July 2012 by San Diego Physician

official publication of the san diego county medical society juLy 2012

Reaching

8,500 Physicians

total work hours

Every Month

medi-cal

specialty-specific shortages

time to obtain an appointment

specialty-specific recruiting

specialty-specific compensation data

hours with patients (Dis)satisfaction with the practice of medicine

medicare

county medical services

sdcms workforce & compensation survey

“Physicians United For A Healthy San Diego”

NUMBERS THAT WORK AS YOU DO Callers assisted in 2011

CALL

is all it takes

24/7 phone access to live experts

25,000

phone

credentialing letters issued

22,800

AS HARD

What is great service? For NORCAL Mutual insureds, just 1 phone call is all it takes for great service. That means calling during business hours and immediately reaching a live, knowledgeable, friendly expert. After hours, it means promptly receiving a call back from a professional qualified to help with your issue. No automated telephone tango. Questions are answered and issues resolved—quickly. We’re on call 24 hours a day, every day of the year. Great service brings you peace of mind. Great service 24/7. Hard-working numbers you can count on.

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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 7 TOTAL WORK HOURS

MEDI-CAL Managing Editor: Kyle Lewis

TIME TO OBTAIN AN APPOINTMENT

SPECIALTY-SPECIFIC SHORTAGES

SPECIALTY-SPECIFIC RECRUITING

Editorial Board: Van L. Cheng, 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

SPECIALTY-SPECIFIC COMPENSATION DATA

HOURS WITH PATIENTS (DIS)SATISFACTION WITH THE PRACTICE OF MEDICINE

geographic and geographic alternate Directors East County: Alexandra E. Page, MD, Venu Prabaker, MD

features

MEDICARE

Hillcrest: Theodore S. Thomas, MD (A: Gregory M. Balourdas, MD)

sdcms workforce & compensation survey 21 Summary of Key Findings

COUNTY MEDICAL SERVICES

departments

background and history Demographics medicare medi-cal county medical services (Dis)satisfaction with the practice of medicine physician shortage specialty-specific shortages general recruiting retention total work hours hours with patients satisfaction with the time spent with patients time to obtain an appointment compensation compensation trend specialty-specific compensation data

Kearny Mesa: John G. Lane, MD, Jason P. Lujan, MD (A: Sergio R. Flores, MD) La Jolla: Geva E. Mannor, MD, Wynnshang “Wayne” Sun, MD (A: Matt H. Hom, MD) North County: Niren Angle, MD, Douglas Fenton, MD, James H. Schultz, MD (A: Anthony H. Sacks, MD) South Bay: Vimal I. Nanavati, MD, Michael H. Verdolin, MD (A: Andres Smith, MD)

At-large Directors Karrar H. Ali, MD, David E.J. Bazzo, MD, Jeffrey O. Leach, MD (DELEGATION CHAIR), Mihir Y. Parikh, MD (EXECUTIVE COMMITTEE BOARD REP), Peter O. Raudaskoski, MD, Kosala Samarasinghe, MD, Suman Sinha, MD, Mark W. Sornson, MD (EXECUTIVE COMMITTEE BOARD REP) At-large ALTERNATE Directors James E. Bush, MD, Theresa L. Currier, MD, Thomas V. McAfee, MD, Carl A. Powell, DO, Elaine J. Watkins, DO, Samuel H. Wood, MD, Holly Beke Yang, MD, Carol L. Young, MD other voting members Communications Chair: Theodore M. Mazer, MD (CMA VICE SPEAKER) Young Physician Director: Van L. Cheng, MD Retired Physician Director: Rosemarie M. Johnson, MD Medical Student Director: Suraj Kedarisetty

OTHER NONVOTING MEMBERS

30 A Tale of Three Practices

Young Physician Alternate Director: Renjit A. Sundharadas, MD

31 Specialty-specific Information

Retired Physician Alternate Director: Mitsuo Tomita, MD SDCMS Foundation President: Stuart A. Cohen, MD, MPH CMA President: James T. Hay, MD (AMA DELEGATE)

4 Briefly Noted

SDCMS Board of Directors Officers President: Sherry L. Franklin, MD (CMA TRUSTEE) President-elect: Robert E. Peters, PhD, MD Treasurer: J. Steven Poceta, MD Secretary: William T-C Tseng, MD, MPH Immediate Past President: Robert E. Wailes, MD (CMA TRUSTEE)

CMA Past Presidents: Robert E. Hertzka, MD (LEGISLATIVE COMMITTEE

Calendar • Featured Member • Legislator Birthdays • Get in Touch! • And More …

CHAIR, AMA DELEGATE), Ralph R. Ocampo, MD CMA Trustee: Albert Ray, MD (AMA ALTERNATE DELEGATE) CMA Trustee (OTHER): Catherine D. Moore, MD

8 Advice for New Graduates and Young Physicians

CMA SSGPF Delegates: James W. Ochi, MD, Marc M. Sedwitz, MD CMA SSGPF Alternate Delegates: Dan I. Giurgiu MD, Ritvik Prakash

Mehta, MD

by stephen r. hayden, md

12 Seniors Who Fall

by Roneet Lev, MD, FACEP

14 Estimates of Patient Life Expectancy

by karl e. steinberg, md, cmd

16 Referring Patients to Clinical Trials

by howard l. taras, md

34 Physician Marketplace Classifieds

36 Welcome Dr. Sherry L. Franklin SDCMS President for 2012–13 2 SAN DIEGO PHYSICIAN .org j u ly 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.]

Designated as one of the Top 5 centers in the world for Extracranial Treatments in 2010.

CyberKnife of Southern California at Vista is the only center in California to have received this designation!

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The physicians of Oncology Therapies of Vista, Pacific Radiation Oncology Medical Group, and CyberKnife of Southern California at Vista are the trusted experts bringing Image Guided Radiation Therapy (IGRT), Intensity Modulated Radiation Therapy (IMRT), High and Low Dose Brachytherapy including Accelerated Partial Breast Radiation (APBI), 3-D Conformal Radiation Therapy, as well as Cyberknife Stereotactic Radiosurgery to the many communities of San Diego County.

Trust your patients’ treatment to the area’s trusted authority. Oncology Therapies of Vista 916 Sycamore Avenue, Vista, CA 92081 Tel: 760-599-9545 | Fax: 760-599-9549 www.onctherapies.com Pacific Radiation Oncology Medical Group 477 N. El Camino Real, Suite D100 Encinitas, CA 92024 Tel: 760-634-4300

j u ly 2012 SAN DIEGO PHYSICIAN.org 3

brieflynoted 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. EHR Incentives (seminar/webinar) AUG 9 • 11:30am–1:00pm Practice Valuation (seminar/webinar) SEP 6 • 11:30am–1:00pm How To’s of Appeals (seminar/webinar) SEP 20 • 11:30am–1:00pm Certified Medical Office Manager (course) SEP 14, 21, 28, OCT 5 • 9:00am–4:00pm

Cma Webinars

CMAnet.org/events

Coding for Medical Necessity AUG 1 • 12:15pm–1:15pm CMA and the Courts: Accessing CMA’s Legal Library AUG 8 • 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–1:45pm California Workers’ Compensation E-bill Part 2: Implementation AUG 23 • 12:15pm–1:45pm California Workers’ Compensation E-bill Part 3: Understanding Remittance Advice Rules AUG 30 • 12:15pm–1:45pm

featured member 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. Movement Disorder Review Course AUG 11 • Sheraton La Jolla • 8:00am–3:45pm • Presented by the University of Kansas Medical Center • $100 • (913) 588-7159, kelly.lyons@att.net Hyperglycemia Management Using Insulin Therapy SEP 19 • Bombay Restaurant, Hillcrest, San Diego • 6:00pm • scripps.org/conferenceservices Hyperglycemia Management Using Insulin Therapy OCT 10 • Ruth’s Chris Steak House, Del Mar • 6:00pm • scripps. org/conferenceservices CMA / CMA Foundation Gala — Save the Date! OCT 14 • California Museum, Sacramento • Contact Enid at egallegos@cmanet.org for sponsorship and advertising or Shelley at stirsbeck@ thecmafoundation.org for individual or group ticket sales. 13th Annual Science and Clinical Application of Integrative Holistic Medicine OCT 28 – NOV 1 • Hilton San Diego Resort • www.scripps.org/events/ science-and-clinical-applicationof-integrative-holistic-medicine 13th Annual Science and Clinical Application of Integrative Holistic Medicine NOV 2 • Hilton San Diego Resort RCMA’s “Cruisin Thru CME” — French Waterways: Highlights of Burgundy & Provence JUL 1–13, 2013 • Call RCMA at (800) 472-6204

A Guide to Reviewing Payor Contracts SEP 5 • 12:15pm–1:15pm

4 SAN DIEGO PHYSICIAN.org j u ly 2012

Arthur L. Gruen, MD

EA Health announced that Arthur Gruen, MD, SDCMS-CMA member since 2010, received the Ernst & Young Entrepreneur of the Year 2012 Award in the Life Sciences and Health Care category in the San Diego Region. The award recognizes outstanding entrepreneurs who demonstrate excellence and extraordinary success in such areas as innovation, financial performance, and personal commitment to their businesses and communities. Dr. Gruen was selected by an independent panel of judges and was presented with his award at a special gala on June 13, 2012. As a San Diego Region award winner, Dr. Gruen is now eligible for consideration for the National Entrepreneur of the Year 2012 Award, to be announced at the annual awards gala in Palm Springs, California, on Nov. 17, 2012. Congratulations, Dr. Gruen!

legislator birthdays

One way to let your legislators know that you’re paying attention and that you vote is by wishing them a happy birthday! BIRTHDAY: AUG. 1

BIRTHDAY: SEPT. 4

State Assemblywoman Toni Atkins (District 76)

U.S. Representative Bob Filner (District 51)

E: (via website) asmdc.org/members/a76 E: assemblymember.atkins@assembly.ca.gov Sacramento Office: State Capitol, PO Box 942849, Sacramento, CA 94249-0076 T: (916) 319-2076 • F: (916) 319-2176 San Diego Office: 2445 Fifth Ave., Ste. 401, San Diego, CA 92101 T: (619) 645-3090 • F: (619) 645-3094

E: (via website) house.gov/filner Washington, DC, Office: T: (202) 225-8045 • F: (202) 225-9073 Chula Vista Office: 333 F St., Ste. A, Chula Vista, CA 91910 T: (619) 422-5963 • F: (619) 422-7290

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!

3 employee Benefit Plans

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

3 Profitability Reviews 3 outsourced Professional services (CFo, Controller) 3 organizational and Compensation structure 3 succession Planning 3 Practice Valuations 3 internal Control Review and Risk Assessment

akt A KT LLP, CPAs and Business Consu LTAnTs CARL SBAD

ESCONDIDO

760-431-8440

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 resource development director Erich Foeckler, CFRE, at (858) 565-7930 or Erich.Foeckler@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

S A N DIEGO

W W W.AKTCPA.COM

RMITCHELL@AKTCPA.COM

ron mitchell, cpa director of health services

“think SDCMS FIRST!” Start by contacting SDCMS at (858) 565-8888 or at SDCMS@SDCMS.org.

j u ly 2012 SAN DIEGO PHYSICIAN.org 5

brieflynoted SDCMS COO/CFO Leadership Award Finalist

SDCMS membership Welcome New Members! Hanny Chan, MD Dermatology San Diego (619) 446-1549 Alan T. Chang, MD Internal Medicine San Diego (619) 521-2370 Jeffrey Chen, MD Physical Medicine and Rehabilitation La Jolla (858) 657-8200 Kinji L. Hawthorne, MD Infectious Disease San Diego Karl M. Jacobs, MD Psychiatry La Jolla (858) 750-2411

James Beaubeaux, SDCMS COO and CFO, was recognized at the 2012 LEAD San Diego Visionary Awards dinner as one of five finalists for the “Herbert G. Klein Memorial Award for Exemplary Leadership.” The award is named in honor of Herb Klein, whose contributions of leadership, dedication, and service to San Diego are almost unparalleled. It was within

the spirit of Herb’s commitment and achievement that LEAD San Diego created this annual award. The finalists are recognized by both fellow class members and the LEAD board of directors as among San Diego’s key future leaders. SDCMS is proud to congratulate James Beaubeaux for his acknowledged leadership within San Diego County.

L–R: James Beaubeaux, COO/CFO, San Diego County Medical Society; Dr. Danell Scarborough, executive director, Human Relations Commission; Doug White, manager, Government Affairs, Cricket Communications, Inc.; Pauline Martinson, executive director, I Love A Clean San Diego; Victor Baker, supplier diversity manager, SDG&E

6 SAN DIEGO PHYSICIAN.org j u ly 2012

Naing T. Kyaw, MD Internal Medicine Oceanside (760) 966-2499 Elizabeth O. Marquart, MD Emergency Medicine La Mesa (619) 740-6000

Suneil R. Ramchandani, MD Internal Medicine San Diego (619) 532-5548 Elizabeth Revesz, MD Surgery Poway (858) 675-3108 Kristen N. Rice, MD Hematology San Diego (858) 637-7888

Welcome Returning Members! Aidan M. Clarke, MD Physical Medicine and Rehabilitation Palm Springs Lynn L. Leventis, MD Obstetrics and Gynecology Anaheim (619) 315-4247 Wendell M. Smoot, MD Plastic Surgery La Jolla (858) 587-9850 Howard L. Taras, MD Pediatrics San Diego (619) 681-0665

Erratum In our June 2012 issue, author London Carrasca was mistakenly referred to as “Mr.” in her article, “The Integration Model Trifecta.” Our sincere apologies to Ms. Carrasca for this error!

SDCMS Foundation Awards Scholarships to Two Residents Two new residents received Hertzka Medical Student scholarships from the SDCMS Foundation in June. Mai Duong, MD, and Jane Bugea, MD, both SDCMS-CMA members since 2009 and graduates of UC San Diego Medical School, are pursuing medical careers in family practice. Dr. Duong will be starting her residency at UCSD’s medical pediatric program, and Dr. Bugea will begin her residency at Rady Children’s Hospital. Both are dedicated to meeting the healthcare needs of the underserved in our community, in line with the mission of the San Diego County Medical Society Foundation. They are pictured with SDCMS Foundation Vice President and SDCMS Secretary William T-C Tseng, MD, MPH.

Movement Disorder Review Course

6.5 hours of category I CME offered by the University of Kansas Medical Center Covering differential diagnosis of parkinsonism, medical and surgical treatment of Parkinson’s disease motor and nonmotor symptoms, diagnosis and treatment of restless legs syndrome, tremor, dystonia, chorea and tics, psychiatric aspects of movement disorders, and treatment of movement disorders with botulinum toxins and deep brain stimulation.

speakers:

movement

disorder review course

RAY L.WATTS,M.D. Dean, School of Medicine Professor of Neurology University of Alabama at Birmingham Birmingham, Alabama CYNTHIA COMELLA, M.D. Professor, Department of Neurological Sciences Movement Disorder Center Rush University Medical Center Chicago, Illinois

8:30am - 3:45pm

JERROLD L. VITEK, M.D., Ph.D. Professor and Chairman Department of Neurology University of Minnesota Minneapolis, Minnesota

Sheraton La Jolla La Jolla, California

Contact Dr. Kelly Lyons at kelly.lyons@att.net or 913-588-7159 for more information.

AuguST 11, 2012

j u ly 2012 SAN DIEGO PHYSICIAN.org 7

Preparing to Practice

Advice for New Graduates and Young Physicians Avoiding the Pitfalls by Stephen R. Hayden, MD

Acknowledgment: Thank you to all the members of the Council of Residency Directors (CORD) for your sage advice and invaluable contributions to this work! Some time ago I was asked to speak to a group of graduating residents at the San Diego County Medical Society’s “Preparing to Practice” workshop on the topic of avoiding pitfalls. Having been unsuccessful in avoiding a few of them myself, I turned to a group of colleagues at CORD and asked them what advice they gave to their graduates as they were leaving the program. The response was overwhelming, to say the least. I did my best to categorize and compile the replies, and they seemed to fall into a number of different groups below. Altogether, this advice emanates from program directors with more than 300 years of combined experience in guiding residents! I hope you find it useful and practical; I wish I had heard even a portion of this wisdom when I graduated. PITFALL 1: Not Taking Care of Yourself Physically, Mentally, and Spiritually: • “Tell them to rediscover their passion outside medicine so that they can rely on it to de-stress and add dimension to their life. For me it is ballet, but many others do sports, music, church groups, community organizations, art, etc. The nice thing is that they get a circle of 8 SAN DIEGO PHYSICIAN.org j u ly 2012

nonmedical friends to add perspective to their lives. For most people, all these interests were suppressed during clinical training.” • Make time for yourself (separate from time for your family) …. Get back into that exercise routine that fell by the wayside during residency (or sport or instrument you used to play). • Find a balance between work and play; don’t forget to take care of yourself. • Taking a job that they end up loathing for whatever reason, and then not having the courage to leave and find another one. PITFALL 2: Getting in Over Your Head: • Start saving up during residency for the first year out. “There are a LOT of expenses no one told me about. Moving, security deposits, first and last month’s rent, board fees (both written and oral, plus travel and lodging to Chicago!), cost of licensure. It adds up to several thousand dollars.” • Don’t spend more than you earn. Spending quickly rises to match income. Don’t live beyond your means now that you are getting a real paycheck. Don’t buy a house too soon, or buy a very modest one initially. Owning a home can get you in over your head faster that you can imagine. Don’t buy a $60,000 BMW right away!

• “Do not underfund your savings plan; do not overpay for a car. I see too many recently graduated residents buy a big-ticket item as soon as they become attendings (usually some ridiculously expensive car) but not put money into savings. They need to max out their 401(k)/403(b) from day one. If they never see the money going into their savings plan, they never feel the hurt.” • Realize that you are immediately in a new tax bracket, and plan accordingly. • Pay off some debt. Live like a resident financially for a while, which allows for saving money so you can travel, change jobs if needed, etc. • Start saving for retirement as early as possible, and start college funds for your kids the minute they are born. • Continue short-term disability plans from residency if possible, as they are often fairly inexpensive and not all groups offer short-term disability (some policies allow this, and this is particularly important for females who may get pregnant). Some companies offer a guaranteed-issue disability policy to residency graduates; take advantage of it. • Many residents do not understand their contracts or sign ones that may get them into trouble, i.e., agreeing to restrictive covenants, etc. Don’t feel like you won’t get the job if you don’t agree to all the provisions; in the end, almost everything is negotiable. Look to your specialty societies if you are not sure or have questions. PITFALL 3: Being Afraid to Ask Questions or Ask for Help: • You can always call “home.” If you are out moonlighting or on your own and just want to bounce something off one of your colleagues from where you trained, you can always call. Someone from your department is on 24/7. Sometimes it just helps to think out loud and with another brain that knows your brain. Stay in communication with the mother ship! • Never lose your humility or be too afraid/too proud to ask for help. Just because you’ve graduated doesn’t mean you know it all/can do it all. Medicine is the most humbling of professions; if you don’t know the answer, ask! • If you’re not sure about a patient case,

ask your colleague who’s working with you. It’s not a sign of weakness. Your colleague has one thing that a new grad does not: experience. • The first five years out of residency is a steep learning curve. You’ll see stuff you’ve never seen before; you may do procedures you’ve never done before; better to admit you’re not sure than make something up. PITFALL 4: Forgetting Why You Got Into Medicine in the First Place: • “Take the time to make a true connection with a minimum of ONE of your patients per day or shift. Take the extra time and make the extra effort to create a connection and find out something about them as a person. It helps you keep your humanism and remember why you got into this business: to help people.” • Graduates must never lose their compassion. If they see themselves moving toward indifference, do something about it; compassion is the most important quality associated with a long and happy career. And the obvious corollary … never forget your patient is an actual person and not a scientific problem. • In the first few years of practice, most graduates end up making an important, but unconscious, choice between compassion and indifference toward their patients. Young physicians who seem jaded and annoyed by their patients (or “hits”) frequently become bitter as the years go by. Others who really take the time to listen and care for their patients seem to become more satisfied as they go on. • Consistently regarding your next patient as an opportunity to care, rather than a burden or an obstacle to getting home, is the best guarantee for long-term success. • Be nice to as many people as possible. “Kindness is contagious.” PITFALL 5: Succumbing to the Pressures of Clinical Practice and Burning Out • “I see a certain curve in young physicians … nervous/uncertain at first, then they gain confidence and after a few years become a bit overconfident, until something bad happens; for the high performers particularly, as they expect more and more from themselves, often forgetting to maintain their private lives, there is a tendency to burn out in years

3–5 (loss of compassion/empathy, dehumanizing patients, judgmental, shorttempered, hard on their colleagues, etc.). This is a repetitive pattern, and, over the years, I have come to look for it. Noted early, it can be readily reversed, but if allowed to progress, it can become a crippling issue. So I warn people about this, and I have been told it helps.” • “One of the things I wish someone told me was to watch the amount of overtime I take on. New grads are seeing real money/paychecks for the first time. OT is really alluring because new grads think they need all this money to pay off bills and other debts they have accumulated. However, if they do too much OT, they get burnt out and cranky, and they can’t enjoy their new jobs/positions.” • Remember what you enjoyed as a resident. PITFALL 6: Thinking You’re Above Your Coworkers Now That You’re a Real Doctor: • Listen to your nurses and staff. They will save your ass more than you know! Scorn the nurses … look for a new job! • Not being a team player (you are the new guy; that means watching more than talking). • Telling all the “old” guys how to do it! • Get to know other medical staff, and review a list of your consultants with the current staff to find out who is really helpful/unhelpful, who has a personality disorder, who you can call in a pinch even if they’re technically not on call, etc. You need to feel you are part of the larger physician team of the hospital — even if you don’t like all of them. • Bring food for everyone to your department/office for at least the first month (or longer). • Ask the nurses/techs what you can do to help out, and clean up after yourself without being asked (I promise the return is greater than the effort!). • Not treating other physicians as if they were members of your own family, especially when one of them becomes ill. • Be the “yes” person. If you can do it, and there is no reason to say no, then say “yes.” Be the dependable person others can count on. What goes around comes around. • Your character is revealed by the manner in which you treat those least important to you.

Remember the Six C’s 1. Compassion: • Remember why we do this in the first place. • Be careful to avoid callousness, hardness, and burnout (“Easy to be hard …”). 2. Compulsiveness — Be Compulsive in Your: • charting • record completion • filling out paperwork • patient care • lifelong learning • showing up on time 3. Caution (Conservatism): • Be neither the first nor the last to adopt anything new. • Most new, pushed drugs are not necessary (Vioxx, Celebrex, Ketek). • First, do no harm. 4. Conflict Resolution: • There will be lots of potential fights with patients, privates, partners, boss, staff, RNs, etc. • Learn to gracefully and diplomatically avoid or resolve real and potential conflicts. • Prevent escalation. • It usually isn’t really worth it, after all. • Being right isn’t enough. To get ahead, you’ve got to get along. • You don’t want to be the one who everyone thinks is “difficult to deal with.” 5. Committees: • Despite the hassle, be involved professionally at the departmental level, hospital level, community level, and professional organizational level. • The investment in time pays off in multiple ways. • But wait until after your boards! 6. Communication: • In your documentation and with your patients and families. • Always spend an extra minute or two with ED staff. • Learn their names. • Show respect for them.

j u ly 2012 SAN DIEGO PHYSICIAN.org 9

Preparing to Practice “Privileged to Provide Care and Clinical Research Since 1975”

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• As my 9-year-old daughter tells me often, “Smile. It’s contagious.” :-) PITFALL 7: Not Doing What You Know Is Right • Do not make a “fence decision” that you will lose sleep over. If you are secondguessing yourself while the patient is still in the ED, office, or on your service, you WILL wake up in a sweat at 3 in the morning questioning why you did what you did (or didn’t!). • There are very few absolutes in medicine. Practice varies from hospital to hospital, region to region, and by provider, so learn the local standards. Be cognizant of this and be flexible. Don’t sacrifice your training and principles but decide which battles to fight. • Forgetting to use their history and physical exam skills to diagnose their patients, not the CT scanner • Be prepared for change: Clinical practice will change, and you must keep up with current medical knowledge. Develop a regular reading plan. • Becoming complacent in patient care; at graduation they are proficient, but it will take many thousands of patients and many years to become a master. Keep working at it; like the flight community says, “Complacency kills!” • You will have to reinvent yourself, maybe several times. Be open to it (protect yourself from tunnel vision). • Document scrupulously and honestly. Always do the right thing, DESPITE: managed care, cost-effectiveness, and administrative pressures. • You are a professional; maintain professional standards at all times and in all situations. Whether you like it or not, everyone looks up to you. Beware of social media — don’t post ANYTHING that is even remotely socially questionable. Invariably your boss will end up seeing it, and it could cost you your job. • Ask yourself, “How would your mother feel about the way you conducted yourself if she had read it in the newspaper?” PITFALL 8: Not Learning the Art of Saying Both Yes and No: • Not going that extra mile if you are in academics because you are just starting out, e.g., reviewing, research, taking on the med student rotation, etc. • Learning to say no is an art form; however, don’t say no too often early in your career because the offers may stop com-

ing. Rather, learn to say yes to the right things and seek out something that you can become passionate about and that can take you places. That one random “yes” could lead to a niche you never would have thought possible. Create a niche for yourself. • Talk to your chair early. Ask for help getting involved in important departmental activities but at the same time limiting them so you can focus on becoming very comfortable with your new role as a clinical attending physician. • “We give people titles in academics too quickly. I think I ruined one of my best grads by making him an APD right out of residency. Now he’s stuck in a wrong path and not very successful. My new rule: No promotions for two years — awards, thanks, gifts, sure. No titles.” PITFALL 9: Not Placing a High Enough Priority on It: • Forgetting that the first day after graduation is the beginning of a process in which you actually learn how to practice your specialty, not the end. • Get involved with hospital committees, county and state medical societies, etc. Get involved at a local/regional and national level. • Specifically getting on your departmental or hospital QA committee; it’s a good way to learn your clinical processes and what the standard of care is for your institution. Also, always best to learn from others’ “mistakes.” • Consider a leadership development program. • Find good mentors and continue mentor relationships from residency. • Give back to your specialty. PITFALL 10: Not Allowing Enough Time to Prepare for Them: • Do not slack in studying. You are not really done until you pass your boards. • Seriously review for your board examination regardless of your last in-service score. Every PD can relate a story about an excellent, competent resident with a great final in-service exam score who then flunked the written or oral certification examination! Dr. Hayden, SDCMS-CMA member since 2011, is professor of clinical emergency medicine and associate dean for graduate medical education at the UC San Diego Health System.

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Emergency Medicine

Seniors Who Fall Fall Prevention and

Information Resources by Roneet Lev, MD FACEP

Mr. John Smith (altered name, but true story) is a 73-year-old San Diegan who was going for his routine health checkup at the office. He is a retired teacher and enjoys golfing and the company of his grandchildren. He was walking out of his doctor’s office toward the elevator when he accidentally tripped. It caused quite a little scene in the medical office, and various nurses and doctors came out into the hallway to see how they could help. Mr. Smith did not lose consciousness, was quite embarrassed by his fall, and said he was feeling fine. He sustained only a small bump to his right forehead. He was able to get up with minimal assistance, and eased into a chair. His doctor examined him and assured him that he did not injure the “bleeding” part of the brain. Mrs. Smith was with him and was told that she could take her husband home and just watch him to make sure he did not get sleepy or have vomiting. The elderly couple was quite satisfied with the medical care and attention they received. Five days later, Mrs. Smith brought her husband to the emergency department because he was having headaches. The emergency physician obtained a history that Mr. Smith was on warfarin for atrial fibrillation. He had been having headaches and did not feel quite right, but he never had loss of consciousness or vomiting. Mrs. Smith was not too worried because her husband did not have any of the serious warning signs they had been warned about after his fall. A head CT scan was obtained and showed a large subdural hematoma with 3cm midline shift. Mr. Smith was admitted to the trauma unit. The neurosurgeon performed a surgical evacuation of the subdural and the patient was discharged to a skilled nursing facility after five days. This article is being written to alert our community physicians that patients on blood thinners who fall and hit their 12 SAN DIEGO PHYSICIAN.org j u ly 2012

head — any part of their head — must be evaluated. This is especially true if there is some external sign of injury. For patients on blood thinners, you cannot rule out a serious intracranial injury with a good history and physical. These patients need a STAT head CT. Just ask Dr. Carolyn Barber, an emergency physician at UCSD. Her mother is an active, athletic 65-year-old who enjoys playing tennis. She never remembered falling when her kids urged her to go to the ER for her headache. She was diagnosed with a large subdural with midline shift that required several surgeries. Only weeks later did her family see the indentation in her closet where she fell. She later recalled falling, but didn’t think it was a big deal at the time. More than one out of three seniors fall each year, and three out of four of those who fall will fall again within six months. An older San Diegan dies from a fall every 28 hours. With the changing demographics of the county, this is expected to increase to a death every three hours in the year 2030. Reviewing the San Diego trauma registry over the past 10 years, we find that although the total number of trauma patients has remained stable, the demographics of trauma have changed significantly. A decade ago the average trauma patient was between 20 and 54 years old, and was involved in a motor vehicle collision. The typical trauma

patient is now 45 or older and was injured in a fall. Of the 10,386 patients in the San Diego trauma registry in 2010, the leading cause of trauma was falls (3,523), followed by motor vehicle accidents (2,067). The County of San Diego Medical Audit Committee for Trauma prepared a guideline for patients on blood thinners who fall and is intended for patients at nontrauma hospitals, but can be useful for clinic patients as well. This guideline is available at the San Diego County Medical Society website by searching “EMOC,” (Emergency Medical Oversight Commission). Any patient on a blood thinner who falls requires emergent evaluation. Any patient on a blood thinner who falls and sustains a loss of consciousness, vomiting, or altered mental status warrants trauma activation. It would be appropriate to review patients’ indications for blood thinners at intervals to see if the blood thinner can be discontinued according to existing care guidelines. Fall prevention information and resources for the public and providers are available at www.sandiegofallprevention.org. 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).

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Bioethics

Patient Life-Expectancy Addressing Unrealistically Optimistic Estimates by Karl E. Steinberg, MD, CMD

14 SAN DIEGO PHYSICIAN.org j u ly 2012

There is plenty of evidence that we physicians, as a group, tend to paint unrealistically optimistic estimates of our patients’ life expectancy, for a number of reasons. In January 2012, JAMA published a review article titled “Prognostic Indices for Older Adults” that addresses this tendency and helps healthcare providers determine and stratify mortality risk. Lindsey Yourman, MD, the lead author of this important piece, is currently in her PGY1 year at Scripps Mercy Internal Medicine Residency Program. Yes, Dr. Yourman and her colleagues did this work while she was still in medical school! The paper is linked to a nifty interactive website called ePrognosis. org, and is a valuable tool for clinicians trying to determine realistic expectations for our patients and their families. And Dr. Yourman has kindly agreed to take time out from her busy intern year (albeit not as busy as most of us recall) to present on her work and demonstrate the ePrognosis tool at SDCMS’ Bioethics Commission meeting on July 25. Dr. Yourman has always had an interest in geriatric medicine and plans to make this her career path. During her clinical years in medical school at UCSF, Lindsey observed firsthand how difficult it was to determine patients’ life expectancies, and also observed the suffering that sometimes resulted from decisions made on the basis of poor prognostication — and inadequate understanding on the part of patients and clinicians alike as far as expectations for survival and recovery. Dr. Yourman believed that people often opted for invasive and aggressive attempts at life prolongation based on inaccurate or overly optimistic prognostication on the part of their physicians. She searched the literature and found that there was a dearth of readily available tools to help determine prognosis in the geriatric population at large, although, with laborious research, certain patient scenarios (like some cancer patients) could yield reasonable estimates of mortality. Dr. Yourman decided that she wanted to make a difference and approached some of her mentors, including Drs. Alex Smith and Eric Widera, about working on a user-friendly, interactive system that healthcare professionals could access to assist them in informing their patients

Dr. Yourman believed that people often opted for invasive and aggressive attempts at life prolongation based on inaccurate or overly optimistic prognostication on the part of their physicians. and families about what to expect. She took an academic year off to work on this project, consolidating multiple studies of hospitalized, skilled nursing facility, and community-dwelling elders into an interactive, Internet-based tool with dropdown menus that can be individualized to specific patients and provide a range of

expected mortality over various timeframes — and that is how ePrognosis came into existence. In addition to the JAMA article from January 2012, that same month Dr. Yourman was published in the Journal of the American Geriatrics Society (JAGS); this ethnogeriatrics piece — titled “Quality of Life in Late-Life Disability: ‘I Don’t Feel Bitter Because I Am in a Wheelchair’” — was derived in part from her work as project manager for interviewing older adults on their feelings about prognosis. This work has also given Lindsey a rich perspective on the attitudes of frail elders on their final phase of life. At the July 25 Bioethics Commission meeting, Dr. Yourman will provide a realtime demonstration of the use of ePrognosis by presenting a case study; then she will discuss ethical issues surrounding discussion of prognosis, including autonomy and nonmaleficence, with attendees. Topics of Project4:Layout

EMR is great for record-keeping but it’s not the answer to getting you paid or managing your claims.

advance care planning, including advance healthcare directives and POLST (Physicians’ Orders for Life Sustaining Treatment) in the context of realistic expectations and a reasonable estimate of prognosis, will be part of the relevant discussion. The Bioethics Commission of SDCMS, chaired by Mits Tomita, MD, and Paula Goodman-Crews, meets quarterly at SDCMS, and visitors are welcome. If you would like further information, please email Kyle Lewis at KLewis@ SDCMS.org. Dr. Steinberg, SDCMS-CMA member since 2008, is a full-time long-term care geriatrician at Scripps Coastal Medical Group, and medical director of two skilled nursing facilities: Kindred Village Square and Las Villas de Carlsbad. He is on the board of the Compassionate Care Coalition of California, is a past president of the California Association of Long Term Care Medicine, and serves as editor-in-chief of AMDA’s monthly periodical, Caring for the 1 9/22/08 11:22 AMAges. Page 1

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Clinical Trials

Referring Patients to Clinical Trials Is It Feasible for the Busy Physician? by Howard L. Taras, MD

Every physician must at some point feel frustrated by the absence of a more effective or affordable device or diagnostic tool. There are occasions where we just wish there were a treatment with fewer side-effects, or one that was more convenient for patients. Unfortunately, new medical advances that start in basic labs typically take more than a dozen years before they are translated to something of use for those in clinical practice, given the hurdles that are currently inherent in the scientific process. As clinicians we are aware that there are always clinical trials going on to help solve some of these impasses. Yet very few physicians in clinical practice refer patients to clinical trials, even though most clinical studies have difficulty accruing human subjects. 16 SAN DIEGO PHYSICIAN.org j u ly 2012

If other clinicians are like me, I understand why this is. First, I am not typically aware of what trials are currently seeking human subjects in my community. At any one moment in time, several dozen studies are actively recruiting human subjects in San Diego County. But even when I have been aware of a study and have been given a written description of the study to hand over to potentially eligible patients, it is rare for me to have the time to find the handout and explain to my patient why I think he or she may be interested. Generally, I want patients to know I am providing information about the study for their consideration, and that I am not necessarily endorsing it. Too much to do, with too little time. Plenty of other factors explain why clinicians rarely refer patients to research trials. Studies show that the primary reason doctors don’t refer potentially eligible patients is that they simply forget to do so (Lovato LC, 1997). I have been told by physicians that if clinical studies were designed to financially compensate practicing physicians to help recruit potential human subjects, they’d be more likely to do so. Many physicians have said that they still would not have the time, but would consider inviting research team recruiters to be present in their offices, to promote research, in selective studies. These schemes do occur for many studies, but we should not anticipate that these strategies will be affordable or feasible in most circumstances. Moreover, they raise other complications, such as conflict of interest if clinicians are compensated for recruiting. There has been some question as to whether the clinicians, or the health system for which they work, should be financially reimbursed for this effort. Some surveys have shown that clinicians are concerned that harm can come to their patients if they become subjects in a clinical trial. Some industry-sponsored clinical trials involve medications that have no clear benefit over existing choices but are being researched to provide a new source of income for pharmaceutical companies. Physicians may fear losing patients to a university practice or other research institution once their patients start participating in clinical research at the trial site and with its doctors. Research-

ers may fail to share clinical information about a patient once he or she is enrolled in a trial protocol. Patients could discontinue an important medication and/or fail to follow up with their regular doctors for chronic conditions during the period they are on a trial. Even given all these barriers, there is a role that busy physicians can play in hastening the pace that important new medical innovations come to fruition. Many physicians in practice recognize their role in the quicker translation of research into clinical innovations that are useful to us, and would deliberately choose to promote research participation to their patients if there were an easy way to do so. Here are some possibilities: 1. On a case-by-case basis, when a clinician is frustrated with a patient’s poor response to available therapies, that physician can actively seek a clinical trial opportunity for the patient. The

website clinicaltrials.gov is a great first start. On a search box, a physician can type in: “San Diego and Eczema” — for example — and a list of trials for that condition will appear. Details such as the inclusion and exclusion criteria and whether the study is actively recruiting are also provided. Unfortunately, the study’s description is often very technical. While this website is useful for referring doctors, it’s not often suitable for your average patient who does not have higher education in science and health. 2. Staying in touch on current research in one content area is far more practical than keeping up to date on dozens of clinical studies that are actively recruiting. For example, a GI specialist or a generalist with a special interest in irritable bowel syndrome could easily be updated (through clinicaltrials.gov) on local studies in just that topic area,

and refer patients to studies that appear appropriate. This not only furthers a physician’s own knowledge of progress in that field years before developments are published, but physicians may find they can develop relationships with local investigators in that field and even influence the design of research. 3. Let your patients know that “research participation can be a good thing.” Many members of the general public understand the selfless good that comes from donating blood, but have never thought of clinical research participation in the same way. Posters or pamphlets in a doctor’s waiting room with messages that remind patients that all innovations in medicine are derived from scientific research may influence them to seriously consider volunteering if ever approached to do so. Physicians who do nothing more than post such messages can, over

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Clinical Trials time, significantly ameliorate the problem of poor patient accrual into research studies. 4. “Research Match” (www.researchmatch.org) is an NIH-funded website located at Vanderbilt University. Any member of the general public can confidentially register his or her geographic location, age, sex, and the medical information he or she wishes to share on this site. The prospective subject is then informed with an email whenever a research study becomes available that may be of interest. Investigators cannot reach a registered user until that user actively expresses an interest in a described project. Only studies approved by accredited human subjects committees are on the website. Physicians who display Research Match posters or pamphlets in their patient areas are simply allowing patients to make themselves aware when research studies are available. 5. In the future, electronic health records may be linked to clinical trial alert systems so that when a certain patient profile is entered in the EHR, the physician of the patient in question receives notice that a clinical trial may be available. Studies on whether physicians find this helpful and informative, or just intrusive, are being conducted. Investigators could arguably be doing more to help busy physicians, but they often do not know what it is they can do. Do physicians want regular contact about their patients, with their permission, who are enrolled in local studies? How often should that be? What kind of information do physicians want? And how do they want to receive it (mail, email, fax)? Do referring physicians want to be notified of study results before the study is accepted for publication? Perhaps investigators need to find ways that unpublished study results can be shared with local physicians, but that won’t jeopardize chances for publication. If you are a physician who is interested in obtaining posters for your office, or if you are interested in offering your advice to investigators about referring your patients to research studies, we invite you to complete a survey on www.MDSurvey. ucsd.edu. We don’t know yet how to optimize the relationship between the in18 SAN DIEGO PHYSICIAN.org j u ly 2012

vestigator and the practicing clinician, but since our patients and society in general will benefit from expediting the development of improved therapies and devices, it’s a relationship worth working on. Dr. Taras, SDCMS-CMA member since 2012, is the director of community engagement for the UC San Diego Health System’s Clinical and Translational Research Institute.

If you are a physician who is interested in obtaining posters for your office, or if you are interested in offering your advice to investigators about referring your patients to research studies, we invite you to complete a survey at www. MDSurvey.ucsd.edu.

Where Are Your Patients Coming From?

“...most experts say referral marketing will only become more entrenched as health care cuts continue”

Each month, every practicing physician in San Diego County receives a copy of this magazine. What better way to ensure they know about your practice? We have advertising packages available at very attractive price points, and member physicians receive 50% off! If your doors are open for business, keep patients coming in with a referral advertisement in San Diego Physician magazine. Contact Dari Pebdani at 858-231-1231 or at DPebdani@sdcms.org j u ly 2012 SAN DIEGO PHYSICIAN.org 19

SDCMS Physician Workforce and Compensation Survey

2011 by tom gehring, ceo, sdcms

20 SAN DIEGO PHYSICIAN.org j u ly 2012

sdcms.org

I. Summary of Key Findings • Background and history • Demographics • Medicare • Medi-Cal • County Medical Services • (Dis)Satisfaction With the Practice of Medicine • Physician Shortage • Specialty-specific Shortages • General Recruiting • Specialty-specific Recruiting • Retention • Total Work Hours • Hours With Patients • Satisfaction With the Time Spent With Patients • Time to Obtain an Appointment • Compensation • Compensation Trend • Specialty-specific Compensation Data II. A Tale of Three Practices III. Specialty-specific Information

I. Summary of Key Findings Background and history In 2002, the San Diego County Medical Society (SDCMS) conducted San Diego County’s first Physician Workforce and Compensation Survey. The results provided SDCMS and local healthcare policymakers with their first insights into physicians’ attitudes toward their work — as well as San Diego County’s physician compensation environment. Subsequent Physician Workforce and Compensation surveys conducted by SDCMS in 2005, 2007, 2009, and now again in 2011, using almost exactly the same questions for consistency, continue to yield valuable data and insights for our San Diego County physician community and local and state legislators.

Demographics The demographics of the 2011 survey respondents were impressive. We received 757 responses (from among a population of 7,200, giving us a 99% confidence level), up from 580 in 2009. The preponderance of respondents were SDCMS members. However, the distribution of respondents was consistent with the physician community in San Diego County across modes of practice, geography, gender, and primary/specialty care.

Medicare Physicians were asked about their history and plans for Medicare. When pediatricians are factored out of the data, given that Medicare for children is a rarity, every statistical grouping except solo physicians (a category defined as either 1 or 2 doctors practicing together) takes Medicare at or near 100%. 87% of nonpediatric solos take Medicare, up from 82% in 2009 and 81% in 2007. Of solos who took Medicare three years ago, 4% do not take Medicare today, an increase in retention from 2009 when 9% dropped Medicare. j u ly 2012 SAN DIEGO PHYSICIAN.org 21

If Medicare rates are unchanged, a political probability despite the onerous rhetoric about the 27% Sustainable Growth Rate (SGR) cut programmed for the end of 2012, about a quarter of San Diego County’s nonpediatric solo and small-group physicians who currently take Medicare will change their Medicare practice. Of note, this is a change from 2009, when more than a third of the same cohort indicated they would change Medicare. Across the board, Medicare seems to be getting “stickier,” assuming no change in rates. If Medicare rates are reduced by 5%, a political possibility, the response of San Diego County’s nonpediatricians who currently take Medicare is graphically represented in Table 1. It shows the percentage of physicians currently taking Medicare who would continue to take Medicare “as is.” All others would eliminate Medicare, significantly reduce the number of Medicare patients, or take no new Medicare patients. The large decrease in solo and smallgroup physicians continuing to take Medicare “as is” is to be expected. What is astonishing is the rate at which mediumgroup and even large-group physicians would change their behavior in the event of even a 5% change in Medicare (see Table 1). In the face of a 5% cut in Medicare, most would significantly reduce the number of Medicare patients.

Table 1: Distribution of Responses to a 5% Cut in Medicare, by Mode of Practice Table 1: Distribution of Responses to a 5% Cut in Medicare, by Mode of Practice 100%

15%

90%

32%

80%

41% 59%

70% 60% 50%

85%

40%

67% 59%

30%

41%

20% 10% 0%

UCSD

Large Group Change Medicare Practice if 5% Cut

Solo and Small Group

Take Medicare As Is if 5% Cut

Table 2: Distribution of Medicare Actions in the Face of a 5% Rate Decrease, by Mode of Practice UCSD

Large Group

Mediumlarge group

Mediumsmall group

Small Group

Solo

Continue to Take Medicare

87%

86%

74%

88%

66%

67%

Eliminate Medicare

Significantly Reduce Medicare

10%

21%

22%

23%

No New Medicare

“Overhead is continually increasing with no signs that it will stabilize. If recession hits, all costs will go up dramatically.” — general anecdotal physician response

“The problem is not an absolute shortage of physicians. The problem is a shortage of good physicians who are willing to work with the poor, the disabled, and the mentally ill.” — general anecdotal physician response

22 SAN DIEGO PHYSICIAN.org j u ly 2012

Medium Group

Medi-Cal Table 3: Distribution of Medi-Cal Acceptance, by Mode of Practice

Table 3: Distribution of Medi-Cal Acceptance, by Mode of Practice

100%

90%

92%

80% 70% 60%

67%

62%

55%

50% 40%

36%

30% 20% 10% 0%

Community Clinic

UCSD

Large Group

Medium Group

Small Group

Solo

Table 4: Distribution of Medi-Cal Actions in the Face of a 5% Rate Decrease, by Mode of Practice UCSD

Large Group

Medium Group

Small Group

Solo

Continue to Take Medi-Cal

79%

70%

62%

20%

25%

Eliminate Medi-Cal

13%

33%

28%

Reduce Medi-Cal

14%

22%

23%

27%

No New Medi-Cal

23%

19%

“The issue is not a physician shortage but a shortage of physicians willing to see underinsured or uninsured patients. Put another way, we have no way to get specialty services for the vast majority of underinsured patients in this county that need a specialist. They can get primary care, but they can’t get to an oncologist, or get their hernia fixed, or see a pain specialist for their chronic pain.”

Physicians were asked about their history and plans for Medi-Cal. On average, 62% of physicians took Medi-Cal in 2011, versus 59% who took Medi-Cal in 2009, 63% in 2007, and 70% in 2005. Of those solo physicians who took Medi-Cal three years ago, 21% have stopped taking Medi-Cal. The drop rate for primary care solo physicians was 29%, and for solo specialists was 17%. The average loss-rate for all other Medi-Cal providers averaged 6%. Table 3 provides a detailed breakdown by mode of practice of Medi-Cal acceptance rates. The next table displays the specific change(s) methodology in the face of a 5% rate decrease for physicians who currently take Medi-Cal. Physicians would have one of three options: reduce the number of hours dedicated to Medi-Cal, take no new Medi-Cal patients, or eliminate Medi-Cal altogether (see Table 4).

“San Diego County is very fortunate to have a plentitude of physicians. The real issue is compensation for services rendered, which allows patients to find a physician.” — general anecdotal physician response

— general anecdotal physician response

j u ly 2012 SAN DIEGO PHYSICIAN.org 23

County Medical Services Physicians were asked about their history and plans for County Medical Services (CMS). 46% of physicians took CMS. This compares with 41% in 2009 and 47% in 2007. Of the doctors who took CMS three years ago, the percentage who are no longer taking CMS is negligible, except for solo and small-group physicians, where 13% dropped CMS. (see Table 5). Table 6 gives a detailed analysis of physicians’ behavior, assuming no change in CMS rates. Table 7 provides details on what the behavior of clinicians will be if CMS rates are left unchanged.

Table 5: Table Distribution of CMS Acceptance, by Mode ofby Practice 5: Distribution of CMS Acceptance, Mode of Practice 100% 90% 80%

83%

70% 60%

63% 54%

50% 40%

40%

38%

30% 20%

21%

10% 0%

Community Clinic

UCSD

Large Group

Medium Group

Small Group

Solo

Table 6: Distribution of of Responses toto CMS’ of Practice Practice Table 6: Distribution Responses CMS’Rates RatesNot NotIncreasing, Increasing,by by Mode Mode of 100%

11%

15%

90%

23%

33%

80% 70% 60% 50%

85%

40%

89%

67%

77%

30% 20%

Down from 79% in 2009

10% 0%

UCSD

Large Group

Medium Group

Take CMS As-Is

Solo and Small Group

Change CMS Practice

Table 7: Detailed Behavior to CMS’ Rates Not Increasing, by Mode of Practice

“Regulatory agencies are truly out of control, and this comes from someone who feels some degree of regulatory oversight is required.” — general anecdotal physician response

24 SAN DIEGO PHYSICIAN.org j u ly 2012

UCSD

Large Group

Medium Group

Small Group

Solo

Continue to Take CMS

85%

89%

77%

70%

66%

Eliminate CMS

15%

Reduce CMS

12%

16%

10%

15%

No New CMS

(Dis)Satisfaction With the Practice of Medicine The dissatisfaction of physicians with the practice of medicine in San Diego County is strong, but 2011 data does not reflect significant changes since 2009. Overall, 59% are less satisfied with the practice of medicine than they were five years ago, as compared with 54% in 2009, 50% in 2007, and 53% in 2005. Doctors reported that 15% are more satisfied and 26% see no change in their satisfaction with the practice of medicine. On a positive note, UCSD physicians continue to be the most satisfied cohort, by far, of San Diego County’s physicians. There is strong variation along several axes of data analysis. Table 8:Table Physician Dissatisfaction by Gender Time-in-Practice Cohorts Cohorts 8: Physician Dissatisfaction byand Gender and Time-in-Practice 80% 75% 74%

70%

67%

66%

65%

61%

60%

63% 57%

55%

55% 53%

50%

53%

45% 40% 35% 30%

36%

0-5 Years

6-10 Years

11-15 Years

Male Dissatisfaction

16-20 Years

21-30 Years

30+ Years

Female Dissatisfaction

“In five years, and certainly in 10 years if current trends continue, nobody will be able to afford to stay in private practice.”

In a worrying trend, female physician dissatisfaction has significantly increased: from 39% in 2007 to 57% in 2009 and 63% in 2011. The dissatisfaction among male physicians has stayed in the mid-50% range since 2007. With the exception of one cohort (doctors in practice 6–10 years), in every case female physicians are unhappier than male physicians. Female doctors in their first five years of practice are significantly unhappier than male physicians. The dissatisfaction among solo and small-group physicians continues to grow linearly; for 2011, 70% of solo and smallgroup doctors are less satisfied with the practice of medicine than five years ago, compared with 67% in 2009, up from 60% in 2007. Dissatisfaction among the large- and medium-group physicians has held steady, in the mid-50% range, as compared to 2009. The differences in dissatisfaction between specialists and primary care physicians is negligible, with specialists slightly more dissatisfied. The dissatisfaction of physicians with medicine increases with time in practice. There is a “honeymoon” in the first five years of practice, where the gap between satisfied and dissatisfied is small. However, there is a huge differential (50%) between satisfied and dissatisfied doctors in the 6–10 years of practice cohort. Then physician dissatisfaction increases almost linearly to peak at 65% dissatisfied in the greater-than-30-years-of-practice cohort.

Physician Shortage Physicians were asked whether they felt there was an overall physician shortage, and, if so, in what areas. Overall, 38% — unchanged since 2009 — felt there was a physician shortage. There is a significant difference in the response of UCSD physicians and non-UCSD physicians. Few (26%) UCSD physicians believe there is a physician shortage, while the other cohorts (large-group, mediumgroup, and small/solo) averaged 41% of physicians who believe there is a physician shortage.

— general anecdotal physician response

j u ly 2012 SAN DIEGO PHYSICIAN.org 25

Specialty-specific Shortages

Specialty-specific Recruiting

Every respondent was asked which specialties were experiencing shortages. The results were tabulated to identify in what specialties there was a consensus of shortage. The following is a list (in priority listing) of specialties where more than 5% of respondents (37 physicians) felt there were shortages. Of those listed, some specialties had longer-than-average wait times for a new patient appointment — an informal indicator that a perceived shortage by physicians is translating into a real problem for patients: • family medicine (repeat from 2009, 2007, 2005) • internal medicine (repeat from 2009, 2007, 2005) • psychiatry (repeat from 2009, 2007, 2005) (longer-than-average wait times) • neurology (repeat from 2009, 2007, 2005) (longer-than-average wait times) • rheumatology (repeat from 2009, 2007) • endocrinology (repeat from 2009, 2007) (longer-than-average wait times) • general surgery (repeat from 2009, 2007, 2005) • pediatrics (repeat from 2009, 2007) • pain medicine (repeat from 2009, 2007) (longer-than-average wait times) • neurosurgery (repeat from 2009, 2007, 2005) • dermatology (repeat from 2009, 2007, 2005) • gastroenterology (repeat from 2009, 2007) (longer-than-average wait times)

Specialty-specific data was then analyzed to identify those specialties with significant recruiting problems. Significant difficulty — defined as in-specialty recruiting with significant difficulty reported by at least 33% — was indicated for the following specialties (sorted alphabetically): • endocrinology (upgraded from “some difficulty” in 2009) • gastroenterology (repeat from 2009) • general surgery (repeat from 2002, 2005, 2007) • internal medicine (upgraded from “some difficulty” in 2009, “significant difficulty” in 2005 and 2007) • neurology (upgraded from “some difficulty” in 2009, “significant difficulty” in 2002, 2005, 2007) • OB/GYN (“significant difficulty in 2009,” “some difficulty” in 2007) • orthopedic surgery (repeat from 2005, 2007, 2009) • otolaryngology (upgraded from “some difficulty in 2009, “significant difficulty” in 2005, 2007) • pain medicine (new in 2011) • psychiatry (repeat from 2002, 2005, 2007, 2009) • vascular surgery (new in 2011, “some difficulty” in 2007) • urology (repeat from 2009) Some difficulty in recruiting, characterized as “no difficulty in recruiting” at less than 50%, was identified for the following specialties: • cardiology (repeat from 2009) • family medicine (“some difficulty” in 2009, “significant difficulty” in 2005, 2007) • hematology/oncology (“some difficulty” in 2005 and 2009, “significant difficulty” in 2007)

General Recruiting Paradoxically, while there is not a strong a sense of physician shortage, there is still a significant concern about recruiting physicians. The recruiting picture does not appear to have changed significantly since 2009. Of those who were involved in recruiting, 39%, consistent with 2009 and 2007, reported some difficulty in recruiting. 26%, down slightly from 2007 and 2009, reported significant difficulties recruiting. An astonishing 78% of solo and smallgroup physicians reported difficulty recruiting (either some or significant difficulty), essentially unchanged from 2009 and 2007.

“State budget cuts have made working with the poor an act of charity and cooperation with Medi-Cal an act of masochism.” — general anecdotal physician response

26 SAN DIEGO PHYSICIAN.org j u ly 2012

“Have not encouraged my kids to become a doctor.” — general anecdotal physician response

• nephrology (downgraded from “significant difficulty” in 2007, 2009) • neurosurgery (repeat from 2009) • pathology (new in 2011) • pediatrics (repeat from 2007 and 2009) • pulmonology/critical care (“some difficulty” in 2005 and 2009, “significant difficulty” in 2007) • radiology (downgraded from “significant difficulty” in 2002, 2005, 2007, 2009)

Retention On the subject of physician retention, the 2011 survey projects 82% of San Diego County physicians will maintain their practice “as is” for the next three years, essentially unchanged from 2009, 2007, and 2005. Physicians were asked what they intend to do with their practice in one to three years. The results, all essentially unchanged from 2009, 2007, and 2005, are as follows: • Leave (retire, change jobs, or move) practice of medicine in one year: 3%, essentially unchanged from 2009, 2007, and 2005. • Leave (retire, change jobs, or move) practice of medicine in three years: 9% essentially unchanged from 2009, 2007, and 2005. • Reduce hours in the practice of medicine in one year: 2%, essentially unchanged from 2009, 2007, and 2005. • Reduce hours in the practice of medicine in three years: 4%, essentially unchanged from 2009. • When analyzed by mode of practice, there is a clear difference: The solos are likely to get out of the practice of medicine at a much higher rate than any of the other cohorts. This data is essentially unchanged from 2009.

“I spend more time on documentation than seeing patients and thinking about their issues.” — general anecdotal physician response

When analyzed by geography, three items were noteworthy: • South Bay physicians are not leaving the practice of medicine. • Kearny Mesa doctors are leaving medicine at a much greater rate, and soon! • Many physicians in La Jolla are going to leave the practice of medicine within three years. Not surprisingly, of those physicians likely to change their practice mode, there was a clear drop-off for physicians in practice for more than 30 years, only 65% of whom said they would be in practice in three years. Of note, that same retention statistic for doctors in practice for more than 30 years was 59% in 2009, perhaps reflecting the economic difficulty of retiring.

Total Work Hours The average number of total hours worked by full-time, active San Diego County physicians, including clinical and nonclinical hours, was 60 hours per week, unchanged from 2007 and 2009. Since 2007, the total hours reported by large- and medium-group doctors has steadily increased (while the total hours reported by solo and small-group physicians has very slightly decreased), to where there is now near parity in reported total hours worked. Doctors in large groups reported working, on average, longer than solo/smallgroup physicians. There was a slight reduction in the reported total work hours for UCSD. Not surprisingly, while the patient load at UCSD is less, the teaching and research load is higher.

Hours With Patients A full-time San Diego County physician spends, on average, about 40 hours per week seeing patients, essentially unchanged from 2007 and 2009. As in 2009 and 2007, there was negligible (less than one hour per week) variation when the data was analyzed by specialist versus primary care physician. The patient hours per week reported for female doctors as compared to male physicians is nearly identical for UCSD and large groups. However, female doctors see about six fewer patient hours per week in solo, small and medium-size practices. Of note, the total work hours for female doctors at large groups and UCSD is higher than for male physicians.

j u ly 2012 SAN DIEGO PHYSICIAN.org 27

28 SAN DIEGO PHYSICIAN.org j u ly 2012

15.9

16.0

Pain Medicine

Neurology

16.0

14.1

14.2

Endocrinology

13.4

14.1

12.5

12.0 11.0

13.3

13.8

Surgery Vascular

13.1

Gastroenterology

13.0

PM&R

14.0

Nephrology

15.0

11.3

10.0 9.0

Psychiatry

8.0 Obstetrics and Gynecology

62% responded that time with patients was adequate, while 38% said time was inadequate. This is consistent with prior surveys. Solos overwhelmingly (72%) felt that time spent with patients was adequate. Of note, small-group doctors, who typically track with solo, are less satisfied (57% satisfied versus 72% satisfied for solos) than their solo peers with the time spent on patient care. Community clinic doctors were overwhelmingly unhappy (69% not satisfied) with the time spent on patient care. Government physicians, on the other hand, were very satisfied with the time spent on patient care. The satisfaction of doctors with time spent on patients in the large/medium group cohort continues to increase since 2007. Within the medium- and largegroup cohort, it was the large-group physicians who were happiest with the time spent on patient care (62% satisfied versus 54% satisfied for medium-group doctors). 67% of physicians practicing in an academic setting were satisfied with time spent with patients, unchanged since 2007. While there was no significant gender differences for solo/small-group physicians, in a change since 2009, female physicians in large and medium groups are more satisfied with time spent with their patients than their male counterparts, while at UCSD, community clinics, and government, the reverse was true. Specialists are overwhelmingly (68%) satisfied with time spent with patients, consistent with 2009.

17.0

Urology

Satisfaction With the Time Spent With Patients

Table 9: Wait Times in Days for Specialties Above the Average Table 8:Average Average Wait Times in Days for Specialties Above the Average

Cardiology

There was also significant variation between the hours spent with patients for the various modes of practice: • Solo and small-group physicians spent about 42 hours per week seeing patients, unchanged since 2007. • Medium- and large-group physicians spent about 42 hours per week, a consistent upward trend since 2007. Of note, large-group physicians have the highest number of reported patient hours of all modes of practice.

Table 10: Approximate Average Pay of Full-time, Active Physicians Over the Last Four Surveys Year

Approximate Pay

2005

$160,000

2007

$180,000

2009

$210,000

2011

$215,000

“It is remarkably still good!” — general anecdotal physician response

“It has been a constantly adaptive process. As our compensation goes down with each passing year, we are expected to do more, take more responsibility, see more patients in less time, and have better results.” — general anecdotal physician response

Primary care physician satisfaction with time spent on patients was unchanged since 2007 at about 55%. One significant anomaly is that primary care physicians at large/medium groups and UCSD were less satisfied with the time spent with patients (around 52% positive) than their peers in solo/small-group settings (63% positive).

Time to Obtain an Appointment The average time for a new patient to obtain an appointment was 2.1 weeks, or 11 business days, essentially unchanged since 2005. When compared to 2007 and 2009 data, there is no significant change in the overall average wait time distribution for new appointments: • 37% in 1 week, essentially unchanged since 2007 • 32% in 2 weeks, essentially unchanged from 2007 • 13% in 3 weeks, essentially unchanged from 2007 • 18% in 4 weeks, essentially unchanged from 2007 Community clinics had the longest wait times, while solo, small groups and medium groups had the shortest wait times. A difference in wait times for female versus male physicians that was noted in the 2009 data has significantly lessened, from 14 vs. 10 days in 2009, to 11.5 vs. 10.4 days in 2011. The significant variation between

the years-in-practice cohorts noticed in 2009 was not repeated in the 2011 data — the variation is under one business day. There was, however, significant variation between modes of practice. Solo wait times are getting shorter, while, paradoxically, small-group waits are increasing. Medium-group wait times are increasing, while large-group and UCSD wait times are holding steady. As would be expected, the data indicated significant variation between specific specialties. Data for those specialties receiving fewer than five physician responses were removed from the chart, and only specialties above the average of 11 days were included (see Table 9). Individual specialty average wait times were calculated and compared to the average. Table 9 displays the specialties that had wait times above the average: • Neurology, psychiatry, ophthalmology, and nephrology had higher-than-average wait times in 2007, 2009 and 2011. • Urology and gastroenterology had higher-than-average wait times in 2009 and 2011. • Allergy and immunology, hematology/oncology, internal medicine, cardiology, obstetrics and gynecology, physical medicine and rehabilitation (PM&R), vascular surgery, endocrinology, and pain medicine were new on the list.

“Love what I do.” — general anecdotal physician response

Compensation The approximate net compensation for full-time active physicians increased very slightly from 2009 to 2011. Primary care physician compensation declined from $171,000 to $166,000, while specialist compensation increased from $229,000 in 2009 to $235,500 in 2011. The approximate self-reported pay for the three cohorts is as follows: UCSD: $196,000; large- and medium-group doctors: $236,000; and solo and small-group physicians: $205,500. Pay for solo and small-group physicians improved slightly since 2009. On the other hand, pay for medium- and large-group physicians improved significantly since 2009. Male doctor compensation remained constant, while female physician pay has increased slightly, from $158,000 to $164,000, but the disparity between men and women doctors is still dramatic. When active, full-time physician compensation is examined over the quarters of the doctors’ professional life cycle, an interesting trend emerges. Everyone expects first-quarter compensation (0–10 years in practice) to be lower, but not by much. However, the next three quarters (11–20 years in practice, 21–30 years in practice, and greater than 30 years in practice) show essentially no growth. Said differently, there are no longevity raises for doctors after they reach 10 years in practice.

Compensation Trend Physicians were asked whether their compensation went up, stayed the same, or went down relative to their compensation three years ago. The general compensation trend is flat: 2/3 of respondents did not get a pay increase: • 36%, down from 43% in 2009, reported that compensation increased in the last three years. • For 31%, almost identical to 29% in 2009, compensation decreased in the last three-year period. • Compensation remained the same in the last three years for 33%, up slightly from 28% in 2009. The female physicians’ opinion of the compensation trend is more positive than their male counterparts. Significantly, more females than males have increasing compensation.

j u ly 2012 SAN DIEGO PHYSICIAN.org 29

When the physicians’ opinions about compensation trends are reviewed by mode of practice, several interesting trends appear: • Government and community clinic physicians believe that their pay is improving. • Solos in particular, and small-group physicians slightly less so, think that their pay is decreasing. • Large-group and UCSD doctors are sensing that their pay is improving. The compensation of primary care physicians has increased, while, relative to three years ago, the compensation trend of specialists has not been as positive as primary care physicians. The data, when broken out by primary vs. specialist, indicate that primary care physicians’ opinions about their compensation is significantly more positive than that of specialists. When analyzed for years in practice, the trends are not surprising: younger physicians see their compensation increasing, while older physicians do not. The data are almost exactly what you would expect for a workforce that thinks there is not a brighter financial future.

Specialty-specific Compensation Data The five lowest-paid specialties with 10 or more respondents are (in ascending order): • pediatrics • family medicine • physical medicine and rehabilitation • internal medicine • obstetrics and gynecology The five highest-paid specialties with 10 or more respondents are (in ascending order): • gastroenterology • orthopedics • radiology • dermatology • neurosurgery

30 SAN DIEGO PHYSICIAN.org j u ly 2012

II. A Tale of Three Practices An underlying theme since our 2005 Physician Workforce and Compensation Survey was the widening gulf between solo and small-group practices on the one hand — defined as fewer than five physicians in a practice — and medium- and large-group practices on the other. With the significant number of academic physicians responding to our 2007 survey, there appeared to be three distinct cohorts in modes of practices. Across a number of factors, there are significant differences between these practice types. Table 11 below summarizes the differences: If there has been a change since 2009, it is so highlighted by a note and a highlight — green for improved, red for degraded, or shadowed if the change is neither good nor bad.

Notes: 1. Medium-Large Group (MLG) doctor satisfaction has improved. 2. MLG total physician hours increased to parity with Solo/Small Group (SSG) doctors. 3. UCSD hours dropped to <need number here>. 4. SSG and UCSD have swapped position on compensation, where UCSD is now lowest, and SSG are middle. 5. UCSD physicians are no longer not concerned about recruiting. 6. Medicare acceptance rate for SSG went from 80% to 89%. 7. Physician retention for UCSD dropped by about 10%. 8. Patient care hours dropped slightly for UCSD.

Table 11: Difference Between Solo and Small-group Practices and Medium- and Large-group Practices Solo or Smallgroup Physicians

Medium- or Large-group Physicians

UCSD Physicians

Dissatisfaction With the Practice of Medicine

Very Dissatisfied

Plurality Are Now Satisfied Dissatisfied

Physician Satisfaction With Time Spent With Patients

Very Satisfied

Satisfied (1)

Very Satisfied

Total Physician Work Hours

Long — about 59 hours/week

Long — about 59 hours/week (2)

Longest — about 65 hours/week (3)

Patient Care Hours

42.5 hrs

40.5 hours/week

32 hours/week (8)

Compensation

Middle (4)

Highest

Lowest (4)

Concerned About Recruiting New Physicians

Very Concerned

Concerned

Concerned (5)

Remain in the Practice of Medicine

About 75%

Almost 90%

Near 80% (7)

Take Medicare

89% (6)

Near 100%

Take Medi-Cal

About 1/3

About 2/3

Near 100%

Take CMS

About 1/4

About 1/2

About 3/4

Table 12: Overview of Specialties in Crisis (Red) and in Difficulty (Yellow) Primary Care

<5 Responses

> Average Wait Times

Perceive This As a Shortage

Difficulty Recruiting

Family Medicine (in difficulty: 2007, 2009)

Yes

Some

Internal Medicine (in difficulty: 2007, 2009)

Yes

Significant

Pediatrics (in difficulty: 2009)

Yes

Some

OB/GYN (in difficulty: 2005, 2009)

Yes

Significant

Allergy and Immunology Anesthesiology Cardiology

Yes

Dermatology (in difficulty: 2005; in crisis: 2009)

Some Yes

Emergency Medicine Endocrinology

Yes

Significant

Gastroenterology (in crisis: 2009)

Yes

Significant

Yes

Significant

General Surgery (in difficulty: 2005, 2009) Hematology/Oncology (in difficulty: 2007) Infectious Disease

Some Yes

Nephrology (in difficulty: 2007, 2009)

Yes

Neurology (in crisis: 2005, 2007, 2009)

Yes

Neurosurgery (in crisis: 2005; in difficulty: 2009)

Some Yes

Significant

Yes

Some

Ophthalmology (in difficulty: 2005) Orthopedic Surgery (in crisis: 2005)

Significant

Otolaryngology (in crisis: 2005; in difficulty: 2007)

Significant

Pain Medicine

Yes

Pathology

Significant Some

Physical Medicine and Rehabilitation

Yes

Plastic Surgery Psychiatry (in difficulty: 2005, 2007; in crisis: 2009)

Yes

Significant

Pulmonology (in difficulty: 2005)

Some

Radiology (in difficulty: 2005)

Some

Radiation Oncology

Yes

Rheumatology (in difficulty: 2005)

Yes

Thoracic Surgery

Yes

Vascular Surgery

Yes

Urology (in crisis: 2005, 2009)

III. Specialty-specific Information Although highly subjective, the study identified specialties in crisis — defined as longer-than-average wait times for new patients, a perception that this specialty was in shortage, and a perception of difficulty recruiting within the specialty — highlighted in red. The specialties that are in crisis in San Diego County are: • neurology (four years in crisis: 2005, 2007, 2009, 2011) • psychiatry (four years in difficulty (2005, 2007) or crisis (2009, 2011)) • urology (three years in crisis: 2005, 2009, 2011) • gastroenterology (two years in crisis: 2009, 2011) • pain medicine (new in 2011) • endocrinology (new in 2011) Four specialties that deal (in part of in whole) with older patients are in crisis for multiple surveys: neurology, psychiatry, urology, and gastroenterology. In addition, those specialties that were in difficulty — defined as meeting two of the three criteria above — were highlighted in yellow: • family medicine (three years in difficulty: 2007, 2009, 2011) • internal medicine (three years in difficulty: 2007, 2009, 2011) • OB/GYN (three years in difficulty: 2005, 2009, 2011) • general surgery (three years in difficulty: 2005, 2009, 2011) • pediatrics (two years in difficulty: 2009, 2011) • cardiology (new in 2011) • nephrology (three years in difficulty: 2007, 2009, 2011) • neurology (two years in difficulty (2009 and 2011) and one year in crisis (2005)) Of note, all four primary care specialties are in difficulty.

Yes

Significant Yes

Significant

j u ly 2012 SAN DIEGO PHYSICIAN.org 31

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Opportunities for Physicians 1

Volunteer for Project Access San Diego:

If you are a specialist in private practice in San Diego, please consider joining more than 180 specialists in the county by seeing a limited number of uninsured adult community clinic patients in your office for free. Project Access coordinates all aspects of care so your volunteerism is hassle-free for you and your office staff.

Volunteer for eConsultSD:

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Obtain a Volunteer or Paid Position at a Local Community Clinic: SDCMSF is happy to connect specialist physicians with a community clinic that needs your services on site. This opportunity involves traveling to a clinic within San Diego County as your schedule permits.

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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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apri j u ly l 2012 SAN DIEGO PHYSICIAN.org 33

classifieds PRACTICE FOR SALE San Diego (Encinitas) Dermatology, Mohs, and Cosmetic Surgery Practice for Sale: Practice address is 477 N. El Camino Real, Encinitas at North Coast Health Center, a large multi-specialty health center. The practice has been at the location for the past 13 years. The seller is a solo, board-certified dermatologist who will be moving on to an academic position. Gross revenue has been in the $930,000 to $1.3 million range over the last four years. The office is about 1,600 square feet and has four exam rooms and two offices, a small lab, and two bathrooms. The practice is located in a populated area comprised of a large skin cancer population, and an affluent population seeking cosmetic procedures. Asking price is $325,000 (including at least $75K in inventory/equipment). If interested, please email dermmd10@gmail.com. [054] PHYSICIAN POSITIONS AVAILABLE mid-career pediatrician: Great opportunity for a mid-career pediatrician with kind manner and strong entrepreneurial spirit to work FT/PT in small solo progressive practice. This position is a partnership track. Night call is minimal but must be willing to work some Saturdays and evenings to help grow the practice. Nice mix of parents in great school area. Salary DOE. Nice, stable office staff with EMR. Send CV to cvp315@sbcglobal.net. [057] looking for per diem physician for busy urgent care: San Diego North County group looking for per diem physician for busy urgent care. Family medicine physician preferred. Need coverage for two days per week. Malpractice is covered. Please email CV to judy@cassidymg.com or fax to (760) 630-2558, attention Judy. [055] PART-TIME BOARD-CERTIFIED FAMILY PRACTICE / INTERNAL MEDICINE PHYSICIAN NEEDED FOR URGENT CARE / FAMILY PRACTICE FACILITY IN FALLBROOK: Fallbrook Medical Center located across from the Fallbrook Hospital is now seeking a part-time, boardcertified physician to work 1–2 days per week. Qualified physician must manage and provide acute, chronic, preventive, curative, and rehabilitative medical care to patients and determine appropriate regimen in specialized area. Candidate must work as a liaison to admit patients into the hospital. Forward resume to karenberrios@fallbrookmedicalcenter.com or call (951) 751-5593. Visit our website at www.fallbrookmedicalcenter.com. [051] PHYSICIAN AND PSYCHIATRIST NEEDED FOR AMBULATORY CLINIC: Southern Indian Health Council is seeking a FT board-certified physician Mon–Fri, 8:00am– 4:30pm, as well as a PT psychiatrist. Must have current CA medical license, DEA license, ACLS, BLS. We offer a competitive salary, health benefits, vacation, holidays, sick, CME and license reimburse, and malpractice coverage. Forward resume to jobs@sihc.org or fax to (619) 659-3145 or website at www.sihc.org. Contact jobs@ sihc.org or HR phone (619) 445-1188, ext. 308 or ext. 307 or HR fax (619) 659-3145. [048] PHYSICIANS WANTED: Board-certified family practice / internal medicine / ER physicians needed for a new urgent care opening around September 1 in the Scripps Ranch area of San Diego. 8:00am to 8:00pm shifts available 7 days/week. Malpractice insurance provided. Hourly wage. Please fax CV to Anne at (858) 622-1025. [047] MEDICAL CONSULTANT — INTERMITTENT: The County of San Diego is accepting applications from qualified BC/BE internist / family practice physicians for an exciting job opportunity as an intermittent medical consultant at the San Diego County Psychiatric Hospital (SDCPH), a publicly funded, free-standing psychiatric hospital. Must possess a valid California medical license at time of application and must be ABIM or ABFM board certified or be eligible for the certification examination. Questions can be directed to Gloria Brown, human resources analyst, at (858) 505-6525 or at Gloria.Brown@

sdcounty.ca.gov. Applications can be submitted online at www.sdcounty.ca.gov/hr. Please include cover letter and curriculum vitae. [045] PHYSICIAN NEEDED — FULL- OR PART-TIME SCHEDULES AVAILABLE: Family Health Centers of San Diego is a private, nonprofit community clinic organization that is an integral part of San Diego’s healthcare safety net. Since 1970, our mission has been to provide caring, affordable, high-quality healthcare and supportive services to everyone, with a special commitment to uninsured, low-income, and medically underserved persons. Every member of our team plays an important role in improving the health of our patients and community. We offer an excellent comprehensive benefits package that includes: malpractice coverage; NHSC loan repay eligibility; and much, much more! For more information, please call Anna Jameson at (619) 906-4591 or email ajameson@fhcsd. org. If you would like to fax your CV, fax it to (619) 8764426. To apply, visit our website and apply online at www. fhcsd.jobs. [046] 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] 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. [039a] PRIMARY CARE/PSYCHIATRY JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com ) is a fast-growing 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 perdiem 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. Bilingual 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] 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] 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 tailcovered 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 OFFICE FOR LEASE SCRIPPS MEMORIAL HOSPITAL MEDICAL OFFICE BUILDING: La Jolla multi-specialty group, excellent referral base, great location, corner office large windows, full- or part-time space available (one doctor retiring). Please call Dr. Shurman cell (858) 3449024 or office (858) 320-0525. [058] 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]

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 ly 2012

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 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) 8402400 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) 909-9033 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] 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) 442-9200, ext. 102. [006] 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] 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 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 pedes-

trian 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 PART-TIME NURSE PRACTIONER, CLINICAL NURSE, OR PHYSICIAN ASSISTANT: Busy family practice with a strong geriatric / pediatric population located in the SDSU area. Bilingual: English, Spanish, or Vietnamese very helpful, not a requirement. Please fax resume to (619) 582-5121 or email to colonialcorner@hotmail.com. [059] Physician Assistant needed: Physician assistant needed on per diem basis for busy urgent care in the San Diego North County area. Hours are evening and/or weekends. Please send CV to judy@cassidymg.com or fax to (760) 630-2558. [056] LOOKING FOR A NURSE PRACTITIONER: Established, busy pain management practice in Mission Valley is looking for a nurse practitioner 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

Where Are Your Patients Coming From?

email your curriculum vitae/resume to sdpainclinc@yahoo.com. [052] MEDICAL BILLER NEEDED FOR BUSY PAIN MANAGEMENT CLINIC IN MISSION VALLEY: Must be knowledgeable and experienced with Allscripts Misys. Please email references, contract, and terms to sdpainclinic@ yahoo.com. [053] OB/GYN NURSE PRACTITIONER WANTED FOR BUSY WOMEN’S HEALTH OFFICE IN DEL MAR AREA: This position conducts annual pap smear exams, deals with all gynecological issues, IUD insertions, as well as obstetric patient weekly appointments. Triage and detailed discussions of lab results. Midwife experience a plus but not required. Ultrasound experience preferred but not required. Position is for Tuesdays and Thursdays, 8:30am to 5:30pm. OB/GYN experience REQUIRED. Ability to keep up with a fast-paced schedule, 18–25 patients a day. Please contact us at cvwh858@gmail.com with resume and salary requirements. [050] PA NEEDED FOR DERMATOLOGY AND COSMETIC SURGERY PRACTICE IN ENCINITAS: Experience in general dermatology a must! Applicant must be knowledgeable in diagnosing and treating common dermatologic conditions, possess excellent interpersonal skills, be a caring and empathetic provider, and possess the highest of ethical standards. Being a team player and having a positive attitude is essential. Please forward resume and cover letter in Word format to dana@doctorlashgari.com. [049] PHYSICIAN ASSISTANT, NURSE PRACTITIONER, OR PART-TIME MEDICAL DOCTOR [039b] — See ad #039a 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] 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]

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

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SDCMS

Welcome Dr. Sherry L. Franklin SDCMS President for 2012–13

Following is Dr. Franklin’s acceptance speech at SDCMS’ June 2 White Coat Gala and Presidential Inauguration. Friends, family, and honored guests, thank you for coming to celebrate the next chapter of the San Diego County Medical Society. I am honored to be part of this Society, which is viewed as one of the best, if not the best county medical society in California. But before I go on, I would like to thank a few people very special to me: my husband, John, and our girls, Melody and Victoria, who have supported me during my time away from our nuclear family to help my second family — the doctors that make up this amazing county. I am honored to stand before you, my second family, not because I am different from you, but because I am exactly like you. Like you, I am happiest during a pure act of caring for a patient. Like you, I spent a decade or more training to care for those patients. Like you, I spent a decade paying off my student loans. Like you, I work to keep my 36 SAN DIEGO PHYSICIAN.org j u ly 2012

practice open while reimbursement rates fail to meet the cost of doing business. Like you, I fear the yearly congressional threats of draconian cuts to Medicare payments. Like you, I am overwhelmed by the bureaucracy involved in getting an authorization for medications or procedures for my patients. Like you, I live under the constant threat of litigation. And, like you, I fear the unknowns in the Affordable Healthcare Act and its creation of an Independent Payment Advisory Board and the state-imposed health benefit exchange. Most importantly, like you, I stand here with our county and state medical societies to make absolutely sure that our voices are being heard in Sacramento and DC. The strength of SDCMS and CMA is that we are rich in the resource that counts most: “physicians united and speaking with one loud voice” on core issues. It doesn’t matter if we are primary care physicians, specialists, or surgeons. It doesn’t matter if we work at Scripps, Sharp, Kaiser, UCSD, or for the Community Clinics. It doesn’t matter if we are in a small-, medium-, or large-group practice. We are all physicians, caring for patients. As the complexities of cost and quality in healthcare dominate the news, I can think of no group better than physicians to sit at the table and fight for what is right for the practice of medicine. One of my favorite quotes states that “if you aren’t sitting at the table, you’re likely on the menu.” With your participation, your Executive Committee and board of directors at the local and state levels keep you and your patients off that menu. Every day, around the clock, new rules and regulations on healthcare are being developed, often by people who have never been involved in the practice of medicine. And every day, around the clock, our organization is standing on the front lines to speak on our behalf. When Congress attempts to slash Medicare payments due

to an outdated “Sustainable Growth Rate” formula, we launch a full-scale campaign to stop the cuts. When there is even the hint of an attack on MICRA, we fight to keep malpractice premiums reasonable so that patients will have doctors to see. When insurers engage in unfair practices, we go to court and fight — and we win. For those physicians who might ask you why you are a member of SDCMS when you already have a specialty society to which you pay dues, remind them that someone has to hold the line while they take care of patients. Remind them that if SDCMS and CMA weren’t here, MICRA wouldn’t be here either. Remind them that if SDCMS and CMA weren’t here, Medi-Cal rates would have been cut 10% last year. Remind them that if SDCMS and CMA weren’t here, Medicare rates would have been cut by close to 30% by now. And, most importantly, remind them that as reimbursement declines, so do the number of good doctors working in California. There was a time when most of the members of the medical profession, if not all, were members of organized medicine. In this day and age, only about one-third of our colleagues belong to a geographically based association. Consider this in contrast: Most, if not all, attorneys belong to the bar association. We have all heard the maxim that there is strength in numbers. It is in the best interest of our profession and our patients that we reclaim that sense of physician community. This community will then be empowered to sit at the table when healthcare issues such as patient satisfaction, performance standards, quality assurance, and cost effectiveness are discussed. Like you, I will go back to seeing patients on Monday morning. Like you, I will be working my hardest to care for my patients. The extra time I take to be part of this larger community of physicians is an honor. Join me, work with me to support SDCMS and CMA so that Sacramento and Washington once again hear loud and clear the voices of physicians and their patents. Please stand and join me in a toast to the doctors who make up the San Diego County Medical Society. And remember, when you sit back down, know that because of this physician community, you have a seat at the table.

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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