May 2013

San Diego Physician

100 celebrates

official publication of the san diego county medical society May 2013

years

Empowering our

patients

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B

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

Contents May

Volume 100, Number 5

features

Managing Editor: Kyle Lewis 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

EMPOWERING OUR PATIENTS

20

istilling Wisdom for the D Informed Consumer

SDCMS Board of Directors

JAMES SANTIAGO GRISOLIA, MD

Officers President: Sherry L. Franklin, MD (CMA TRUSTEE)

22 Empowering Diabetes Patients to Take Charge of Their Care

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)

geographic and geographic alternate Directors

ATHENA PHILIS-TSIMIKAS, MD, AND DANIEL EINHORN, MD

East County: Alexandra E. Page, MD, Venu Prabaker, MD Hillcrest: Theodore S. Thomas, MD (A: Gregory M. Balourdas, MD)

24

departments

TRACY SALAZAR, PHD

4 Briefly Noted: Calendar • Get in Touch • Commercial Real Estate Tips & Trends • And More …

ho Is the Best Doctor W to Go To? One Patient's Perspective

26

MySharpTM

8

27

My Health Manager

28

An Interview With Thomas Lenox, Supervisory Special Agent, DEA: Part 2

RONEET LEV, MD

MyUCSDChart

12

30

ommunication Matters: C The Most Important CME We Receive All Year HELANE FRONEK, MD, FACP, FACPH

32

Local Health Charities

UC San Diego’s 2013 Residency Match

14

A Safety I Have Known

DANIEL J. BRESSLER, MD

16

When Prescribing Drugs, A Physician Has a Duty to Warn Patients

THE DOCTORS COMPANY

18

Malpractice Claims Consume Years of a Physician’s Career

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 SPEAKER) Young Physician Director: Van L. Cheng, MD Retired Physician Director: Rosemarie M. Johnson, MD Medical Student Director: Suraj Kedarisetty

OTHER NONVOTING MEMBERS Young Physician Alternate Director: Renjit A. Sundharadas, MD Retired Physician Alternate Director: Mitsuo Tomita, MD SDCMS Foundation President: Stuart A. Cohen, MD, MPH CMA Past Presidents: James T. Hay, MD (AMA DELEGATE), Robert E. Hertzka, MD (LEGISLATIVE COMMITTEE CHAIR, AMA DELEGATE), Ralph R. Ocampo, MD CMA Trustee: Albert Ray, MD (AMA ALTERNATE DELEGATE) CMA Trustee (OTHER): Catherine D. Moore, MD CMA SSGPF Delegates: James W. Ochi, MD, Marc M. Sedwitz, MD CMA SSGPF Alternate Delegates: Dan I. Giurgiu MD, Ritvik Prakash Mehta, MD ama alternate delegate: Lisa S. Miller, MD

THE DOCTORS COMPANY

34

Physician Marketplace: Classifieds

16 2 May 2013

36

San Diego Physician Celebrates 100 Years: February 1955

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

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/////////briefly ///////////////////noted ////////////////////////////////////////////////////////////////////// calendar SDCMS Seminars, Webinars & Events SDCMS.org

For further information or to register for any of the following SDCMS seminars, webinars, workshops, and courses, email Seminars@SDCMS.org.

SDCMS and SDCMS Foundation 2013 White Coat Gala (event) JUN 8: 6:00pm–10:30pm • JOhmstede@SDCMS.org Guidance to Effective Disciplinary Practices (seminar/webinar) JUN 20: 11:30am–1:00pm Financial and Legal Life Skills for Financially and Legally Clueless Docs (workshop) JUN 22: 8:00am–12:00pm • Gehring@SDCMS.org Hospital Discharge Planning: Lost in Transition (seminar/ webinar) JUL 18: 11:30am–12:30pm Taming Microsoft Outlook (workshop) JUL 20: 8:00am–12:00pm

Cma Webinars CMAnet.org/events Estate Planning After the Fiscal Cliff MAY 29 • 12:15pm–1:15pm Essentials for ICD-10-CM: Part 3 MAY 30 • 12:15pm–1:15pm A Guide to Updating Your Partnership and Shareholder Agreements JUN 5: 12:15–1:15pm Paid Family Leave: A Valuable Safety Net JUN 12: 12:15pm–1:15pm What to Expect From a Medi-Cal Audit JUN 19: 12:15pm–1:15pm Meaningful Use: What You Need to Know for This Year and Stage 2 JUN 26: 12:15pm–1:15pm

4 may 2013

get in touch 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.

Affordable Care Act (ACA) Implementation on the U.S./ Mexico Border: Focus on HIV, STDs, TB, Addiction, and Family Planning Concerns MAY 30 • 2 Webinars: 9:00am or 12:00pm • Registration is required. To receive registration materials, email Joel Peisinger at jpeisinger@mednet.ucla.edu.

Please indicate Webinar 1 or Webinar 2 in the subject line.

Prenatal Diagnosis 2013 MAY 31–JUN 1 • CME provided at no cost by San Diego Perinatal Center to those serving the families of our region • Scripps Memorial La Jolla, The Schaetzel Center • No fee for registration or lectures • bmacnabb@rchsd. org or (858) 966-4992

Your SDCMS and SDCMSF Support Teams Are Here to Help!

SDCMS Contact Information 5575 Ruffin Road, Suite 250, San Diego, CA 92123 T (858) 565-8888 F (858) 569-1334 E SDCMS@SDCMS.org W SDCMS.org • SanDiegoPhysician.org CEO • EXECUTIVE DIRECTOR Tom Gehring at (858) 565-8597 or Gehring@SDCMS.org COO • CFO James Beaubeaux at (858) 300-2788 or James.Beaubeaux@SDCMS.org DIRECTOR OF ENGAGEMENT Jennipher Ohmstede at (858) 300-2781 or JOhmstede@SDCMS.org DIRECTOR OF MEMBERSHIP SUPPORT • PHYSICIAN ADVOCATE Marisol Gonzalez at (858) 300-2783 or MGonzalez@SDCMS.org DIRECTOR OF RECRUITING AND RETENTION Brian R. Gerwe at (858) 300-2782 or at Brian.Gerwe@SDCMS.org DIRECTOR OF MEMBERSHIP OPERATIONS Brandon Ethridge at (858) 300-2778 or at Brandon.Ethridge@SDCMS.org DIRECTOR OF COMMUNICATIONS AND MARKETING • MANAGING EDITOR Kyle Lewis at (858) 300-2784 or KLewis@SDCMS.org

CMA’s 16th Annual California Healthcare Leadership Academy MAY 31–JUN 2 • Planet Hollywood, Las Vegas • www. caleadershipacademy.com

OFFICE MANAGER • DIRECTOR OF FIRST IMPRESSIONS Betty Matthews at (858) 565-8888 or Betty.Matthews@SDCMS.org

DSM 5: What You Need to Know JUN 8–9 • 8:00am–5:50pm on Saturday, 8:00am– 12:30pm on Sunday • Hyatt Regency La Jolla Hyatt • www.dsm5sandiego.org

SDCMSF Contact Information

Create Your Own Wave: Surviving the Riptide of SB 863 JUN 20–23 • Newport Beach, Calif. • (800) 692-4199 • https://csims.org SDAFP Symposium, Family Medicine Update: 2013 JUN 28–30 • Paradise Point Hotel, Mission Bay • www. sandiegoafp.org RCMA’s “Cruisin Thru CME” — French Waterways: Highlights of Burgundy & Provence JUL 1–13 • Call RCMA at (800) 472-6204

LETTERS TO THE EDITOR Editor@SDCMS.org GENERAL SUGGESTIONS SuggestionBox@SDCMS.org

5575 Ruffin Road, Suite 250, San Diego, CA 92123 T (858) 300-2777 F (858) 560-0179 (general) W SDCMSF.org EXECUTIVE DIRECTOR Barbara Mandel at (858) 300-2780 or Barbara.Mandel@SDCMS.org project access PROGRAM DIRECTOR Francesca Mueller, MPH, at (858) 565-8161 or Francesca.Mueller@SDCMS.org Patient Care Manager Rebecca Valenzuela at (858) 300-2785 or Rebecca.Valenzuela@SDCMS.org Patient Care Manager Elizabeth Terrazas at (858) 565-8156 or Elizabeth.Terrazas@SDCMS.org IT PROJECT MANAGER Rob Yeates at (858) 300-2791 or Rob.Yeates@SDCMS.org IT PROJECT MANAGER Victor Bloomberg at (619) 252-6716 or Victor.Bloomberg@SDCMS.org

/////////////////////////////////////////////////////////////////////////////////////////////////// Commercial Real Estate Tips & Trends

By Chris Ross

Market Update: San Diego County | Q1 2013 Overview The medical office market, both nationally and locally, can be a challenging one to analyze. On the one hand, many primary care physicians and traditional specialists are faced with challenging real-estaterelated decisions given the rapidly evolving landscape of healthcare and the threat of a reduction in Medicare rates.

Tenants are avoiding, whenever possible, long-term leases and significant moves such as relocations or remodel projects, oftentimes opting for short-term renewals — even if it comes at a premium rent or involves the continuation of less-than-ideal conditions.

On the other hand, mergers, acquisitions, consolidations, and strategic partnerships, particularly among larger medical groups and health systems, are becoming more frequent and will only gain more momentum.

“Physician integration” seems to be the new buzzword as hospitals strategically position themselves to create or enhance relationships with the right medical groups, deliver improved accessibility (both from

“

a physical location standpoint and otherwise), and maintain or expand their position in the marketplace as they prepare for the upcoming effects — both positive and negative — of healthcare reform.

Add to all of this the increased pressure hospitals, physicians, and other providers are feeling to integrate new technology and to deliver higher-quality care, and the result is an increase in activity among well-located medical buildings. This is driving heightened levels of demand for mid-size and large blocks of space, and will soon result in the decline in vacancy that many experts have been predicting for some time.

The San Diego County market has been no exception to the rising tide of activity. In particular, Scripps Health, Sharp HealthCare, UC San Diego Health System, Rady Children’s Hospital, Kaiser Permanente, and Palomar Health, among others, have been extremely active in the leasing, acquisition, and/or construction of both acute care and outpatient facilities, especially over the past 18 months.

Vacancy and Rental Rates Historically, the San Diego County medical office market has been in relative balance, with new supply coming on at nearly the same rate as demand.

With the exception of 2008, this has kept vacancies stable.

The past 12 months have maintained this trend.

Countywide vacancy at the end

of Q1 2013 came in at 12.4%, no change from that of Q4 2012 and up slightly from the Q1 2012 rate of 12.1%. This is a positive sign for the market given the large amount of recently delivered space across the county.

Going forward, with only two medical buildings under construction and nothing else in the pipeline for 2013, new supply will be surpassed by continued steady demand, and vacancy will likely see a modest decline throughout the rest of the year.

The average gross asking rent was at $2.51 per square foot at the end of Q1 2013, up from the $2.50 rate of Q4 2012 and down from the $2.60 average rate in Q1 of last year. Most of this decline is attributed to the reduced rents among Class B medical buildings, a result of the recent flight into newer Class A developments. Nearly two-thirds of the county’s vacancy now lies among Class B MOBs. Contrarily, asking rents among Class A and C buildings have remained relatively flat over the past two years.

Deliveries and Net Absorption Supply and demand were at a relative balance in Q1, with 60,889 square feet of positive net absorption and 71,541 square feet of newly delivered space. Similarly, over the past year, 289,000 square feet of net absorption was offset by 370,000 square feet of new “competitive” inventory (competitive space excludes single-purpose facilities that otherwise would not generally be competitive in the marketplace), causing the slight uptick in vacancy. Since the start of

2012, 10 medical buildings totaling 694,000 square feet (including non-competitive space) have been completed.

With most of this product preleased and additional steady demand among existing buildings, the past 18 months have posted the highest amount of leasing activity since prerecessionary levels.

Forecast Most submarkets in San Diego County have a shortage of quality medical office space, even though recent vacancy and rental rate trends do not necessarily reflect this. The remainder of 2013 is expected to post the types of absorption and other market statistics that will support the strong demand that most healthcare real estate professionals are hearing and seeing. Leasing concessions and price reductions have started to taper off, and new development — even speculative (“spec”) development — is now a part of the conversation again. The abundance of commercial real estate investors interested in acquiring outpatient medical buildings is at an all-time high, which has brought pricing back to the peak levels of 2007 and 2008.

Within the next six months, the talk of a strong medical office market in this county will be prevalent.

Mr. Ross is vice president of healthcare real estate services at Colliers International. He is a commercial real estate broker, specializing exclusively in medical office and healthcare facilities in San Diego County. He can be reached at (858) 677-5329 or at chris.ross@colliers.com.

If there is no struggle, there is no progress. Those who profess to favor freedom and yet deprecate agitation are men who want crops without plowing up the ground, rain without thunder and lightning. They want the ocean without the awful roar of its many waters. This struggle may be a moral one, or it may be a physical one, and it may be both moral and physical, but it must be a struggle. Power concedes nothing without a demand. It never did and it never will.

— Frederick Douglass, American Social Reformer, Orator, Writer, and Statesman (1818–1895)

”

SAN DI EGO PHYSICIAN.org 5

/////////briefly ///////////////////noted ////////////////////////////////////////////////////////////////////// drug abuse

Welcome New and Rejoining SDCMS-CMA Members!

New Members Nora M. Faine, MD General Preventive Medicine San Diego (858) 614-1580 Dhruvil P. Gandhi, MD Colon and Rectal Surgery Vista (760) 295-2924

Record Numbers Sign up to Access CURES System at SDCMS A California record of 123 physicians and other healthcare providers signed up to gain access to the Controlled Substance Utilization Review and Evaluation System (CURES) at SDCMS this past April 12.

Because a CURES representative was here in person, physicians did not need to take the additional step of having their applications notarized — a significant savings in time and money.

The CURES system makes it much easier for physicians to quickly review controlled substance information via the automated Patient Activity Report in order to identify and deter drug abuse and diversion through accurate and rapid tracking of Schedule II through IV controlled substances: https://pmp.doj. ca.gov/pdmp/index.do.

Any SDCMS member physician who wasn’t able to attend our April 12 event but would still like to gain access to the CURES system is invited to have his or her documentation notarized, free of charge, at SDCMS’ offices in Kearny Mesa. For further details, contact SDCMS at (858) 565-8888 or email SDCMS@ SDCMS.org.

6 may 2013

Loretta E. Gordon, MD Family Medicine Bonita

Paul J. Manos, DO Emergency Medicine National City (619) 470-4141 Fady S. Nasrallah, MD Surgery La Jolla (858) 626-6353 Marie P. Shieh, MD Oncology and Hematology La Jolla (858) 558-8666

Rejoining Members William W. Hooper, MD Pulmonary Disease Encinitas (760) 753-3424 Gail C. Salganick-Erfani, MD Colon and Rectal Surgery Chula Vista (619) 271-6703 John D. Smoot, MD Plastic Surgery La Jolla (858) 587-9850

financial planning

The Physician Retirement Shortfall Dilemma

By SDCMS-endorsed AKT Wealth Advisors, a wealth management firm that provides healthcare professionals with comprehensive financial planning, investment management, and tax planning and preparation services.

Contact Carl Pinkard, CFP, at (760) 431-8440 or at cpinkard@wealthadvisors.com.

Physicians face several obstacles in amassing enough wealth during their careers to maintain their lifestyles after retirement, e.g., average medical school debt of more than $161,000, modest residency salaries, and a relatively compressed period to fund their retirement needs. Despite this, there are several actions physicians can take to help improve their probability of retiring comfortably.

First, develop a plan that balances debt repayment and retirement savings. Compare

the after-tax interest expense of the education debt to the expected return of investing for retirement. Reduce income and your overall tax burden with retirement deferrals.

And take advantage of any retirement plan matching contributions.

Next, understand that when it comes to saving for retirement, it is the time and the amount saved that has the biggest impact on achieving a successful retirement nest egg. $1,000 invested each month for 40 years at a 6% annual return, for example, grows to more than four times the same amount invested for 20 years and two times the same amount invested for 30 years.

And finally, take advantage of those retirement plans that, by their design, allow business owners and highly compensated individuals the ability to contribute more than traditional retirement plan annual limits. Although saving for retirement isn’t easy, a proactive approach should reduce anxiety and stress, and greatly improve the prospect of meeting your retirement goals.

Become an SDCMS Featured Member!

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

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Lorie Zapf (District 6) E: loriezapf@sandiego.gov City Administration Building 202 C Street, 10th Floor San Diego, CA 92101 T: (619) 236-6616 • F: (619) 236-7329 Birthday: May 27

3 Profitability Reviews 3 outsourced Professional services (CFo, Controller) 3 organizational and Compensation structure

Scott Peters E: (via website) scottpeters.house.gov Washington, DC Office: United States Congress 2410 Rayburn House Office Building Washington, DC 20515 T: (202) 225-0508 • F: (202) 225-2558 San Diego Office: 4350 Executive Drive, Suite 105 San Diego, CA 92121 T: (858) 455-5550 • F: Birthday: June 17

3 succession Planning 3 Practice Valuations 3 internal Control Review and Risk Assessment

Dianne Feinstein E: (via website) www.feinstein.senate.gov Washington, DC Office: United States Senate 331 Hart Senate Office Building Washington, DC 20510 T: (202) 224-3841 • F: (202) 228-3954 San Diego Office: 750 B Street, Suite 1030 San Diego, CA 92101 T: (619) 231-9712 • F: (619) 231-1108 Birthday: June 22

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Marty Block (District 39) E: senator.block@sen.ca.gov E: (via website) http://sd39.senate.ca.gov Sacramento Office: State Capitol, Room 4090 Sacramento, CA 95814 T: (916) 651-4039 • F: (916) 327-2188 San Diego Office: 701 B Street, Suite 1840 San Diego, CA 92101 T: (619) 645-3133 Birthday: June 28

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prescription drug abuse

An Interview With Thomas P. Lenox, Supervisory Special Agent, Drug Enforcement Administration Interview by Roneet Lev, MD

Note: To read Part 1 of this interview, please see the April 2013 issue of San Diego Physician.

8 may 2013

PART 2 Dr. Lev: Let’s talk a little bit about the patient and DEA. If a patient gets investigated, what happens to them? If a physician reports doctor-shopping or if you discover doctor-shopping, what happens?

Mr. Lenox: The first thing we do when we obtain a lead of potential doctor-shopping is to do a preliminary background check. We run a CURES report to see if there are any violations. We may not see anything and not pursue things further.

Out of 300-plus leads we receive a year, we investigate about 60 cases — so for many people there’s no further action.

The cases that go further get a preliminary on what their prescription records are. We may look to see if they have any criminal history or any offenses of prescription fraud or other narcotic charges.

Next we prioritize the cases. Highest priority goes to investigate employees within the medical profession — for example, a receptionist in a doctor’s office, medical assistant, surgical tech, LVN, RN, physician’s assistant, physician pharmacy tech, pharmacist, etc. This group of people knows how to call in prescriptions, they know what the “better” drugs are, they know what to say to the pharmacist, and they learn very quickly how to access prescriptions. That’s a serious concern of ours.

In addition, people within the medical community may potentially be treating patients in some way, shape, or form, whether it’s simply taking their blood pressure, checking them in, doing preliminary work before the doctor, or, in the pharmacy case, they’re dispensing medications. If they make mistakes, they’re potentially endangering the lives of patients. That is why medically related cases are our priority. The general public is potentially at a higher level of danger when people within the medical profession are abusing or are addicted to controlled substances.

When people not in the medical field are reported, we’ll look at their prescription records and then make a determination.

Many times we may just file that name away. We don’t do a report, it doesn’t go into any database, doesn’t go anywhere, we just hold onto it. We may go back six months later and run their prescription records again. Often we don’t see any issues. If a doctor tells their patient, “Look,

I ran your CURES, I’m reporting you to DEA,” patients realize this is serious and get help themselves.

There’s a percentage of people who see two or three doctors in a month, getting small quantities of opiates from each, but clearly they’re lying to the doctors to get them. They’re on the path to abuse and addiction, but because we have to prioritize our workload, these patients won’t become a target of an investigation right away.

Dr. Lev: What’s the worst thing that could happen to a patient?

Mr. Lenox: The worst thing is we don’t get to them in time, and they overdose and die. We’ve had a couple of those cases where we start investigating and we find out that they overdosed and didn’t make it. We had a couple of cases where we’ve actually gone out and made the arrest, and, while they were pending court, they overdosed and died, so that’s the worst.

That’s the frustrating part of this job because we’re trying to really avoid that.

Dr. Lev: That’s a sad situation, and definitely the worst. How about a criminal case? Do people serve time in jail or go to court-mandated rehab?

Mr. Lenox: Most of the individuals that we have cases on will be sent to rehab.

They are initially given a felony charge.

After rehab they can work through the legal system and may have their charge reduced to a misdemeanor and be on probation. It’s really up to the judge, but there’s a whole variety of possibilities.

We have had some individuals who were out on probation or who were out on parole for other crimes and were put back into custody, either jail or prison, because they were career criminals. But the typical person who’s never been arrested will work their way through the legal system.

The judge and district attorney’s office can advise a variety of options.

Dr. Lev: Let’s talk about the physicians.

If a physician is under investigation by the DEA, would they know it? Would they be getting a phone call, or does that happen in a different way?

Mr. Lenox: Those cases typically happen in a different way. Physician investigations are very long-term cases. We’re very SAN DI EGO PHYSICIAN.org 9

TrusT

cautious before we determine that there’s an issue with a physician. We need to make sure that there is actually a case to be made.

In other words, we want to make sure that the offense was not just a one-time event where a doctor was extremely busy and wrote a script they shouldn’t have written.

We are typically after cases where there is a consistency. Most cases of patient prescription fraud could take a month or a month and a half. A case on a physician could take a year, or maybe two years.

Dr. Lev: Can you give us an example — without using any physician names or names of hospitals — of some of your memorable cases against physicians?

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Mr. Lenox: We had one physician who was addicted to pain pills, using almost 1,500 pain pills a month. He was calling prescriptions into 12 to 15 different pharmacies under bogus patient names.

Then he went to the pharmacy himself to pick them up. This physician also used his colleague’s DEA registration number to call in prescriptions under their name.

Obviously, that was a problem. He was taking that many pills while practicing medicine and clearly endangering the lives of patients.

Dr. Lev: How did you find out about it?

Mr. Lenox: It was reported through a pharmacist who recognized the physician. When the physician came to pick up a prescription for an unknown name, the pharmacist went down and asked the clerk what the doctor was doing there. The clerk said the customer was picking up his prescription. It didn’t make sense to the pharmacist, so the pharmacist reported it. The Medical Board had begun the investigation and then notified us, and we worked the case jointly.

Dr. Lev: What happened to the doctor?

Endorsed by

10 may 2013

Mr. Lenox: We did a search warrant of the doctor’s office and house, which is never pleasant. To have the neighbors see that law enforcement is at your house, searching your house, is an embarrassing situation to say the least. And again to have that happen at an office where you have colleagues, I can’t image the embarrassment that you’d go through for something like that. But the doctor was arrested and charged, and agreed to go into treatment. He voluntarily surrendered his DEA registration number as well as his medical license. The physician retired.

Dr. Lev: Do physicians pay fines?

Mr. Lenox: No fines are paid to DEA. They may to the Medical Board, and they might go to the courts as part of a criminal case.

Dr. Lev: Can you tell us about a memorable patient case?

Mr. Lenox: I recall a very young girl, in her early twenties, that we investigated for doctor-shopping. When we interviewed her, she was intelligent, well-educated, and adamant that she did not have a problem.

Her attorney said, “Oh no, I’ve talked to her, and she’s not an addict.” Then we find out that she overdosed and died. I was in shock because I never expected that to happen.

Dr. Lev: Do you remember what drugs were involved?

Mr. Lenox: She was calling in hydrocodone. She was actually in the lobby of the pharmacy calling on her cell phone. We saw her on camera calling the pharmacy.

Of course she denied it, but the doctor whose DEA registration number she was using was the pharmacist’s doctor. The pharmacist knew everybody that worked in the doctor’s office, and she knew that there was nobody by that name in the office. She also knew the voices of the people in the office because they would call her pharmacy and she’d talk to them.

Dr. Lev: Physicians can get in trouble when they write prescriptions for their employees or relatives.

Mr. Lenox: When I do training for the physicians, one of the things I do discuss is prescribing for employees and family. DEA’s focus is controlled substances.

There are regulations that require patient charts, a medical exam, and documentation to justify prescriptions. An employee will say, “I slipped over the weekend. I was cleaning my house. I was working in the yard. I slipped and fell, and now my back’s hurting me.” The doctor will agree to write a script; it may be for a small amount: 20 or 30 pills. But what the doctor may not realize is that that patient is probably already addicted or abusing pills and has been seeing other doctors. Now the doctor is just adding to their abuse and addiction. Also, that physician just wrote a script without doing any type of legitimate medical exam, without having a patient chart — all violations for both the Medical Board and for DEA.

Dr. Lev: Physicians want to be the nice guy, the hero. But writing a simple prescription is not always the right thing to do and can get you into trouble. It’s not just a problem with the DEA and the Medical Board. If you write a prescription outside your normal work environment without a chart, you are not covered by your malpractice insurance. There is one famous case where a physician received a curbside consult for his gout and received a prescription of colchicine. Unfortunately, he suffered a Stevens-Johnson reaction and died. His surviving wife sued the prescriber on the bottle.

Mr. Lenox: And if you’re a pediatrician and you’re writing a script for 30 hydrocodone to an adult in your office, that’s a red flag. It’s a red flag for the pharmacist, and it’s a red flag for us.

Dr. Lev: You’ve mentioned cases where the computer is left open and there’s a link to the pharmacies.

Mr. Lenox: We’ve had a couple of cases where physicians trust their employees and give them their password and access.

We have seen situations where employees will place orders to drug distributors — it’ll appear as though the orders are coming from the doctor. Then the drugs come in to the doctor’s office and the employee steals them. We had another case where an employee was using a physician’s computer access to write himself prescriptions on a regular basis via the internal hospital system. The pharmacy was thinking the prescription was coming from the doctor, but they weren’t. They were coming from the employee. There are so many different scams. We had one employee who got so creative that he forged letterhead and was faxing in prescriptions from a medical office. If you looked at the letterhead side by side, it was hard to tell which was the counterfeit one and which was legitimate.

Dr. Lev: Where do the majority of your leads for investigation come from? A pharmacy, doctors, CURES, the Medical Board?

Mr. Lenox: We get most of our leads through pharmacists and physicians that report suspicious activity. We get some family members that will report because they just don’t know what to do anymore or where to turn. And we will get reports from other law enforcement agencies that will call us because our unit is so unique. We’re the only ones in San Diego County who

Email Editor@SDCMS.org to have any of the following documents sent to you: ✓ Patient Pain Medication Agreement and Consent ✓ Safe Pain Medication Prescribing Guidelines ✓ Safe Pain Medication Prescribing in the Emergency Department ✓ PowerPoint on Scope of Problem and How to Access CURES

specifically deal with prescription drugs, so a lot of the other law enforcement agencies may send us cases to look at.

out that she talked him into giving her an entire physician prescription pad. He gave her the pad and ended up losing his career.

Dr. Lev: Any other interesting cases?

Mr. Lenox: Yeah, it’s just not worth it.

You’ve sacrificed so much to get to where you are. It’s not worth jeopardizing your DEA registration number and your medical license. We work very closely with the Medical Board, the Pharmacy Board, the Nursing Board, so you just don’t want to jeopardize your career. Besides, you have a built-in excuse as to why you can’t just hand out prescriptions: “I can’t do it because of the DEA. I can’t do it because of the Medical Board. As much as I’d like to help you, I can’t. But if you want my help, then we can make an appointment, have you come in, do it the right way, and no problems.”

Mr. Lenox: We have had cases where people order secure prescription pads using a doctor’s name and DEA; it’s like stealing the physician’s identity. It’s very easy for them to pay for it online and get it shipped to a P.O. box that would be listed as, for example, 123 Main Street, Suite 201, but it’s actually a mail drop place. The prescriptions show up and now somebody has 500 prescriptions with your name and DEA registration number on it. What the suspects have done in the past is put their own cell phone number on the pads so if anybody calls the number to verify the prescription, the call actually goes to them.

There are a lot of different types of scams that are going on out there. That’s one of the reasons why we try to encourage medical groups and physicians to talk to the DEA. If they come to you, just say, “Come in, sit down, and let’s talk. I want to know what’s going on.” Don’t put up a wall and say, “Sorry, I can’t talk to you guys. I’m not going to talk to you guys.”

By talking to us, you’ll learn a lot about what’s happening and how your registration number may be abused. It’s your name, it’s your reputation, and you don’t want that to happen to you.

Dr. Lev: We had a physician assistant student who was rotating in our department, and I sent him to do a history and physical on a female patient. I later found

Dr. Lev: So, in general, you investigate only one or two doctors a year. If they are being investigated, they probably don’t know it, and they’re really the outliers. To the majority of physicians and any of my friends and colleagues, if you get a phone call from the DEA, answer it and be nice.

It’s simple and it’s interesting.

Mr. Lenox: Exactly.

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).

SAN DI EGO PHYSICIAN.org 11

Physician Workforce

UC San Diego’s 2013 Residency Match Note: Deferred residencies are not included.

PERCENTAGE

NUMBER

43.9%

54

Internal Medicine

17.9%

22

Pediatrics

14.6%

18

Family Medicine

7.3%

9

Obstetrics and Gynecology

4.1%

5

42.3%

52

Anesthesiology

6.5%

8

Emergency Medicine

6.5%

8

Psychiatry

5.7%

7

Radiology

5.7%

7

Ophthalmology

4.9%

6

Radiation Oncology

4.9%

6

Neurology

4.1%

5

Dermatology

2.4%

3

Pathology

1.6%

2

Surgical Specialty:

13.8%

17

General Surgery

4.9%

6

Orthopedic Surgery

3.3%

4

Urology

2.4%

3

Otolaryngology / Health and Neck Surgery

1.6%

2

Pediatric Neurological Surgery

0.8%

1

Plastic Surgery

0.8%

1

Grand Total:

100%

123

Primary Care:

Specialty:

12 may 2013

Four-year Trend

by Category Note: This count excludes transitional IM programs but does not account for post-residency specializing, e.g., cardiology.

60% 50% 40% 30%

Primary Care Surgical Specialty Specialty

20%

(Linear) Primary Care (Linear) Surgical Specialty (Linear) Specialty

10% 0%

2010

2011

2012

2013

60%

Four-year Trend by Residency Location Note: San Diego keeps about 25% of UC San Diego medical school graduates, and California (including San Diego) keeps about 70% of UC San Diego medical school graduates.

50% 40% 30%

San Diego California ex-SD Out of State

20% 10%

(Linear) San Diego (Linear) California ex-SD (Linear) Out of State

0%

2010

2011

2012

2013

35 30

Four-year Trend — Primary Care

25 20 15 9

10 6 4

5 0

Internal Medicine Family Medicine Pediatrics Obstetrics and Gynecology

2

2010

2011

2012

2013

SAN DI EGO PHYSICIAN.org 13

POETRY AND MEDICINE A Safety I Have Known (For Bernice)

A Safety I Have Known Introduction

by Daniel J. Bressler, MD

I grew up in a middle-class suburb of Los Angeles smack dab in the middle of the post-war baby boom. My mother, like all the mothers I knew in our neighborhood, was a homemaker. Her physical and psychological presence, through the first dozen years of my life, was synonymous and synchronous with home and security.

Although far from the breezy happiness of Leave It to Beaver and similar suburban sitcom portrayals of the era, my childhood did have a stability and sweetness, at least on the surface. My mother served in the PTA. My sisters participated in Brownies and Girl Scouts. I played third base on the Little League team. In family photos of those years, we are smiling.

But there were the night terrors. In my early school years I had frequent bad dreams that would shake me awake. Most involved being chased by monsters or falling into infinite black chasms. The predators and scenes came not from my brief biographical experiences but from mythologies, stories, and movies. With no perspective or inner resources to comfort myself, I’d flee my blankets, somehow stumble into my parent’s bedroom, and curl up with my mother.

In the half-century since those days, my nightmares have mostly disappeared only to be replaced by real-world worries aplenty.

The news provides fodder for a daily barrage of fearful thoughts. Where will the terrorists strike next? Will my family and friends be OK? Is my house safe? Will Southern California crumble in an earthquake? And then there’s the particular worries that come from my medical practice: Did I miss that melanoma? Did the addition of that antifungal drug exacerbate his arrhythmias? Was her C. difficile infection from my overzealous use of antibiotics? I reassure myself — when I can — with a logical review of the circumstances and an experience of 30 years 14 may 2013

Nightmares drove me to their bed Startled and fear-frozen after tumbling Over cliff edge or fleeing the approaching fangs.

I jolted, being seven, and sleepwalked to safety.

The stations of my midnight hegira are hazy: A knit hallway rug and a dented hollow bronze doorknob Marked the portal between the two worlds Finally, the frayed frills of the knit bedspread led upwards, From the dark floorboards to shroud the huddled giants.

The secret entrance lay on my mother’s side Digging deep, I’d find the sheet and burrow under to her.

Hand-over-hoisting-hand myself along her warmed nightgown Until, my pilgrim head lay on her breastbone, Gradually rocking with her moist breath.

Sleep came quickly then and was peaceful. No demons dare Enter this layered sanctuary. The smells were all magic.

The protective elixir of night sweat coated me and I flew Above the rooftops of our street and over the outstretched Jaws of dragons.

of medical practice.

Mother’s Day has passed. This year it came on Sunday, May 12. I am fortunate that my mother is still very much alive and kicking. I am grateful to her for many things — starting, of course, with the gift of life itself. As I inventory my gratitude, high on that list is my unshakeable sense born of those terrifying nights that some-

where, down some physical or psychological hallway, behind some inner or outer doorway, there is a place of safety.

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

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risk management

When Prescribing Drugs, a Physician Has a Duty to Warn Patients

by SDCMS-endorsed The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/ patientsafety.

Prescribing physicians have a primary duty to warn patients about the risks and complications of prescribed medications. While legal arguments have been made that the drug manufacturer should be responsible for this duty to warn, courts continue to hold physicians accountable.

In a recent lawsuit, a patient claimed a prescribed medication caused lupus-like symptoms and that the manufacturing company, along with three physicians, failed to adequately warn of the drug’s risks and, in fact, overemphasized its benefits.

Two physician defendants settled with the patient, while the third physician was dismissed. The trial resulted in a $4.7 million jury verdict against the manufacturer.

The company appealed, claiming it had no duty to directly warn the patient after providing the patient’s prescribing physician with adequate warning. Based on the legal doctrine of “learned intermediary,” the court ruled in favor of the manufacturer. The doctrine states that a prescribing physician acts as a “learned intermediary” between manufacturer and patient: The manufacturer has a duty to inform the physician about drug uses and hazards, and in turn the physician has a duty to relay to each patient the dangers of using the prescribed medication. As such, the prescribing physician has the responsibility or “duty to warn” a patient of a prescription drug’s side-effects.

16 may 2013

Review these tips to ensure you fulfill your duty to warn: • Stay abreast of FDA prescription drug warnings and recalls.

• Use PDR Network as a reference for FDA-approved drug labeling and as a source for drug safety information.

• Be aware of prescription drug manufacturer product disclosures and warnings.

• Determine if additional information about the drug is available, including studies suggesting dangers that the FDA has yet to act on.

• Require that patients provide a list of all prescription and over-the-counter drugs being taken.

• Advise patients of other available

•

• • • • • • •

medications and the medical rationale for the one being prescribed.

Counsel patients about the difference between brand-name and generic drugs.

Inform patients of potential drug-food and drug-drug interactions.

Document all disclosures and warnings made to patients.

Instruct patients to read drug labels.

Provide patients with written, simplified dosing instructions.

Obtain written informed consent when prescribing for off-label use.

Date and archive product manufacturer disclosures and warnings.

Seek legal or risk management guidance when uncertainty arises.

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risk management

Malpractice Claims Consume Years of a Physician’s Career

by SDCMS-endorsed The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

• Do not ask patients if they understand — instead, ask them to repeat back the information.

• Document patient understanding of instructions.

• Provide the patient with written instructions.

• Use a translator when necessary.

2. Document Carefully and Objectively: • Do not point fingers at other staff or providers.

• Do not impeach the integrity of a medical record by altering it.

• Use only approved abbreviations.

• Review patient information that is automatically populated in the EMR.

3. Monitor Handoffs and Ensure Follow-ups: • Establish a formal tracking system for missed appointments.

• Follow up with patients to reschedule.

• Document missed appointments in the patient record.

• Send a letter to patients who repeatedly miss appointments.

• Explain the importance of follow-up care.

• Refer the patient to another physician if necessary.

4. Avoid Medication Errors: • Keep prescription pads secure.

• Document samples in the medical record.

• Check allergies at every visit and document in the same place in the record.

• Review and reconcile medications at every patient visit.

• Be aware of LASA (look-alike soundalike) medications.

On average, each physician spends

50.7 months, or approximately 11% of an average 40-year career, resolving medical malpractice cases — the majority of which end up with no indemnity payment. That’s the conclusion of a recent study1 by the RAND Corporation based on The Doctors Company data. Researchers found that 70% of the time physicians spend on claims is spent defending claims that end in no payment to the plaintiff. Key findings of the study include: • Physicians experience additional stress, work, and reputational damage from the time spent defending claims.

18 may 2013

• Fighting claims takes time away from practicing medicine and from the opportunity for the physician to learn from his or her medical errors.

• The lengthy time required to resolve claims also negatively impacts patients and their families.

• To help prevent claims that can take up years of your career, follow these key tips to promote patient safety:

1. Communicate With Patients: • Understand the new vital sign: health literacy.

5. Follow HIPAA Regulations: • Avoid unauthorized release or breaches of PHI (protected health information).

• Safeguard against lost or stolen PHI through laptops or drives.

• Examine office practices and layout that may compromise confidentiality.

• Assess your methods to protect electronic communications.

• Follow federal requirements and know your state regulations, which may be stricter.

Note: 1. Seabury SA, Chandra A, Lakdawalla DN, Jena AB. Health Affairs. 2013;32(1):1-9.

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SAN DI EGO PHYSICIAN.org 19

Empowering our Patients

Distilling wisdom for the informed consumer The Physician’s Role in the Information Age

by James Santiago Grisolía, MD

20 may 2013

T

he Information Age both threatens and enhances our relationships with our patients. According to a recent survey [Pew Research Center http://tinyurl.com/blqudew] 81% of U.S. adults use the Internet and 59% say they have looked online for health information in the past year.

Fully 35% of all adults say they have gone online specifically to try to figure out what medical condition they or someone else might have.

The good news is that more than half consulted a physician about their findings.

Maybe it is also good news that 38% of online self-diagnosers decided their condition could be treated at home without physician consultation. That is, if they interpreted their own symptoms correctly, and that’s one of our nightmares.

Of course, we love being in control, or we wouldn’t have gone into medicine. Patients looking up their own symptoms and treatments unsettle

us because control is passing out of our hands. We all commonly see patients with minor ailments who decide, on the basis of WebMD, that they really have cancer or Lou Gehrig’s. And we worry about delay in care because someone erroneously thought dangerous symptoms were benign.

But when patients become more involved and active, positive and exciting things may happen.

The California Healthcare Foundation performed a survey [www.chcf.org/ publications/2010/04/ consumers-and-healthinformation-technology-anational-survey] that showed that patients with access to a personal health record (PHR, combining the electronic health record with patient access) were more engaged and proactive in managing their healthcare. Although higherincome individuals are the most likely to have used a PHR, lower-income adults, those with chronic conditions, and those without a college degree are more likely to experience positive effects from having their information accessible online. As we will increasingly be held accountable for patient outcomes, improved patient motivation and compliance will enhance our practices.

How can we best cope with this brave new world? In my view, we only need minor updates to what we should have been doing all along: • It’s still true that without patient compliance/ adherence, your brilliant diagnosis was worthless. If you haven’t done so already, think of your patient and his or her family/support network as the healthcare team, with you

•

•

•

•

•

•

as the coach. Assign them responsibilities and monitor progress — encouraging them to understand the why’s behind your directions enhances compliance.

I still encourage patients to write out their concerns and issues before coming to the office, but then I take the list and group the questions together that can be answered at once.

If a patient worries about a specific online article or posting, but can’t recall enough for me to discuss it, I encourage him to print it out and bring it to the next visit. This is the modern corollary to my old practice of bringing in the spouse or well-meaning friend who gives a list of off-the-wall suggestions from home.

Dealing with the “problem” directly saves phone calls later.

Complications — sideeffects or drug-drug interactions, for example — typically are complete and therefore overwhelming. I try to focus patients on the few, important nuggets in a field of mud.

Remember that sideeffects are much more important to the patient than they are to you.

When a patient has a chronic condition, especially a rare condition, accept that he may know more about it than you do, particularly how he responded to prior treatments. Respect his expertise and, when possible, offer choices.

When a patient brings in some new treatment or information, don’t be threatened. I try to tell him

what I do know, then discuss what to do about the part I don’t know. Sometimes I find I can research the issue. Sometimes I can refer him to an appropriate specialist. Patients sense the difference between self-confidence and insecurity masquerading as false pride.

• Fearlessly smite myths and nonsense, like the “harm” caused by vaccinations.

The Internet bulges with misinformation, and patients mostly appreciate your wisdom as long as your opinion is founded on knowledge. The occasional “true believer” can be gently referred elsewhere.

• Review HIPAA to decide how to use email with your patients. Unlike leaving a message with whoever answers the phone, there is a discoverable record.

Many physicians feel threatened by the onslaught of data flooding our inboxes, our journal piles, and our patients.

But data is disembodied, devoid of any meaning without a context and interpretation.

Wisdom coordinates raw facts with experience. Our patients continue to come to us for wisdom, for explanation and interpretation, for advice. Far from pushing us aside, the Information Age will make our role more central than ever.

With reams of data at their fingertips, our patients will need us more than ever. Our work will be harder, but more interesting.

Although higher-income individuals are the most likely to have used a PHR, lower-income adults, those with chronic conditions, and those without a college degree are more likely to experience positive effects from having their information accessible online.

Dr. Grisolía, SDCMS-CMA member since 1983, practices neurology at Scripps Mercy Hospital. He currently serves on the San Diego Physician editorial board.

SAN DI EGO PHYSICIAN.org 21

Empowering our Patients

N

early 26 million U.S. adults have diabetes and 79 million have pre-diabetes, according to the CDC. If current trends continue, 52% of U.S. adults may have diabetes or pre-diabetes by 2020. The economic burden of diabetes is tremendous, with total costs of $218 billion in 2007 — most of it for treatment of preventable complications. Diabetes care is often poorly coordinated, and many individuals show inadequate control of their condition, which reduces quantity and quality of life.

Through a multi-faceted, multidisciplinary diabetes management program, the Scripps Whittier Diabetes Institute and Scripps Diabetes Care Line proactively address the needs of diabetes patients across the continuum of care.

Following initial diagnosis at a physician’s office, hospital visit, or one of Scripps’ free community screenings, patients are referred to comprehensive outpatient educational programs designed to optimize their knowledge and management of their disease and prevent complications and hospitalizations. Through these programs, offered at more than 20 sites county-

Empowering Diabetes Patients to Take Charge of Their Care

The Scripps Whittier Diabetes Institute and Scripps Diabetes Care Line

by Athena Philis-Tsimikas, MD, and Daniel Einhorn, MD

22 may 2013

wide, Certified Diabetes Educators (CDE) provide one-toone consultation, education, and training for people with type 1, type 2, and gestational diabetes; topics include home blood glucose monitoring, insulin pump training, and self-management skills, as well as education on associated cardiovascular risk factors and other complications. Four core group classes and one follow-up class led by CDEs, registered nurses, and registered dietitians teach diabetes management information and skills. Ongoing support groups help patients maintain their efforts and share successes and challenges. All programs are recognized by the American Diabetes Association and, therefore, often at least partially covered by insurance.

Diabetes outpatient services are also made available to hospitalized patients upon discharge to help them manage their disease and avoid readmission for related complications such as heart attacks, stroke, amputations, and kidney failure. To date, Scripps’ outpatient education programs have reached more than 20,000 patients.

Diabetes care services delivered through the Scripps Whittier Diabetes Institute extend to the hospitalized patient as well.

Research has demonstrated that keeping blood sugars well managed during a hospital stay can decrease infection risk, length of stay, and other complications associated with elevated glucose values. Teams of advanced practice nurses, CDEs, and health coaches who are specially trained in diabetes management are deployed to all five Scripps hospitals, where they manage high-risk individuals with diabetes in the acute setting. These teams work closely with the physicians and nurses to identify patients with high blood sugar early in their hospitalization; protocols and individualized recommenda-

tions are made to bring blood sugars under control and offer the best outcomes. In the last year, more than 2,000 patients were seen by the Scripps glucose management teams.

Preliminary outcomes of this program were presented in June 2012 at the national American Diabetes Association meeting in Philadelphia, PA. Addressing the Needs of Culturally Diverse Populations To address the growing prevalence of diabetes in culturally diverse and low-income populations, Scripps Whittier Diabetes Institute created Project Dulce, a diabetes care and education program that provides culturally appropriate, community-based diabetes management, education, and support programs countywide. Initiated in 1997, Project Dulce was designed by a broad collaboration of San Diego healthcare and community-based organizations as a “Chronic Care Model.”

A nurse-led team consisting of an RN/CDE, medical assistant, and dietitian provides clinical care in collaboration with the patient’s primary care provider.

The Project Dulce model includes training for peer educators to provide diabetes selfmanagement education and support to their peers, clinical standards, and algorithms used to guide treatment, and an electronic diabetes registry used to track patient care, monitor compliance with standards, and report clinical outcomes. In addition to helping patients, Project Dulce staff also trains other healthcare providers on the design and implementation of a culturally appropriate diabetes management program. The patient education curriculum, multilingual patient handouts, peer educator training guide and operations manual are also available.

Mobilizing Diabetes Management for Low-income Latinos Recently, Scripps Whittier Diabetes Institute received a $250,000 grant from The McKesson Foundation’s Mobilizing for HealthSM initiative, with the goal of analyzing the value of mobile applications in improving improve health outcomes among patients with chronic diseases.

Research is testing the effectiveness of utilizing devices such as mobile phones to improve the management of diabetes among low-income Latinos who have recently been diagnosed. Participants receive ongoing text messages for one year regarding medication management and behavior changes.

Twenty-six patients (out of 200 targeted) have been enrolled thus far; patients selected at random to receive text messages will receive a total of 352 messages over the six-month period, with an average of 14 messages per week. Text messages include healthy lifestyle information, medication use, appointment reminders, and blood glucose monitoring information.

Patients will be seen at the start of the program and again at three and six months. As patients finish their six-month visits, appointment data will be reviewed to assess the efficacy of the mobile messaging.

If successful, widespread use of mobile applications may lead to dramatic improvements and outcomes in patient care, and the study findings could indirectly impact millions of patients worldwide.

To address the growing prevalence of diabetes in culturally diverse and low-income populations, Scripps Whittier Diabetes Institute created Project Dulce, a diabetes care and education program that provides culturally appropriate, communitybased diabetes management, education, and support programs countywide.

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Dr. Philis-Tsimikas, SDCMSCMA member since 2013, is corporate vice president of the Scripps Whittier Diabetes Institute. Dr. Einhorn, SDCMS member since 1984, is medical director of the Scripps Whittier Diabetes Institute.

SAN DI EGO PHYSICIAN.org 23 CAP_1402.indd 1

2/5/13 11:13 AM

Empowering our Patients

Who Is the Best Doctor to Go to? one patient's perspective

by Tracy Salazar, PhD

24 may 2013

A

s a mother of a child with Lennox-Gastaut Syndrome (LGS), an advocate, and an epilepsy researcher, I meet many other families living with epilepsy.

The question I get asked most often (besides “Have we found a cure yet?”) is, “Who is the best doctor to take my loved one to for his (or her) particular type of epilepsy?” My answer is always the same. The best doctor is not necessarily your syndrome’s namesake, who has published the most, who recently gave a talk, or who works at the most prestigious hospital.

The best doctor is anyone who has these five qualities, all of equal importance: (1) They know a great deal about the nuances of the different types of epilepsy, and they are continually learning; (2) They are compassionate and truly desire to help alleviate your suffering; (3) They listen to you and include you as part

of the decision-making team; (4) They are accessible; and (5) They never give up.

How do you find such a doctor? After 17 years of living with epilepsy and seeing literally dozens of doctors with my child, here’s what I look for.

First, are they knowledgeable? I always ask the doctor how they keep up to date with all the changes happening in the field of epilepsy. This is especially important when the epilepsy is difficult to treat.

Some say they attend an annual epilepsy meeting, or they religiously read the epilepsy journals. This question isn’t meant to challenge or interrogate doctors. What we know about epilepsy is rapidly and constantly changing, and I have learned that the best care comes from someone who is aware of these changes and integrates them into his or her clinical practice. A doctor with an inch-wide, mile-deep

knowledge of your condition is more likely to do no harm rather than someone whose knowledge is a mile wide and only an inch deep.

Second, are they compassionate? During the visit, I watch how they interact.

Do they listen to us? Are our concerns their concerns, or do they dismiss us? For us specifically, the cause of our child’s epilepsy has always been paramount. Nearly two decades after our child’s first seizure, we still have no idea why our healthy 2-year-old developed epilepsy. This haunts us. It haunts all families who don’t know the why behind their seizures. Therefore, we need a doctor who still helps us look for the cause, even all these years later. Surprisingly, many doctors dismiss this concern for any number of reasons. But this is what is important to us. Someone who is compassionate understands this and tries to help us. Furthermore, I’m always wary of doctors who make definitive statements such as “Your child will outgrow this” or “We will get these seizures under control.”

Doctors may think they are telling us what we want to hear by saying these things, but if they don’t come to pass, as they don’t in 1 in 3 people with epilepsy, trust can be lost.

Telling someone what he or she wants to hear is not an act of compassion — stating the facts in a kind way is.

Third, do they include us as part of the decision team? Not all patients and families want to be involved in decisionmaking about epilepsy care, but many do. The best doctor for you will include you if you desire. I prefer a doctor who will listen and understand what concerns us, who will entertain new ideas, even if

not mainstream, and who will work with us as opposed to telling us what we must do. Frankly, if the patient and family don’t have buy-in for a particular plan, the plan won’t be successful.

Fourth, are they accessible?

Epilepsy is an unpredictable, terrorizing disorder that if left unchecked can cause severe damage to one’s brain and one’s life. We really need our doctor’s help fighting this scourge. If we can’t access a doctor in a timely manner, we are alone.

Finally, do they see it through? My daughter has a difficult case of epilepsy. I know this. I don’t expect a doctor to fix her and reverse the years of damage that more than 30,000 seizures have caused. All I really want at this point is someone who doesn’t give up the fight. We want to give up, but we can’t. It means the world to us to know that we’re not in this alone. Our doctor is in it with us.

The best epilepsy doctor is a knowledgeable, compassionate team member whom patients can reach in a time of crisis and, above all, listens.

Every doctor has the ability to be the best epilepsy doctor for his or her individual patients with epilepsy.

They need only listen.

Ms. Salazar, who joined Citizens United for Research in Epilepsy (CURE) as a research manager in 2013, received her PhD in neurobiology from UC San Diego.

She then did a post-doctoral fellowship, identifying genes that underlie epilepsy and studying their disease-causing function by using induced stem cell and animal models. She is a staunch epilepsy advocate, instilling hope that by working together we will one day find a cure.

SAN DI EGO PHYSICIAN.org 25

mySharpTM

empowering our patients Personal health records 26 may 2013

In December 2009, Sharp Rees-Stealy Medical Centers launched mySharpTM, a secure and personal way for patients to manage their healthcare — and the care of loved ones — online.

Patients use this free service to schedule and cancel appointments, track health history, read office visit summaries, view select lab results, email their doctor’s office, order prescription refills, view hospital discharge instructions, and more. Individuals can also manage healthcare for their child, spouse, parents, or loved ones who are also Sharp ReesStealy patients. This anytime, anywhere solution enhances operational efficiency and engages patients to take a more active role in their health, all while enjoying greater choice and convenience.

I

Today, more than 105,000 patients have signed up for a mySharp account, empowering them with the ability to self-serve. Each month, another 2,000 to 3,000 new patients enroll, and usage of the various features has steadily increased.

Much of this success has been grounded in 100% participation by physicians in the medical group. Physicians enjoy the enhanced communication and ease of connecting with patients, and the ability for their office to email patients and handle simple, routine issues more efficiently. In addition,

This anytime, anywhere solution enhances operational efficiency and engages patients to take a more active role in their health, all while enjoying greater choice and convenience.

once a physician reviews lab results, they can be published to mySharp for the patient to view online along with accompanying notes that they can reference to achieve a greater understanding of their health. “mySharp provides a closer link to my patients,” says Anthony Sacks, MD, Sharp ReesStealy Department of Family Medicine, and SDCMS-CMA member since 2008. “Additionally, patients have emailed me to discuss topics, including side-effects to medication, lack of response to a treatment plan, or other concerns that my

office staff or I can immediately address without having to worry about telephone tag.”

This January, more than 6,000 patients scheduled primary care appointments at Sharp Rees-Stealy. With the ability to schedule appointments online through mySharp, patients save time, and it simultaneously eases call volume for staff. Many other features, such as the patient’s ability to track and print immunization records, are also designed to provide immediate access to health information while saving a phone call or trip to the doctor’s office.

Taking this ability to manage healthcare online one step further, mySharp went mobile in 2012, with the launch of the mySharp app for the Apple iOS. Six months after its launch, the app has been downloaded to more than 16,000 iPhones and iPads. In the spring of 2013, this on-the-go functionality will further expand with the introduction of the mySharp app for Android phones and Nook and Kindle tablets.

So, what’s next for this portal powerhouse? With patient communication and engagement being a cornerstone for high quality, coordinated care, mySharp will soon be used for patient reminders and alerts regarding important screenings, preventive care, and chronic care management.

From mammograms and cervical cancer screenings to influenza vaccines and lab work for diabetes and other disease management programs, these educational communications help ensure patients receive the information they need to live better and take a greater role in their care.

My Health Manager

Last year, Kaiser Permanente made the largest electronic health record system in the world accessible to members through mobile devices with the launch of its apps and mobile-optimized website.

Now more than 9 million Kaiser Permanente members — including 519,000 San Diegans — have secure, 24/7 access to their medical information anywhere in the world.

According to a 2012 Pew study, more consumers are using smartphones for healthrelated activities than ever.

The study found that more than half of smartphone owners gather health information on their phones and that 19% of smartphone owners have at least one health app on their phones. Kaiser Permanente members’ mobile phone usage is also on the rise. The mobile app has been downloaded half a million times, and 24% of total traffic to kp.org came from mobile devices in March, up from 16% at this time last year.

The app is a natural extension of Kaiser Permanente’s already robust online personal health record: My Health Manager on kp.org. For more than five years, Kaiser Permanente members have used My Health Manager on kp.org to become more engaged in their healthcare and connect with their care providers. In fact, more than four million members are registered to use My Health Manager.

In 2012 alone, Kaiser Permanente members viewed 32 million lab test results, sent 13 million emails to providers, refilled 11.8 million prescriptions, and scheduled three million appointments through My Health Manager. The mobile apps allow our San Diego members to perform these same convenient, timesaving tasks whenever and wherever they choose: waiting in line, on the elevator, at the beach, camping, traveling, or right before bed.

Allowing our San Diego members access to their health SAN DI EGO PHYSICIAN.org 27

“Offering mobile access to medical information helps increase patient-centered care, even if a patient is away from the hospital or a computer.”

MyUCSDChart

information and providers is more than just convenient — it also can improve health outcomes. According to Kaiser Permanente research, secure, patient-physician email messaging improves the effectiveness of care for patients with diabetes and hypertension.

The study, published in Health Affairs in 2010, showed that health information technology improves quality of care scores. The study observed 35,423 Kaiser Perman-

ente patients in Southern California who had diabetes, hypertension, or both.

It found that use of secure patient-physician messaging in any two-month period was associated with statistically significant improvements in Healthcare Effectiveness Data and Information Set (HEDIS) care measurements. Results included 2–6.5% improvements in glycemic, cholesterol, and blood pressure screening and control.

In 2012 alone, Kaiser Permanente members viewed 32 million lab test results, sent 13 million emails to providers, refilled 11.8 million prescriptions, and scheduled 3 million appointments through My Health Manager.

28 may 2013

Anytime, anywhere access to health information is now available to patients of UC San Diego Health System who carry an iPhone, iPad, or Android.

Patients who are signed up for MyUCSDChart and use a mobile device can instantly access their medical history, message their doctor, view upcoming appointments, and request prescription renewals.

“MyUCSDChart allows safe and secure online access to a patient’s medical information,” says Marlene Millen, MD, primary care physician, UC San Diego Health System.

“The application increases patient satisfaction by allowing two-way communication between the patient and their medical team. I like the capability because I’m able to give patients lab results right away, and know they’re going to read them and follow up.”

Dr. Millen says the mobile application is another way of putting patients first by allowing them to see their records when and where they want.

“Patients who connect to MyUCSDChart with their mobile phone are engaged in their managing their healthcare around the clock,” says Dr. Millen. “Offering mobile access

to medical information helps increase patient-centered care, even if a patient is away from the hospital or a computer.”

Dr. Millen’s team says patients who travel for business or vacation have found the application useful away from home. For example, they have used their mobile device to inform her of hospitalizations while traveling. Appointments and tests were scheduled so patients could see Dr. Millen within hours of their return.

Another special feature of the mobile application is customized health alerts based upon the patient’s medical history.

“As a physician, we can send a message such as ‘You’re due for your annual exam, or colonoscopy, or flu shot,’ says Dr. Millen. “It’s a great way of getting information to patients ahead of time to prevent illness or to track an ongoing health condition.”

Beyond the ability to view their records anywhere they carry their phone, patients say they appreciate the ability to download summaries to their computer. Patients can read and review the actual lab results as well as medication lists and directions. All this information can be shared with family members if the patient chooses.

“This technology is improving the care we provide,” says Dr. Millen. “It’s not going to take the place of a doctor’s visit, but it is a way to increase access to health information and therefore timely care. If a patient likes being able to communicate and wants to keep up with their health while on the go, the mobile application for MyUCSDChart is a great way to do it at no cost.”

SDCMS & SDCMS FOUNDATION For Ticket Information, Call SDCMS at (858) 565-8888

2013

White Coat Gala Saturday, June 8, 6:00pm – 10:30pm Hyatt Regency La Jolla at Aventine Installing Robert E. Peters, MD, PhD SDCMS President, 2013–14

SAN DI EGO PHYSICIAN.org 29

Empowering our Patients

Communication Matters The Most Important CME We Receive All Year

by Helane Fronek, MD, FACP, FACPh 30 may 2013

Much of our time is spent explaining things to patients, yet it seems as if they recall very little.

C

ommunication is one of the four core clinical skills, along with knowledge base, problem-solving ability, and physical examination; a large body of evidence proves its importance. In one study, the duration of headache symptoms correlated more closely with a patient’s perception that they were able to discuss their concerns with their doctor than it did with the diagnosis, treatment, or referral to a specialist. In 70% of malpractice suits, communication issues are cited as a major factor.

And more than 80% of doctors agree that the most significant factor in their personal satisfaction is the relationship with their patients. Given these impressive benefits, commu-

nication is a skill that we are wise to hone.

Our initial interaction sets the stage for the visit. By greeting our patient with a smile and pronouncing his or her name correctly, we begin to establish rapport. Knowing the reason for the visit before walking into the room allows us to demonstrate our competence and helps our patient trust us.

In How Doctors Think, Jerome Groopman, MD, presents numerous cases in which the physician’s communication style interfered with good medical diagnosis and treatment. He criticizes medical education that trains us to immediately construct a mental differential diagnosis, after which we listen only selectively. In Skills for Communicating With Patients, Kurtz et al explain that we routinely interrupt patients 16–18 seconds after they begin to speak, firing off a series of questions to home in on our presumed diagnosis. Since patients rarely talk longer than two minutes, we would actually obtain much more relevant information by allowing them to tell us their history, uninterrupted.

Our patient’s first complaint is frequently not his most important concern. After our patient’s opening remarks, we can ask, “What other concerns do you have today?” By repeating this question, we can develop an agenda for the visit that will satisfy our patients and allow us to prioritize based

on everything we need to address.

Much of our time is spent explaining things to patients, yet it seems as if they recall very little. Since people remember 20% of what they hear and 70% of what they hear and see, we can assist them by using visuals as often as possible — models, drawings, or handouts that we can personalize. In addition, using the “chunk and check” technique, we can ensure that patients understand what we are telling them. After each major point, pause and summarize or ask your patient to repeat what they understood from your explanation.

In closing the session, take advantage of the fact that after we use our patient’s name, we have his or her attention for 30 seconds. This is the best time to repeat the most essential information. Ending with a hopeful wish for his or her improvement, as Stephen C. Beeson, MD, suggests in Practicing Excellence: A Physician’s Manual to Exceptional Health Care, helps to cement your partnership, an important skill in reducing malpractice claims. This suggestion may also create an expectation that will result in an improved outcome for your patient.

Many physicians feel that communication is something we do naturally, so there’s no reason to learn anything new.

With better outcomes, fewer lawsuits, and our own happiness at stake, the few minutes spent learning these new skills might be the most important CME we receive all year.

Dr. Fronek, SDCMS-CMA member since 2010, is a certified physician development coach, certified professional co-active coach, and assistant clinical professor of medicine at the UC San Diego School of Medicine.

You can read her blog at helanefronekmd.wordpress.com.

SAN DI EGO PHYSICIAN.org 31

Empowering our Patients

Local Health Charities ALS Association Greater San Diego Chapter 7920 Silverton Ave., Ste. E San Diego, CA 92126 T: (858) 271-5547 www.alsasd.org Alzheimer’s Association San Diego/Imperial Chapter 6632 Convoy Court San Diego, CA 92111 T: (858) 492-4400 www.sanalz.org American Diabetes Association 5060 Shoreham Place San Diego, CA 92122 T: (619) 234-9897 www.diabetes.org American Liver Foundation Pacific Coast Division 2515 Camino del Rio South, Ste. 122 San Diego, CA 92108 T: (619) 291-5483 www.liverfoundation.org American Lung Association in California 2750 Fourth Ave. San Diego, CA 92103 T: (619) 297-3901 www.lungusa.org American Melanoma Foundation 4150 Regents Park Row, Ste. 300 La Jolla, CA 92037 T: (858) 882-7712 www.melanomafoundation.org

32 may 2013

Arthritis Foundation San Diego Area Chapter 9089 Clairemont Mesa Blvd., Ste. 104 San Diego, CA 92123-1228 T: (858) 492-1090 www.arthritis.org Autism Society of America San Diego County Chapter 4699 Murphy Canyon Rd. San Diego, CA 92123 T: (858) 715-0678 www.sd-autism.org Being Alive San Diego — AIDS/HIV Services 4070 Centre St. San Diego, CA 92103 T: (619) 291-1400 www.beingalive.org Burn Institute 8825 Aero Dr., Ste. 200 San Diego, CA 92123 T: (858) 541-2277 www.burninstitute.org Cystic Fibrosis Foundation 10455 Sorrento Valley Rd., Ste. 103 San Diego, CA 92121 T: (858) 452-CURE www.cff.org Epilepsy Foundation of San Diego County 2055 El Cajon Blvd.

San Diego, CA 92104 T: (619) 296-0161 www.epilepsyfoundation.org Fresh Start Surgical Gifts 2011 Palomar Airport Rd., Ste. 206 Carlsbad, CA 92009 T: (760) 944-7774 www. freshstart.org

www.combinedhealth.org Hemophilia Association of San Diego County 3550 Camino del Rio North, Ste. 105 San Diego, CA 92108 T: (619) 325-3570 www.hasdc.org

National Multiple Sclerosis Society Pacific South Coast Chapter 12121 Scripps Summit Dr., Ste. 190 San Diego, CA 92131 T: (760) 448-8400 www.mspacific.org

Juvenile Diabetes Research Foundation San Diego Chapter 5665 Oberlin Dr., Ste. 106 San Diego, CA 92121 T: (858) 597-0240 www.jdrfsd.org

Parkinson’s Association of San Diego 8555 Aero Dr., Ste. 308 San Diego, CA 92123 T: (858) 273-6763 www.pdasd.org

Leukemia & Lymphoma Society 9150 Chesapeake Dr., Ste. 100 San Diego, CA 92123 T: (858) 277-1800 www.leukemia-lymphoma. org/hm_lls

Sickle Cell Disease Association of America 837 South 47th St. San Diego, CA 92113 T: (619) 263-8300 www.sicklecelldisease.org

Lupus Foundation of Southern California 4699 Murphy Canyon Rd. San Diego, CA 92123 T: (858) 278-2788 www.lupussocal.org Mental Health America of San Diego County 4069 30th St. San Diego, CA 92104 T: (619) 543-0412 www.mhasd.org Muscular Dystrophy Association 9990 Mesa Rim Rd. San Diego, CA 92121 T: (858) 492-9792 www.mdausa.org

Stepping Stone of San Diego 3969 Fourth Ave. San Diego, CA 92103 T: (619) 278-0777 www.steppingstonesd.org United Way of San Diego County 4699 Murphy Canyon Rd. San Diego, CA 92123 T: (858) 636-4100 www.liveunitedsd.org

YOU ARE OUR HERO thank you for giving access to healthcare for those without!

San Diego County Medical Society Foundation’s Mission Is To Improve Health, Access To Care, And Wellness For Patients And Physicians Through Engaged Volunteerism.

You are the Heart & Soul of Project Access San Diego Through your support of our flagship program, Project Access San Diego, we have been able to assist over 1,850 uninsured adults in our community to improve their health through access to specialty healthcare services. You have provided over $6.3 million in contributed healthcare services to community members since our program’s beginnings in December 2008!

Thanks to more than 625 volunteer physicians providing specialty healthcare services to those who most need our help, we are getting people back to work, and able to care for their families.

Without the generous support and dedication of all of our physician volunteers, hospitals and outpatient surgery centers, imaging, labs, physical therapy, and other ancillary health providers, hundreds of hard-working but uninsured adults would go without care every year. Thank you for being a hero to our community!

Get Involved San Diego County Medical Society Foundation needs you! Join us to volunteer for Project Access, or provide specialty consultations to primary care physician colleagues through eConsultSD, our HIPAA-compliant, web-based system from the comfort of your home or office. Attend an event, assist us to recruit fellow physicians, or provide educational opportunities for primary care physicians or medical students. Our first annual Golf Tournament on Thursday, February 28, 2013 at Del Mar Country Club was a huge success; we hope you can join us next year! Watch for news on our Fall Heroes de la Salud event. And please consider making a contribution to SDCMS Foundation to support our efforts at www.sdcmsf.org, or call us at 858.300.2777.

5575 Ruffin Road, Suite 250, San Diego, California 92123 p: 858.300.2777 f: 858.569.1334 n

n

Daniel “Stony” Anderson, MD Sandra Freiwald, MD Paul Bernstein, MD And the Kaiser Permanente Saturday Surgery Day Team Spirit of Volunteering Drs. Anderson, Freiwald and Bernstein have championed Saturday Surgery Days at Kaiser Permanente since Project Access’ beginnings; October 2012 marked our 10th Surgery Day at KP. More than 150 physicians, nurses, physician assistants, and medical staff assure that patients regain their health through surgeries and GI procedures. The KP team is recognized as our heroes thanks to their dedication to Project Access patients; 342 patients have benefited from their care.

The majority of PASD patients require just office consultations and procedures. 30% of patients require surgery or GI procedures, which occur during a Carlsbad or Kaiser Permanente Surgery Day, or are accommodated at our partnering hospitals and outpatient surgery centers throughout the year.

Thank you to all of our physician volunteers-- you are all our heroes!!

www.sdcmsf.org SAN DI EGO PHYSICIAN.org 33

classifieds PHYSICIAN POSITIONS AVAILABLE seeking full-time BC/BE Family Medicine physicians: SHARP Rees-Stealy Medical Group, a 400+ physician multi-specialty group in San Diego, is seeking full-time BC/BE family medicine physicians to join our staff. We offer a first-year competitive compensation guarantee and an excellent benefits package. Please send CV to lori.miller@ sharp.com or upload CV at https://home2.eease.adp.com/ recruit/?id=5346922. [135] seeking full-time BC/BE Internal Medicine physicians: SHARP Rees-Stealy Medical Group, a 400+ physician multi-specialty group in San Diego, is seeking fulltime BC/BE internal medicine physicians to join our staff.

We offer a first-year competitive compensation guarantee and an excellent benefits package. Please send CV to lori. miller@sharp.com or upload CV at https://home2.eease. adp.com/recruit/?id=6795752. [136] RECRUITING A CARDIOLOGIST TO VOLUNTEER ONCE A MONTH: The UCSD Student-Run Free Clinic Project is recruiting a cardiologist to volunteer once a month (Monday in downtown San Diego OR Wednesday evening in Pacific Beach). This is a unique opportunity to serve the community as well as teach the eager medical students that will become tomorrow’s physicians. If you are interested in learning more about this volunteer position, please contact Dr. Michelle Johnson at mlj001@ucsd.edu and / or visit our website at http://meded.ucsd.edu/freeclinic. [131] HIRING BC/BE PSYCHIATRISTS: Hiring BC/BE psychiatrists for full-time, home call, and weekend rounding positions at award-winning Palomar Health. Competitive pay.

Contact Susan Linback at (760) 739-2973 or send CV to susan.linback@palomarhealth.org. [130] PER DIEM PHYSICIANS: Imaging Healthcare Specialists is actively seeking per diem physicians to monitor patient examinations requiring contrast. Current openings are for Saturday and Sunday shifts. Applicants must be available a minimum of three weekend days per month and to work at multiple locations. For more information, please contact Brandy at (858) 658-6589 or email a copy of your updated CV / resume to careers@imaginghealthcare.com. [129] MEDICAL DIRECTOR: Part-time medical director needed for a medical spa in East County. Retired physicians welcome. Malpractice and salary will be paid. Please call Nancy at (619) 456-4555. [128] FAMILY MEDICINE OPPORTUNITY IN NORTH COASTAL SAN DIEGO COUNTY (VISTA): This is with a longestablished group, which is physician owned and governed.

Board-certified / board-eligible candidates only. Full time. If interested, please send CV to judy@cassidymg.com or call (760) 630-5487. [123] PHYSICIAN NEEDED IMMEDIATELY! Southern Indian Health Council is seeking a board-certified physician for family practice Mon–Fri, 8:00am–4:30pm. Must have CA medical license, DEA license, ACLS, BLS. We offer: competitive salary, health benefits, vacation pay, holiday pay, sick pay, CME and license reimburse, and paid malpractice coverage. No weekends. Contact: tdentice@sihc.org or HR phone (619) 445-1188, ext. 308 or ext. 307, or HR fax (619) 659-3145. Visit www.sihc.org. [120] PRIMARY CARE 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] 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 occa-

sional admission, NO delivery standby or rushing out in the night. Benefits include tail-covered liability insurance, paid holidays/vacation/sick time, professional dues, health and dental insurance, uniforms, CME, budgets, disability and life insurance. Please contact Venk at (619) 504-5830 or at venk@gpeds.sdcoxmail.com. Salary $ 102–108,000 annually (equal to $130–135,000 full-time). [778] PRACTICE WANTED WE BUY URGENT CARE OR READY MED-CLINIC: We are interested in purchasing a preexisting urgent care or ready med-clinic anywhere in San Diego County. Please contact Lyda at (619) 417-9766. [008] OFFICE SPACE / REAL ESTATE LA JOLLA (NEAR UTC) OFFICE FOR SUBLEASE: Scripps Memorial medical office building, 9834 Genesee Ave. (great location by the front of the main entrance of the hospital between I-5 and I-805). Multidisciplinary group.

Excellent referral base in the office and on the hospital campus. Please call (858) 455-7535 or (858) 320-0525 and ask for the secretary, Sandy. [127] GET 1 MONTH FREE RENT: A 1215 sq.ft. office space is available for rent in a well-maintained professional building.

This space is ready for move in. It has three large offices, a break room, a common space, a private bathroom, and a big reception area. Excellent for accounting office, insurance, medical office, chiropractor, real estate, complementary/alternative medicine, physical therapy, chiropractic, acupuncture, massage/body work, etc. Located close to Rancho Bernardo, Scripps Ranch, 4-S Ranch, Poway. Get one month of free rent in the form of two half-months of rent. $1,400 net is all you pay, no NNN added. Please call Heather for any questions at (858) 909-9033 or email olgald@palomarneurosurgery.com. [124] OFFICE SPACE IN ENCINITAS — 477 N. EL CAMINO REAL: 1600sf beautiful office occupied by a dermatologist.

One or two rooms available. May have the space to yourself for a full day and some half days. Prime location in a multispecialty, four-building complex with an outpatient surgery center. Close to Scripps Encinitas Hospital. Available immediately and staff available if needed. Great for solo physician or a small group seeking a presence in North County. Please contact Dana at (760) 436-8700 or at dana@doctorlashgari.com [122] RECENTLY RENOVATED MEDICAL OFFICE IN VISTA, CALIF. AVAILABLE FOR SUBLEASE: Available Wednesday, Thursday, and Friday for $500 per room. Staff can also be provided based on need. Near Tri-City Hospital. Call or email for more details: (858) 735-9879, drsameergupta@ gmail.com. [119]

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 firstyear 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 sq-ft 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] 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 / WANTED

SCRIPPS-XIMED MEDICAL OFFICE SPACE FOR SUBLEASE PART-TIME: Newly renovated office for sublet 0.5–1.5 days per week. Perfect for Scripps physician desiring on-campus presence. Full use of 1100sqft, including reception, business office, three exam rooms, consultation room, nurses station, and breakroom. Suitable for internist, internist specialty, surgeon, or psychiatrist. Receptionist help available if needed. Call (858) 354-1088. [118] 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) 8238111. Thank you. [836] NORTH COAST OFFICE SPACE TO SUBLEASE: North Coast Health Center, 477 El Camino Real, Encinitas, office space to sublease. Newly remodeled and beautiful office space available at the 477/D Building. 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) 840-2400 or at (858) 452-0306. [041]

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 may 2013

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]

EXPERIENCED MEDICAL RECEPTIONIST FOR FULLTIME EMPLOYMENT: My name is Ashley Richards. I recently moved to the San Diego area, and I am looking for employment. Collectively, I have 6+ years medical reception / management experience in optometry, audiology, and ENT offices. All included high call volumes, team work, EMR, insurance verification, and copay collections. References on request. Thank you. Cell: (805) 433-2983. Email: sff_mo@yahoo.com. [137] NORTH COUNTY PRACTICE SEEKS RNP: Multi-specialty practice in need of part- or full-time RNP for growing practice. Prefer internal medicine / nephrology experience.

Ehr experience a plus. Please send CV with references to rnpvacancy@gmail.com. [134] NURSE PRACTITIONER OR PHYSICIAN’S ASSISTANT: Established, busy pain management practice in Mission Valley is looking for a nurse practitioner or physician’s assistant, 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 paindoctorstaff@hotmail.com. [094] PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Needed for house-call physician in Coachella Valley (Palm Springs / Palm Desert). Part time, flexible days/hours.

Competitive compensation. Call (619) 992-5330. [038]

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at 858-231-1231 or DPebdani@sdcms.org SAN DI EGO PHYSICIAN.org 35

San Diego Physician Celebrates 100 Years!

The Bulletin of the San Diego County Medical Society February 1955

In celebration of 100 years of publication of San Diego Physician (formerly known as The Bulletin), we will be reprinting throughout the year excerpts from past issues, and we will devote our December 2013 issue to recognizing the achievements of the official “Bulletin” of the San Diego County Medical Society. If you would like to contribute in any way to our December issue, please email Editor@SDCMS.org. Thank you!

the bulletin

Personal Notes The February wedding of Miss Martha Louise B. Belford to Donald Everett Root, son of Cmdr. Amos her by nced annou ly recent was Root, Root and Mrs. parents, Dr. and Mrs. W. W. Belford.

Mrs. William Booth, widow of Dr. William

uest Booth formerly of Coronado, was a recent houseg Booth Mrs. of Dr. and Mrs. W. W. Woods in La Jolla. now resides at 612 Landers Lane, Pasadena.

Miss Margaret Newman, daughter of Dr. and Mrs. April Willard H. Newman, will be sailing for Europe, Exs. zation organi Scout Girl ean 7, for a tour of Europ NewMiss ies, countr l severa into travels tending her man will return to the U. S. in November.

The holidays found Dr. and Mrs. H. O. Cozby in at Grand Saline, Texas where Dr. Cozby convalesced . the home of his mother, Mrs. V. B. Cozby Dr. and Mrs. Frederick R. Allen returned to San many Diego for the holiday week and were visited by n at surgeo flight as g servin friends. Dr. Allen has been Base. the Oxnard Air Force Dr. and Mrs. Hervey King Graham moved into 3977 their new home early in January. Their address is .

Street i Bandin A modern new office building for Dr. Martin Koke Third is nearing completion at the northeast corner of le. and Hawthorn Street. A vacancy is availab Dr. and Mrs. Edwin P. Woodward are the happy is parents of a little girl born December 17. Her name here came who ard, Woodw Mrs. Jessica Jean. Dr. and at from Shreveport, Louisiana last summer, are living

36 May 2013

3844 Belmont Street.

Dr. and Mrs. W. L. Garth of La Jolla, who reeling turned here during the holidays, have been remod s, a 150-year-old Spanish house they bought in Alamo Mexico.

Dr. and Mrs. M. D. Ballard returned early in Janu. ary from a trip to New York City and a Caribbean cruise of birth the nce annou n Dr. and Mrs. Gilbert Kinyo ns a little girl, Michele Marie, their firstborn. The Kinyo proud Other Iowa. from ago half a and came here a year Robparents of the last few months are Drs. and Mrs. d Bernar y, Rumse e Eugen , Rogers te Everet y, ert Murph Wells.

J. John and Hark, Dr. Walter Nickel and Cmdr. James Lockwood blue of Naval Hospital were honored recently with a g of meetin the at t ribbon for their educational exhibi o.

Chicag in tology Derma the American Academy of by e diseas skin of ion evolut the The exhibit illustrates to Atmeans of colored transparencies. It will be taken AMA. the of tion conven the for June lantic City next A goodly number of surgeons traveled to Palm l conSprings on January 22 and 23 to attend the annua Amerference of the Southern California chapter of the Paul ican College of Surgeons. Drs. Ward Woods and me, syndro e scalen Shea read a paper on the anterior as Thom Drs. s, injurie al Dr. Michael Feeney on ureter the of us volvul on n Gleaso O’Connell and Mathew in sigmoid colon, and Drs. Clarence Rees and Benjam . cancer breast in ens Stimmel on estrog Antoinette LeMarquis, M.D.

Special mortgage financing for physicians Our special home financing program is designed specifically to meet your needs as a busy physician for the purchase of your primary residence.

• Financing available with low down payment up to $1,750,000; refinances with high loan-to-values also available • Private mortgage insurance is not required • Single family homes are eligible

For details contact or visit: Daniel Schroeder Mortgage Banking Officer NMLS# 633034 Daniel Schroeder (858) 356-2601 Daniel.Schroeder@bbvacompass.com

All loans subject to approval, including credit approval. Eligible properties must be located in Alabama, Arizona, California, Colorado, Central Florida, North Florida, New Mexico or Texas where BBVA Compass has a market presence. BBVA Compass is a trade name of Compass Bank, Member FDIC.

$5.95 | www.SANDIEGOPHYSICIAN.org

San Diego County Medical Society 5575 Ruffin Road, Suite 250 San Diego, Ca 92123

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