requires a practitioner to explain “the likelihood of success and the risks of agreeing to a medical procedure in language that the patient can understand.” He must give the patient as much information as is needed to make an informed decision, including any risk that a reasonable person would consider important in deciding to have the proposed treatment or procedure, and any other information skilled practitioners would disclose to the patient under the same or similar circumstances. The patient must always be told about the risk of death, serious injury, or significant potential complications that may occur if the procedure is performed” (6). There are only a few exceptions to these rules. Physician practices vary widely on how compliance with this responsibility is documented. Some don’t document it at all. Some simply give the patient the information verbally and make a chart note that reads “R.B.A. given.” While this may technically document that the physician has given informed consent, it may later make it very difficult for a juror to understand what the discussion included. Thus it is always better to write a detailed chart note about the discussion, and better still to ask the patient to read a document outlining the risks (after a thorough discussion with the physician), initial various paragraphs

acknowledging understanding, and sign the document in front of a witness. Occasionally, a patient’s mental competence to make a decision is not clear. Patients are under an unusual amount of stress during illness, and many experience anxiety, fear, and depression. This stress should not necessarily preclude one from making an informed decision however, and an assessment should be made of the patient’s ability to understand his or her situation, the risks associated with the decision at hand, and to communicate a decision based on that understanding. When competence is not clear, a further analysis of the appropriate next step (an interpreter, a psychiatric consultation, or workup by other specialist) can be helpful. Keep in mind that a patient’s refusal of treatment does not mean the patient is incompetent. Competent patients have the right to refuse treatment, even those treatments that may be lifesaving. Informed consent is about patient autonomy, with the goal of giving the patient the opportunity to be an informed participant in healthcare decisions, regardless of what that decision is. Ms. Vaughan is an attorney who has specialized in healthcare law. She is currently teaching bioethics at California Western School of Law and at Thomas Jefferson School of Law. References: 1. Original Code of Medical Ethics of the American Medical Association, adopted at the adjourned meeting of the National Medical Convention in Philadelphia. May 1847 2. Principles of Medical Ethics, American Medical Association, adopted June 1957; revised June 1980; revised June 2001. 3. Schloendorff v. Society of New York Hospital, 211 N.Y. 215, [1914] 4. Salgo v. Leland Stanford Jr. University Board of Trustees, 154 Cal.App.2d 560 (1957) 5. Cobbs V. Grant, 8 Cal. 3d. 229 (1972) 6. California Civil Jury Instructions (CACI) #532

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Bioethics

A Test of Autonomy The Dax Cowart Case By Marilyn Mitchell, RN, BSN, MAS

n 1973, Donald Cowart was a 26-yearold Air Force pilot in the Reserves visiting his father in Texas. They were surveying some property his father was considering purchasing. Unknown to them, there was a gas leak on the property at the time. As they were leaving, they turned the ignition to their car, which sparked an explosion, engulfing them both in flames. Instinctually, they both screamed in pain. A neighbor came running to their aid. When he arrived, Donald asked the neighbor for a gun so he could shoot himself. He’s been quoted as saying, “Can’t you see I’m a dead man?” The neighbor replied that he was unable to do that and instead got them help.

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Donald’s father died on the way to the hospital, and Donald survived, despite being burned on 65% of his body. Treatment for burn victims was very different in the 1970s, and much of what Donald experienced would be considered torture by today’s standards. Just as treatment wasn’t ideal, pain control was dominated by a fear of creating drug addiction. The combination of treatments that caused excruciating pain along with inadequate medication for pain was too much for Donald to endure. He repeatedly requested that he be allowed to die a natural death. Plus he had been a very active young man and did not want to live as a blind and physically damaged person. The medical team refused to heed his requests for discontinuing treatment. He was evaluated by two different psychologists and found to be mentally competent, yet his continued requests were ignored. After more than a year of treatment, he was discharged and began a new life. He changed his first name from Donald to Dax. He completed a law degree from Texas Tech University in 1986 and successfully sued the oil company responsible for the gas leak that led to his condition. He also continues to speak out publicly for the rights of individuals to accept or refuse medical treatment.

In his own words, “No one has the right to force other kinds of medical treatment upon you without your consent. There is no legitimate law, there is no legitimate authority, there is no legitimate power anywhere on the face of this earth that can take the right away from a mentally competent human being and give it to a state, to a federal government, or to any other person.” Fundamental to his case is the concept of autonomy and each person’s right to make his or her own decisions. His case illustrates the challenge the medical community may have in allowing a patient to make a decision they do not agree with or the patient’s right to make a decision that could be considered mistaken. It’s tempting to believe that if someone does not agree with standard medical treatment, they must be wrong. You may consider cases you have encountered where a person requested not to be treated and later changed their mind after undergoing treatment. They may even express gratitude that their requests were ignored. Those experiences make this kind of case extremely difficult for the medical team. In general, there are instances where the medical team would be right to ignore a competent patient’s requests. Those instances include when a patient requests assisted suicide (except in Oregon, Washington, and Montana), if a patient requests willful self-injury (such as an unnecessary amputation of a healthy limb), if a patient requests medically unnecessary treatment, if a patient requests a medication or treatment that is prohibited by law, or if a patient requests to be included in a medical experiment since there is no right to participate in research and often research protocols are very specific. On the other hand, though, everyone does have a right to refuse treatment, and it has been well established through numerous cases. In the case of Bouvia v. Superior Court in 1986 in California, it was ruled that a competent adult could refuse tube feeding, even if the person did not have a terminal illness. The right to accept or refuse treatment is intertwined with the process of informed

consent. The reason I call it “the process of informed consent” is that there is more to it than asking a patient to sign a document. Patients can and do file malpractice claims if they believe they did not receive adequate informed consent. Patients need to be informed, in language that they understand, of the risks, benefits, and alternatives to treatments, and they need to be given an opportunity to confirm their understanding prior to the treatment. The process needs to be done honestly, with no effort to coerce them, for it to be valid. Perhaps Dax would have consented to treatment if there had been an agreement to manage his pain more adequately. Dax has gone on to lead a life that by his own admission is happy. He is married and financially secure. Yet he continues to speak on the topic of patient’s rights. When asked if he would still want the freedom to die back during those days after his accident, even though he has gone on to lead a happy life, he always says yes. He has said, “Another individual may well make a different decision. That’s the beauty of freedom.” Ms. Mitchell has been an RN for nearly 32 years and received her master of advanced studies in health law degree from UCSD/California Western School of Law in 2009. She works for Kaiser Permanente in the Department of Service Quality. References: • to a video where he speaks about his case: http://www.youtube.com/ watch?v=lSsu6HkguV8 • Problems in Health Care Law, R.D. Miller, Jones & Bartlett Publishers, 2006 • Intervention and Reflection: Basic Issues in Medical Ethics, Thomson Wadsworth, 2004

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Bioethics

26 SAN DIEGO PHYSICIAN.org j u n e 2012

Global Health Ethics

A Response to ‘Total Pain’ By Katherine Irene Pettus, PhD

Question: How are the following three sets of facts related?

• Americans account for 4.6% of the world’s population but consume approximately 80% of the world’s opioid supply, 99% of the world’s supply of hydrocodone, and roughly two-thirds of the world’s illegal drugs. The mainstream media and the medical journals proclaim an “epidemic” of prescription drug abuse, death from overdoses, and painkiller addiction. • Yet, the Institute of Medicine’s 2011 report on pain in America estimates that 116 million Americans suffer from chronic, untreated pain that persists for weeks to years, with total financial costs of $560–$635 billion per year in direct medical costs and lost wages, at an annual price tag of $100 billion to state and federal budgets. The IOM calls this a “public health crisis.” • Furthermore, the World Health Organization (WHO) estimates that 5 billion people live in countries with little or no access to controlled medicines, and »

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have no or insufficient access to treatment for moderate to severe pain. This includes people with late-stage cancer and AIDS. For other causes of lingering pain — burns, car accidents, gunshots, diabetic nerve damage, sickle-cell disease, and so on — it issues no estimates but believes that millions go untreated. Bonus points for readers who know how San Diego County physicians are helping to solve the world “crisis of pain.” The three sets of facts are related in that, together, they represent a global scenario of “total pain.” Global health ethics can frame an appropriate response to this scenario. In what follows, I will briefly define both concepts. Modern hospice and palliative care pioneer Dr. Cicely Saunders was trained as a social worker, nurse, and physician. She was also a person of deep faith. Dr. Saunders’ concept of total pain […] saw pain as a key to unlocking other problems and as something requiring multiple interventions for its resolution. Thus was formulated the idea of total pain as incorporating physical, psychological, social,

emotional, and spiritual elements. Crucially, total pain was tied to a sense of narrative and biography, emphasizing the importance of listening to the patient’s story and of understanding the experience of suffering in a multifaceted way. (1) Understanding global suffering in a multifaceted way requires listening to the voices of those in pain, rather than marginalizing them or repressing them. Such an approach is beneficent and amplifies autonomy. While access to opioid analgesics is essential to good medical practice, and opioids are the only remedy for some kinds of severe physical pain, Dr. Saunders acknowledged that the multifaceted sense of “total pain” could not be relieved solely through analgesics. Addiction to painkillers, for example, and the widespread fear of opioid addiction among medical practitioners and patients, para-

doxically generates its own dimensions of lethal pain. Certainly, the greatest happiness is not correlated with the greatest consumption of painkillers: Americans may be “awash in opioids,” according to one analyst, but the United States ranks only 14th in the Gallup World Happiness Poll (2). As Dr. Saunders said, “Mental distress may be perhaps the most intractable pain of all.” What can the “narrative and biography” of the American people reveal about the so-called “epidemic” of painkiller abuse? How is that narrative connected to the fact that opioids are unavailable for medical use throughout most of the world? To discern the answer to this complex question, Saunders directs us to listen to the patient’s

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(our) (his)story. Physicians have the model at hand: Listening in order to clarify goals of care is the cornerstone of ethical medical practice. Such listening (rather than simply talking) is also a core practice of democratic citizenship. “The branches of your intelligence grow new leaves in the wind of this listening.” — Rumi The concepts of total pain and global health ethics both have sufficient scope to frame the three sets of facts cited at the beginning of the article. They can unlock the (global) problems of untreated suffering that require multiple interventions. According to Solomon Benatar, emeritus professor of medicine and founding director of the University of Cape Town Bioethics Centre, “The domain of global health ethics provides a context within which the many relevant disciplines that have valuable insights to offer can usefully engage, and through that engagement promote, better understanding of the extensive changes that are needed” (3).

Global health ethics is more than the sum of its individual national parts: Its discourse acknowledges and calls out the local deficits of autonomy, beneficence, and justice that allow suffering to metastasize on a global scale. The inverse of those deficits is embodied in those collaborative educational and public health responses oriented toward distributive justice conceived as the equitable distribution of pain relief. Moving from the abstract to the concrete: A new series of documentary films at www.treatthepain.com (the Global Access to Pain Relief Initiative) provides an accessible and compelling entry point into the larger conversation. Other resources include organizations such as the International Association for Hospice and Palliative Care (www.hospicecare.org) and the Pain Policy Studies Group (www.painpolicy.wisc.edu), a WHO collaborative at the University of Wisconsin. PPSG conducts and distributes careful, evidence-based studies, provides trainings and fellowships for practitioners, and even publishes a regular blog on pain issues.

The answer to the bonus question is: The Institute for Palliative Medicine in San Diego trains U.S. medical students, pharmacists, nurses, and physicians in palliative care, and trains international palliative care physicians to access and promote pain relief in their home countries through its fellowship program and leadership development initiative. Dr. Pettus (political theory, Columbia University) is a new member of the SDCMS Bioethics Commission and is writing a book on palliative care and public policy for SUNY Press (forthcoming 2013). She can be reached at kpettus@ucsd.edu or at (858) 775-0429. References: 1. Clark, David PhD (2000) “Total Pain: The Work of Cicely Saunders and the Hospice Movement” APS Bulletin • Volume 10, No. 4. 2. www.forbes.com/2010/07/14/world-happiest-countries-lifestyle-realestate-galluptable.html 3. Benatar, Solomon and Gillian Brock (2011) Global Health and Global Health Ethics Cambridge University Press

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Bioethics

The Integration Model Trifecta Good Medicine, Good Bioethics, and Good Palliative Care ByLondon Carrasca, MPH, RN “The task of medicine is to cure sometimes, to relieve often, and to comfort always.” — Attribution to French Surgeon Ambroise Pare (16th Century)

n this article, I wish to explore the underlying concepts that the above epigraph addresses and how it is (or isn’t) incorporated into our current healthcare paradigm. I hope to provide ideas for bioethics education and dialogue that we as healthcare providers can implement to foster change in our healthcare culture and community.

30 SAN DIEGO PHYSICIAN.org j u n e 2012

We seem to have become a society of technologists and at times have lost sight of the goals of medicine and the lost art of healing. The role of the humanistic healthcare professional (with all the responsibilities that include difficult and time-consuming conversations that encompass a wide range of topics, from antibiotic prescribing to end-of-life discussions) has been replaced by the role of the technologist (expensive utilization of high technology and aggressive treatments, but not always better quality of life and functional capacity outcomes, and with harm attached to them). As noted above, the bioethical duty of the healthcare professional is to cure sometimes, to relieve often, and to comfort always, while addressing the goals of medical treatment, benefit vs. harm (burden), and benefit vs. effect of potential medical treatment options. Factors to be considered are the relief of suffering, the preservation or restoration of functioning, and the quality as well as the extent of life sustained (Jonsen et al, 2002). The obligation to alleviate pain, suffering, and disability is as serious as an obligation to save an endangered life (Jonsen et al, 2002). Throughout this process, respect for and dignity of the patient should be held in high regard, and informed consent should be provided to the patient and/or legally recognized surrogate decision maker(s). One important qualification is that physicians are not obligated to offer nonbeneficial medical treatment (supported by the American Medical Association, California Probate Code, California Medical Association, and SDCMS Bioethics Commission). Indeed, the Patient Self-determination Act gives the patient the right to refuse, but not demand, treatment. The goals of medicine (curative vs. palliative or concurrent focus) should be addressed in a thoughtful manner [including considerations regarding realistic and attainable goals; time-limited trials; shared decision-making with the patient and/or surrogate decision maker(s) and exploration of influencing worldviews; prognostication; framing conversations and collaborative approach of the treating healthcare team].

The physician also has a “systems ethics” responsibility to the healthcare team (not lone decision maker in the process) and a duty to recognize the impact on other physicians, healthcare providers, and the healthcare system. There should be collaboration and coordination with other stakeholders who are involved in the patient’s medical treatment, and they should be included in the decision-making process. To help address these difficult and challenging bioethical issues and dilemmas, healthcare bioethics committees and community bioethics forums may be utilized to promote bioethics education and dialogue regarding these important issues and health policy debates. A healthcare bioethics committee is an advisory group that provides a forum for structured interdisciplinary review and discussion of medical, bioethical, spiritual, and legal considerations for patients, families, and healthcare providers. Community bioethics forums may provide bioethics education to community members via collaboration with healthcare institution bioethics committee members; members of the bioethics community at large; members of the educational community; healthcare students/residents; and members of the nonhealthcare community public. It involves a great deal of time, effort, and resources to build a foundation for this bioethics education and to form networking to expand the reach and breadth of the bioethics community to be able to continue on this educational journey of sharing knowledge and learning from others. Many communities lack the resources to provide any type of comprehensive bioethics education. I believe it is time to look at healthcare organization and community culture, policies, and practices to identify, assess, and solve systems issues that lead to complex bioethical issues and dilemmas. This would enable us to address current issues and future directions of bioethics education from

not only a physician perspective but with mixed disciplines, healthcare organization, and community focus to broaden the worldview; as well as encourage dialogue on these issues and promote compassionate and quality patient care. No discipline exists in isolation, so it is important to address issues across the spectrum. There must be coordination and collaboration among disciplines to address these complex bioethical issues with open and transparent processes. In addition, there should be healthcare organization and community support to bring in recognized leaders in the bioethics field for lectures, clinical education, and discussions regarding these important bioethical issues and dilemmas. Some pearls to address complex bioethical issues are communication, collaboration, respect for all members of the healthcare team, transparency of inquiry, education, and lessons learned for change in culture, practice, and policies. Ms. Carrasca is co-chair of Rady Children’s Hospital-San Diego (RCHSD) Bioethics Committee; RCHSD bioethics consultant; community bioethics committee member at two San Diego-area hospitals, and a member of the SDCMS Bioethics Commission.. Resources: • Dunn, H. Hard Choices for Loving People. Available: www.hardchoices.com • Emanuel, EJ, & Emanuel, L. (1992). “Four Models of the Physician-Patient Relationship.” JAMA, April 22/29, 267(16): 221-226. • Emanuel, L, Librach, SL. (2007). Palliative Care: Core Skills and Clinical Competencies. Saunders Elsevier. • Himelstein, BP, et al. (2004). “Pediatric Palliative Care.” NEJM, 350(17): 1752-1762. • Jonsen, AR, et al. (2002, 2010). Clinical Ethics. McGraw Hill. • Lown, B. (1999). The Lost Art of Healing. Ballantine Books. • Lynn, J, et al. (2008). Improving Care for the End of Life. Oxford University Press. • McPhee, SJ, et al. (2011). JAMA Evidence: Care at the Close of Life. McGraw Hill. • Rushton, CH. (2006). “Defining and Addressing Moral Distress.” AACN Advanced Critical Care.

j u n e 2012 SAN DIEGO PHYSICIAN.org 31

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SDCMSF needs your support to care for the medically underserved in our community. Please consider making a contribution of any size to support the Foundation’s efforts. Contributions can be made online at SDCMSF.org or sent to the San Diego County Medical Society Foundation at 5575 Ruffin Road, Suite 250, San Diego, CA 92123. Thank you for your support!

Thank you for your dedication to the medically underserved. If you are interested in any of the opportunities above, please contact Lauren Banfe, resource development director, at (858) 565-7930 or at Lauren.Banfe@SDCMS.org. The San Diego County Medical Society Foundation is a 501(c)3 organization (Tax ID # 95-2568714). Please visit SDCMSF.org for more information. Telephone: (858) 300-2777 or Fax: (858) 569-1334

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classifieds PHYSICIAN POSITIONS AVAILABLE part- or full-time dermatologist: Busy dermatology and cosmetic surgery practice in Encinitas looking for a part- or full-time dermatologist. Will train in cosmetic procedures. Ideal candidate should have excellent leadership and organizational skills and have excellent patient rapport. There is great growth potential with this practice. If interested, please send your letter of interest and CV to dermmd10@gmail.com. [044] MEDICAL DIRECTOR — Sunny San Diego: County Psychiatric Hospital needs a full-time medical director. This is a key leadership role in our very physician-friendly, dynamic behavioral health system. Facility includes an inpatient unit and a very busy psychiatric emergency unit. County has partnered with UCSD to develop a community psychiatry fellowship, and teaching opportunities will be available, though the facility does not do research. Medical director does limited direct clinical care. Required: Proven administrative, leadership, and supervisory skills, and a “big-picture” orientation to help us evolve our entire system. Salary competitive and excellent County employee benefit package. San Diego combines the lifestyle of a resort community and the amenities of a big city. Hospital centrally located, minutes from many recreational opportunities and great residential communities. Wonderful year-round weather, of course! CV and letter of interest can be submitted online at www. sdcounty.ca.gov/hr. For questions, please contact Gloria Brown, human resources analyst, at (858) 505-6525 or at gloria.brown@sdcounty.ca.gov, or Darah Frondarina, human resources specialist, at (858) 505-6534 or at darah.frondarina@sdcounty.ca.gov. Questions and interest can also be directed to Marshall Lewis, MD, Behavioral Health Clinical Director, Health & Human Services Agency, at marshall.lewis@sdcounty.ca.gov. [021] PSYCHIATRIST: San Ysidro Health Center, a Federally Qualified Health Center with nine medical clinics serving southern San Diego, is recruiting for a psychiatrist. Performs psychiatric assessments, medication management, and diagnostic evaluations of assigned mental health patients as ongoing patients or walk-ins. Qualifications: MD degree in medicine. Valid/current/unrestricted California license to practice for at least two years; board eligible/ board certified for adult psychiatry. Minimum one year internship in hospital. Extensive knowledge of local resources, community organizations, and entitlement programs. Bilingual (Spanish/English) preferred but not required. Send resume to euclidjobs@syhc.org. [033] PHYSICIAN ASSISTANT, NURSE PRACTITIONER, OR PART-TIME MEDICAL DOCTOR: Established and busy pain management practice in Mission Valley is looking for a physician assistant, nurse practitioner, or part-time medical doctor, preferably experienced in pain management or family practice. Knowledge of controlled substance prescriptions and regulations is required. Interpretation of diagnostic tests and the ability to apply skills involved in interdisciplinary pain management is necessary. We offer a competitive salary and benefit package that provides malpractice coverage, CME allowance, as well as an excellent professional growth potential. Please email your curriculum vitae/resume to sdpainclinic@yahoo.com. [39a] PRIMARY CARE/PSYCHIATRY JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com ) is a fastgrowing group of house-call doctors. Great pay ($140– $220+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. [037] PHYSICIANS WANTED: Vista Community Clinic, a private, nonprofit clinic serving the communities of North San Diego County, has openings for part-time and per-diem positions. Five locations in Vista and Oceanside. Family medicine, OB/GYN medicine, pediatric medicine. Requirements: California license, DEA license, CPR, board certified, one (1) year post-graduate clinic experience. Bi-

lingual English / Spanish preferred. Benefits: malpractice coverage. Email resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. Visit website at www.vistacommunityclinic.org. EOE/M/F/D/V [035] CLINICAL RESEARCH PHYSICIAN: Profil Institute for Clinical Research needs a clinical research physician. Requirements: Three years MD experience in clinical research, hospital, family practice, or other related clinical environment in adult medicine. Unrestricted California MD license. Responsibilities: Serve as sub-investigator or principal investigator on studies. Perform medical histories, physical exams, admit, discharge, and monitor subjects, including reviewing labs results, EKGs, and telemetry as part of clinical research trials. Assess and manage adverse events and medical emergencies. Interested parties please apply online at profilinstitute. com under “News and Career Opportunities.” If you have further questions, please contact Robyn Nielsen, recruitment manager, at (619) 419-2048. [034] BOARD-CERTIFIED FAMILY PRACTICE PHYSICIAN NEEDED: To cover hours at busy urgent care/family practice office in Carlsbad. Nights and weekend coverage needed. Please Fax CV to (760) 603-7719 or email CV to gcwakeman@sbcglobal.net. [031] PHYSICIAN WANTED: Physician wanted to assume a parttime practice by Paradise Valley Hospital from retiring physician who has been in the area for 35 years. Please email me at bpmedina@msn.com if you are interested. [029] GENERAL SURGEONS NEEDED IN SAN DIEGO: Sharp Rees-Stealy Medical Group, a 400+ physician multi-specialty group in San Diego, is seeking two well-rounded general surgeons to join our group. Competitive firstyear compensation guarantee, excellent benefits and shareholder eligibility after two years. Please send CV and letter of interest to: Lori Miller, 2001 4th Ave., San Diego, CA 92101. Fax: (619) 233-4730. Email: lori.miller@ sharp.com. [023] SEEKING BOARD-CERTIFIED PEDIATRICIAN FOR PERMANENT FOUR-DAYS-PER-WEEK POSITION: Private practice in La Mesa seeks pediatrician four days per week on partnership track. Modern office setting with a reputation for outstanding patient satisfaction and retention for over 15 years. A dedicated triage and education nurse takes routine patient calls off your hands, and team of eight staff provides attentive support allowing you to focus on direct, quality patient care. Clinic is 24–28 patients per eight-hour day, 1-in-3 call is minimal, rounding on newborns, and occasional admission, NO delivery standby or rushing out in the night. Benefits include tail-covered liability insurance, paid holidays/vacation/sick time, professional dues, health and dental insurance, uniforms, CME, budgets, disability and life insurance. Please contact Venk at (619) 504-5830 or at venk@gpeds.sdcoxmail.com. Salary $ 102–108,000 annually (equal to $130–135,000 full-time). [778] PRACTICE WANTED WE BUY URGENT CARE OR READY MED-CLINIC: We are interested in purchasing a preexisting urgent care or ready med-clinic anywhere in San Diego County. Please contact Lyda at (619) 417-9766. [008] OFFICE SPACE / REAL ESTATE

new equipment and furniture. New hardwood floors and exam tables. Full ultrasound lab and tech on site for extra convenience. Will sublease partial suite for two exam rooms and office work area or will consider subleasing the entire suite, totally furnished, if there is a larger group. Plenty of free parking. For More information, call Irene at (619) 840-2400 or (858) 452-0306. [041]

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] SCRIPPS HM POOLE BUILDING OFFICE SPACE AVAILABLE FOR SUBLEASE: One doctor’s office and use of three exam rooms, as well as the use of our conference room, are available for sublease in a newly updated and beautifully designed office in the HM Poole Building. A few feet away from Scripps Memorial Hospital. Terms are flexible, perfect for someone looking for a part-time presence on campus. Please contact Olga at (858) 9099033 for more information. [040] SCRIPPS / XIMED BUILDING, LA JOLLA OFFICE SPACE TO SUBLEASE: Currently occupied by one fulltime and three part-time physicians. One office available plus one exam room. Receptionist space available for your employee. For more information, contact Mary at (858) 457-3270. [975] LA JOLLA OFFICE SPACE: Share reception, waiting area, and exam/consultations rooms in brand new office. Four exam rooms. Office is close to Scripps Memorial Hospital. In Golden Triangle between 805 and 5 freeways. Terms negotiable. Please contact Kathy Koppinger at (858) 678-0455. [025] LUXURIOUS / BEAUTIFULLY DECORATED DOCTOR’S OFFICE NEXT TO SHARP HOSPITAL FOR SUB-LEASE OR FULL LEASE: The office is conveniently located just at the opening of Highway 163 and Genesee Avenue. Lease price if very reasonable and appropriate for ENT, plastic surgeons, OB/GYN, psychologists, research laboratories, etc. Please contact Mia at (858) 279-8111 or at (619) 823-8111. Thank you. [836] NEW — EXTREMELY LOW RENTAL RATE INCENTIVE — EASTLAKE / RANCHO DEL REY: Two office/medical spaces for lease. From 1,004 to 1,381 SF available. (Adjacent to shared X-ray room.) This building’s rental rate is marketed at $1.70/SF + NNN; however, landlord now offering first-year incentive of $0.50/SF + NNN for qualified tenants and five-year term. $2.00/SF tenant improvement allowance available. Well parked and well kept garden courtyard professional building with lush landscaping. Desirable location near major thoroughfares and walkable retail amenities. Please contact listing agents Joshua Smith, ECP Commercial, at (619) 4429200, ext. 102. [006]

HILLCREST MERCY MEDICAL BUILDING OFFICE SPACE: Office space in Mercy Medical Building in hillcrest for psychologist or psychiatrist to share with one PhD and one psychiatrist. Handicap access, panoramic views from consultation rooms, parking in structure. Call H.R. Hicks, MD, at (619) 298-7135. Large wait room and plenty of storage. [042]

POWAY / RANCHO BERNARDO — OFFICE FOR SUBLEASE: Spacious, beautiful, newly renovated, 1,467 sqft furnished suite, on the ground floor, next to main entrance, in a busy class A medical building (Gateway), next to Pomerado Hospital, with three exam rooms, fourth large doctor’s office. Ample parking. Lab and radiology onsite. Ideal sublease/satellite location, flexible days of the week. Contact Nerin at the office at (858) 521-0806 or at mzarei@cox.net. [873]

ENCINITAS OFFICE SPACE TO SUB-LEASE: North Coast Health Center, 477 El Camino Real, Encinitas. Newly remodeled and beautiful office space available at the 477/D Bldg. Occupied by seasoned vascular and general surgeons. Great window views and location with all

TWO MONTHS FREE RENT: 1,215 SQ FT MEDICAL OFFICE NEXT TO POMERADO HOSPITAL: Office has furnished waiting area, front and back stations for four staff members, two exam rooms, a break room, private bathroom, and doctors’ office. Office is updated and ready

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. 34 SAN DIEGO PHYSICIAN .org j u n e 2012

for move in. Located in a great medical/dental complex in Poway, close to Pomerado Hospital, on the border with Rancho Bernardo. Second floor. Elevator/stair access. Large, free patient parking area. Ideal for medical, complementary/alternative medicine, physical therapy, chiropractic, acupuncture, massage/body work, etc. Patients from Poway, Rancho Bernardo, Carmel Mountain, 4-S Ranch, Scripps Ranch, Escondido, Ramona, and surrounding areas. Rent is $1,300/month + NNN. Please contact Olga at (858) 485-8022. [980] 3998 VISTA WAY, IN OCEANSIDE: Four medical office spaces approximately 1,300–2,800 square feet available for lease. Close proximity to Tri-City Hospital with pedestrian walkway connected to parking lot of hospital, and ground-floor access. Lease price: $1.75+NNN. Tenant improvement allowance to customize the suites is available. For further information, please contact Lucia Shamshoian at (760) 931-1134 or at shamshoian@coveycommercial. com. [965] SHARE OFFICE SPACE IN LA MESA: Available immediately. 1,400 square feet available to an additional doctor on Grossmont Hospital Campus. Separate receptionist area, physician’s own private office, three exam rooms, and administrative area. Ideal for a practice compatible with OB/GYN. Call (619) 463-7775 or fax letter of interest to La Mesa OB/GYN at (619) 463-4181. [648] BUILD TO SUIT: Up to 1,900ft2 office space on University Avenue in vibrant La Mesa/East San Diego, across from the Joan Kroc Center. Next door to busy pediatrics practice, ideal for medical, dental, optometry, lab, radiology, or ancillary services. Comes with 12 assigned, gated parking spaces, dual restrooms, server room, lighted tower sign. Build-out allowance to $20,000 for 4–5 year lease. $3,700 per month gross (no extras), negotiable. Contact venk@cox.net or (619) 504-5830. [835] 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] NONPHYSICIAN POSITIONS AVAILABLE PHYSICIAN ASSISTANT, NURSE PRACTITIONER, OR PART-TIME MEDICAL DOCTOR [39b] — See ad #39a under “Physician Positions Available.” PHYSICIAN ASSISTANT: Physician assistant needed for house-call physician in Coachella Valley (Palm Springs / Palm Desert). Part time, flexible days/hours. Competitive compensation. Call (619) 992-5330. [038] NURSE PRACTITIONER, FLOAT — SAN DIEGO NORTH COUNTY COASTAL: North County Health Services (NCHS) is looking for highly competent family practice nurse practitioners. Job Qualifications / Skills: Highly effective communication skills; desire and ability to work autonomously; enjoys the variety of working at NCHS’ multiple health centers; flexible (must be available to work during peak periods of the year); ability to relate to and work with people of all ages; ability to work independently and as a part of a team; comfortable treating patients of all ages. Experience: Minimum 3–5 years clinical experience preferred. Contact Araceli Mercado at fax (760) 7368740 or at araceli.mercado@nchs-health.org. [032] MEDICAL EQUIPMENT MicroMaxx® ultrasound system: MicroMaxx® ultrasound system offers impressive image quality, wireless data transfer, and extreme durability. Portable unit that slides into a stand. The software is hard-wired and purpose-built for faster boot-up times (<15sec), faster digital image processing, and the ability to run for a long time. Can take videos or print images. Comes with a 6cm Micromaxx M-Turbo 6-13mHz transducer (HFL38x). Our Price: $13,000. Compare: $45,999 (new). MicroMaxx Applications Include: Anesthesia; Critical Care; Cardiology; Cardiovascular Disease Management; Emergency Medicine; Musculoskeletal; OB/GYN; Radiology; Vascular; Surgery; Shared Service. Contact our office at sdvi.office@ gmail.com or call (760) 944-9263. [043]

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j u n e 2012 SAN DIEGO PHYSICIAN.org 35

In Memoriam

John A. Bishop, MD, FAAP

June 21, 1918 – April 4, 2012 by David L. Collins, MD, FAAP, FRCS, and H. Glenn Kellogg, MD, FAAP

Dr. John Bishop died of age-related complications at San Diego Hospice. He was inspired to become a physician by his grandfather and two uncles who were physicians. John attended Stanford University Medical School and interned at San Francisco City and County Hospital. He visited San Diego in 1946 as medical officer on a destroyer, and, after a residency at Oakland Children’s Hospital, he returned to practice pediatrics in San Diego from 1951 to shortly before his death. He was associated with Drs. Sam McClendon, Bill Brownlee, and Joel Snyder — who continues to see some of his thirdgeneration patients. He was an expert on cystic fibrosis and was awarded for his “Outstanding Service” from the Cystic Fibrosis Foundation. He was president of the San Diego County Medical Society in 1972 and chief of staff at Rady Children’s Hospital in 1982 and 1983. Dr. Bishop was chair of the “Rub Out Rubella” and “Sabin On Sunday” campaigns. In retirement he volunteered at St. Vincent de Paul Clinic and the County Health Department Clinic in Chula Vista. In 1992 he was named “Physician Citizen of the Year” by the San Diego County Medical 36 SAN DIEGO PHYSICIAN.org j u n e 2012

Society. He was named “One of San Diego’s Twelve Finest Citizens 1993” by the City Club of San Diego, and in 2000 the San Diego County Board of Supervisors named him “Physician Citizen of the Year.” John enjoyed scuba diving and collecting shells. He had an amazing knowledge of nature’s creatures and flowers, and loved to photograph them. He was very proud of his ancestors, who were early missionaries in Kona, and of one in particular who described rings around the moon called “Bishop’s Rings,” which were due to the eruption of Krakatoa. His wife, Elva, and one son predeceased him. He is survived by four devoted sons and daughters and their families.

We Celebrate Excellence – James Strebig, MD CAP member, internal medicine physician, and former President of the Orange County Medical Association.

800-252-7706 www.CAPphysicians.com San Diego orange LoS angeLeS PaLo aLTo SacramenTo

For 35 years, the Cooperative of American Physicians, Inc. (CAP) has provided California’s finest physicians, like Irvine internal medicine specialist James Strebig, MD, with superior medical professional liability protection through its Mutual Protection Trust (MPT). Physician owned and physician governed, CAP rewards excellence with remarkably low rates on medical professional liability coverage – up to 40 percent less than our competitors. CAP members also enjoy a number of other valuable benefits, including comprehensive risk management programs, best-in-class legal defense, and a 24-hour CAP Cares physician hotline. And MPT is the nation’s only physician-owned medical professional liability provider rated A+ (Superior) by A.M. Best. We invite you to join the more than 11,500 preferred California physicians already enjoying the benefits of CAP membership.

Superior Physicians. Superior Protection. 37

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San diego County Medical Society 5575 RUFFIN ROAD, SUITE 250 SAN DIEGO, CA 92123 [ RETURN SERVICE REQUESTED ]

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In 2012,

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