October 2013 by San Diego Physician

San Diego Physician

100 celebrates

official publication of the san diego county medical society Oct 2013

years

Infectious

disease page

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Oct.

Contents

Volume 100, Number 10

MANAGING EDITOR: Kyle Lewis EDITORIAL BOARD: Theodore M. Mazer, MD, James Santiago Grisolía, MD, Robert E. Peters, PhD, MD, David M. Priver, MD, Van C. Johnson, MD, Roderick C. Rapier, MD MARKETING & PRODUCTION MANAGER: Jennifer Rohr SALES DIRECTOR: Dari Pebdani ART DIRECTOR: Lisa Williams COPY EDITOR: Adam Elder

features INFECTIOUS DISEASE

SDCMS BOARD OF DIRECTORS

BY WILMA J. WOOTEN, MD, MPH

OFFICERS PRESIDENT: Robert E. Peters, PhD, MD PRESIDENT-ELECT: J. Steven Poceta, MD TREASURER: William T-C Tseng, MD, MPH (CMA Trustee) SECRETARY: Mihir Y. Parikh, MD IMMEDIATE PAST PRESIDENT: Sherry L. Franklin, MD (CMA Trustee)

Influenza: What Will This Season Bring?

24 Recurrent C. difficile Therapy: Feces Is Usually Understood as Something to Avoid BY FRANK MEYERS

28 Standard Precautions and Respiratory Hygiene / Cough Etiquette: Is It Underestimated?

SDCMS Foundation Recognizes Health Heroes

BY SHANNON ORIOLA, RN, BSN, CIC, COHN

BY BARBARA MANDEL, MBA

An Inventory of Days

Carbapenem-resistant Enterobacteriaceae: A Growing Threat BY MARIE YU, PHARMD, BCPS1

departments 4 Briefly Noted: Calendar • Get in Touch • Welcome New & Rejoining Members • And More …

BY DANIEL J. BRESSLER, MD

Choosing Wisely: Five Things Physicians and Patients Should Question

BY THE AMERICAN COLLEGE OF CARDIOLOGY

Targeting Greater Life Satisfaction

BY HELANE FRONEK, MD, FACP, FACPH

Be Aware of the Risk of Sudden Cardiac Arrest That Killed “Tony Soprano”

BY THE DOCTORS COMPANY

GEOGRAPHIC AND GEOGRAPHIC ALTERNATE DIRECTORS EAST COUNTY: Venu Prabaker, MD, Alexandra E. Page, MD, Jay P. Mongiardo, MD (A: Susan Kaweski, MD (CALPAC Treasurer)) HILLCREST: Gregory M. Balourdas, MD, Thomas C. Lian, MD (A: Sunny R. Richley, MD) KEARNY MESA: Jason P. Lujan, MD, John G. Lane, MD (A: Anthony E. Magit, MD, Sergio R. Flores, MD) LA JOLLA: Geva E. Mannor, MD, Wayne Sun, MD (A: Lawrence D. Goldberg, MD) NORTH COUNTY: James H. Schultz, MD, Eileen S. Natuzzi, MD, Michael A. Lobatz, MD (A: Anthony H. Sacks, MD) SOUTH BAY: Reno D. Tiangco, MD, Michael H. Verdolin, MD (A: Elizabeth Lozada-Pastorio, MD) AT-LARGE DIRECTORS Jeffrey O. Leach, MD (Delegation Chair), Karrar H. Ali, MD, Kosala Samarasinghe, MD, David E.J. Bazzo, MD, Mark W. Sornson, MD (Board Representative), Peter O. Raudaskoski, MD, Vimal Nanavati, MD (Board Representative) AT-LARGE ALTERNATE DIRECTORS Karl E. Steinberg, MD, Phil Kumar, MD, Holly B. Yang, MD, Samuel H. Wood, MD, Elaine J. Watkins, DO, Carl A. Powell, DO, Theresa L. Currier, MD OTHER VOTING MEMBERS COMMUNICATIONS CHAIR: Theodore M. Mazer, MD (CMA Vice Speaker) YOUNG PHYSICIAN DIRECTOR: Edwin S. Chen, MD RESIDENT PHYSICIAN DIRECTOR: Jane Bugea, MD RETIRED PHYSICIAN DIRECTOR: Rosemarie M. Johnson, MD MEDICAL STUDENT DIRECTOR: Jason W. Signorelli OTHER NONVOTING MEMBERS YOUNG PHYSICIAN ALTERNATE DIRECTOR: Renjit A. Sundharadas, MD RESIDENT PHYSICIAN ALTERNATE DIRECTOR: Erin Whitaker, 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

Five Inadvertent HIPAA Violations by Physicians BY TRACEY HAAS, DO, MPH

Physician Marketplace: Classifieds

18 2 Oc tober 2013

San Diego Physician Celebrates 100 Years: January 1962

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.]

Eco Minded Solutions is recognized by the U-T 2013 READER’S POLL in 5 REMODELING CATEGORIES *BEST Landscape Company *BEST Door & Window Replacement *TOP in Kitchen & Bath Remodeling *TOP Local Contractor *TOP Construction Company This UNPRECEDENTED distinction by the Union Tribune is earned because of our passion for innovative design, energy efficiency, water conservation and outstanding craftsmanship. Eco Minded Solutions can provide more outstanding PHYSICIAN references for HOME & MEDICAL OFFICE renovation projects than most any other company in San Diego. Joint Resurfacing

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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.

The Leader’s Toolkit (workshop) NOV 2–3: 8:00am–4:00pm, 8:00am–12:00pm Risk Prevention Tips for the Digital Age (seminar/ webinar) NOV 14: 11:30am–12:30pm

Cma Webinars CMAnet.org/events CMS Quality Reporting Programs: What Physicians Need to Know and Do Now to Improve Care and Avoid Penalties OCT 30: 12:15pm–1:45pm External Auditors and You: Medi-Cal Recovery Audit Contract Process NOV 6: 12:15pm–1:15pm Managing Difficult Employees and Reducing Conflict NOV 13: 12:15pm–1:45pm Medicare: 2014 New Rules DEC 4: 12:15pm–1:15pm ICD-10 Documentation for Physicians: Part 1 DEC 5: 12:15pm–1:15pm ICD-10 Documentation for Physicians: Part 2 DEC 12: 12:15pm–1:15pm ICD-10 Documentation for Physicians: Part 3 DEC 19: 12:15pm–1:15pm

“

Community Healthcare Calendar

To submit a community healthcare event for possible publication, email KLewis@ SDCMS.org. Events should be physician-focused and should take place in or near San Diego County. ILADS 2013 Lyme Disease Basics Course OCT 17 (http://ilads.org/ lyme_programs/sandiego/ ilads_sandiego-lyme-course. php) Festivals of the World Gala (hosted by the Parkinson’s Association of San Diego) OCT 19 (http:// parkinsonsassociation.org) The 2013 San Diego Day of Trauma NOV 1 (www.scripps.org/ events/san-diego-day-oftrauma-november-1-2013) Controversies in Nutrition: Navigating Uncharted Waters NOV 13–16 (www.scripps. org/events/americancollege-of-nutrition54th-annual-conferencenovember-13-2013) Redesign Your Practice, Improve Patient Care, Sustain Your Changes NOV 21–24 (www. stfm.org/conferences/ practiceimprovement)

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 OFFICE MANAGER • DIRECTOR OF FIRST IMPRESSIONS Betty Matthews at (858) 565-8888 or Betty.Matthews@SDCMS.org LETTERS TO THE EDITOR Editor@SDCMS.org GENERAL SUGGESTIONS SuggestionBox@SDCMS.org

Update in Rheumatology 2013 DEC 14 (https://cme.ucsd. edu/rheumatology) New Restorative Frontiers (sponsored by the Naval Medical Center San Diego) DEC 5–8 (www.genevancejr. org)

SDCMSF Contact Information 5575 Ruffin Road, Suite 250, San Diego, CA 92123 T (858) 300-2777 F (858) 560-0179 (general) W SDCMSF.org EXECUTIVE DIRECTOR Barbara Mandel at (858) 300-2780 or Barbara.Mandel@SDCMS.org project access PROGRAM DIRECTOR Francesca Mueller, MPH, at (858) 565-8161 or Francesca.Mueller@SDCMS.org Patient Care Manager Rebecca Valenzuela at (858) 300-2785 or Rebecca.Valenzuela@SDCMS.org

Taking a new step, uttering a new word, is what people fear most.

4 Oc tober 2013

get in touch

”

— Fyodor Dostoyevsky, Russian Writer and Philosopher (1821–1881)

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

/////////////////////////////////////////////////////////////////////////////////////////////////// SDCMS-CMA Membership

legislator birthdays

Welcome New and Rejoining SDCMS-CMA Members! New Members Shervin Alborzian, MD Ophthalmology La Jolla (858) 457-2220 Robert V. Barthel, MD Infectious Disease San Diego (619) 532-7475 Keith A. Beiermeister, MD Colon and Rectal Surgery La Jolla (858) 558-2272 Andrew B. Cummins, MD Gastroenterology Oceanside (760) 724-8782 Oscar M. De La Mora, MD Pediatrics San Diego (619) 264-3107 Dina R. Fainman, MD Obstetrics and Gynecology Solana Beach (760) 635-3777

Ramin Motarjemi, MD Internal Medicine San Diego (619) 543-7832

Sameer Gupta, MD Allergy and Immunology Vista (760) 298-5412

Minh Q. Nguyen, DO, MHA, MPH Occupational Medicine Chula Vista (619) 297-9610

Doyle D. Hansen, MD Dermatology San Diego (858) 576-9630

Tania L. Rivera, MD Rheumatology San Diego (858) 869-1285

Jessin HelmrickBlossom, MD Aerospace Medicine Poway (619) 545-7299

Diana L. Rowell, MD Internal Medicine San Diego (858) 499-2707

D. Scott McCaul, MD Pulmonary Disease La Jolla (858) 625-7200

Karen A. Saroki, MD Family Medicine San Diego (619) 692-4401

Elise A. Reed, DO Psychiatry Vista (760) 941-6062

Alice M-Y Tsai, DO Physical Medicine and Rehabilitation San Diego (858) 552-8585

Rodolfo Ruiz-Velasco, MD Pathology National City (619) 474-9211

Rejoining Members Jerry M. Held, MD Internal Medicine San Diego (619) 440-2751 Frank D. Herrera, MD Occupational Medicine Walnut (626) 407-0300

Marcus Contardo, MD Anatomic Pathology Oceanside (760) 634-3230 Marc Gipsman, MD Anesthesiology San Diego (858) 673-6100

Adrienne L. Lostetter, MD Pediatrics San Diego (858) 495-0500

Daniel N. Sauder, MD Dermatology La Jolla (858) 909-9000 Lila L. Schmidt, MD Obstetrics and Gynecology San Diego (619) 295-4050 Calvin K. Wong, MD Family Medicine San Diego (619) 232-6262

In Memoriam

Samil N. Maywood, MD

SDCMS-CMA member since 1996, was recently discovered to have passed away on May 8, 2013.

One way to let your legislators know that you’re paying attention and that you vote is by wishing them a happy birthday! Senator Mark Wyland (District 38) E: (via website) cssrc.us/web/38 E: senator.wyland@sen.ca.gov Capitol Office: California State Senate PO Box 942848 Sacramento, CA 94248-0038 Telephone: (916) 651-4038 Fax: (916) 446-7382 District Office: 1910 Palomar Point Way, #105, Carlsbad, CA 92008 T: (760) 931-2455 • F: (760) 931-2477 Birthday: Oct. 27

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!

Lawrence J. Zaino, MD

SDCMS-CMA member since 1974, was recently discovered to have passed away on April 12, 2013.

SAN DI EGO PHYSICIAN.org 5

/////////briefly ///////////////////noted ////////////////////////////////////////////////////////////////////// Commercial Real Estate Tips & Trends By Chris Ross

In the past 12 months, medical office vacancy in San Diego County has declined by approximately three percentage points. Rental rates have flattened out and have started to rise in some submarkets. As we close the books on the third quarter of 2013, many physicians, medical groups, and health systems are wondering, “Is it still a tenant’s market?” Most industry experts feel that the pendulum has at least started to swing in favor of the landlord, but there are numerous medical buildings and submarkets where tenants still have the upper hand. To help you determine the best strategy for your lease or real estate needs, consider the trends that are taking place in your building, area, and county.

State of the San Diego Healthcare Real Estate Market The biggest challenges to completing a lease transaction in 2013 are the opposing forces of (a) the tenant’s inability or unwillingness to spend a significant amount of money on a move or to commit to a long-term lease, and (b) the significant costs of building out medical office space. Medical tenant improvements cost approximately double those of general office — not to mention the fact that existing office 6 Oc tober 2013

space is in abundance, while high-quality, fully improved medical space can be scarce or even nonexistent in certain areas. As such, most relocations require a major renovation if not an entirely new buildout from shell condition. With the state of flux the healthcare industry is experiencing, most tenants prefer maximum flexibility and minimal relocation expense, which is limiting leasing activity and leading to a lot of three- and five-year renewals. As a result, landlords and developers with significant vacancy are providing higher-than-normal tenant improvement allowances and leasing concessions. The end result is unique opportunities in the marketplace for tenants who are considering a move or upgrade. On Campus vs. Off Campus Generally, off-campus medical buildings get fewer looks from prospective tenants and are providing the most significant

concessions, while on-campus buildings have less vacancy and are more rigid with the rent and other terms. Providers should ask themselves how much they truly benefit from being on campus. In many cases an on-campus location may be convenient for the provider, but is it convenient for the patient? Consider near-campus office space in your area and compare costs, access, parking, overall quality, and proximity to restaurants, retail, and other amenities. Here’s What’s Happening in Your Neck of the Woods … Industry experts have noted that tenants are now using more strategic and creative ways to offset rising occupancy costs, such as forming groups to gain leverage and/or share in costs and acquiring or investing in medical buildings as income property (regardless of whether the physician or group will be officed there). Regardless of your goals, it is important to plan ahead and stay up to speed on market conditions as you weigh your options. Mr. Ross is vice president of healthcare solutions for Jones Lang LaSalle. He is a commercial real estate broker specializing exclusively in medical office and healthcare properties in San Diego County. He can be reached at (858) 410-6377 or at chris. ross@am.jll.com.

Market Conditions Forecast: Next Six Months Submarket

Vacancy (Class A & B)

Rental Rates

Oceanside/Vista





Escondido





North County Coastal





I-15 Corridor





UTC





Kearny Mesa



East County



Uptown/Hillcrest



South County



web spotlight

www.CMS.gov/ICD10 On Oct. 1, 2014, the healthcare industry will transition from ICD-9 to ICD-10 codes for diagnoses and inpatient procedures. This transition is going to change how you do business — from registration and referrals to superbills and software upgrades. But that change doesn’t have to be overwhelming. At www.CMS.gov/ICD10, under “Provider Resources,” CMS has myriad resources to help your practice prepare for the transition, including: • Understanding the Basics: FAQ sheets to introduce you to ICD-10, explain why it’s necessary, and give you the information you’ll need to get started on your transition. • Implementation Guides, Timelines, and Checklists • Implementation Planning: Step-by-step information to help you plan for the transition. • Communicating About ICD-10: Communication between healthcare providers, software vendors, clearinghouses, and billing services is an important part of the transition process. Learn how to get the conversation started. • Testing: Resources to help providers conduct ICD-10 testing with your trading partners. • Medscape Modules: Guidance for small practices making the transition to ICD-10. • Conferences, Meetings, and Webinars • Stay Up to Date on ICD-10! • Related Links

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micra

Individuals and Groups Donating to Defend MICRA Thank you to the following individuals and groups for their generous support in defense of California’s landmark Medical Injury Compensation Reform Act (MICRA), which is being attacked by trial lawyers waging an aggressive campaign to weaken if not overturn it. San Diegans Who’ve Donated $1,000 or More: Mark R. Bell, MD Richard O. Butcher, MD David J. Bylund, MD Marcus Contardo, MD Michael T. Couris, MD Douglas J. Ellison, MD Douglas K. Fenton, MD Sherry L. Franklin, MD Tom Gehring Nancy L. Harrison, MD James T. Hay, MD Robert E. Hertzka, MD Joseph A. Hughes, MD Rosemarie M. Johnson, MD Susan Kaweski, MD Eric S. Korsh, MD Jeffrey O. Leach, MD Michael D. Linden, MD Michael A. Lobatz, MD Thedore M. Mazer, MD Colleen P. McNally, MD Paul C. Milling, MD Catherine D. Moore, MD Vimal I. Nanavati, MD Slawomir T. Niewiadomski, MD Ralph R. Ocampo, MD, FACS Mihir Y. Parikh, MD Robert E. Peters, MD J. Steven Poceta, MD David M. Priver, MD Seong H. Ra, MD Albert Ray, MD Bruce A. Robbins, MD Carla Stayboldt, MD Mark J. Tamsen, MD Robert E. Wailes, MD William J. Watts, MD Carol L. Young, MD

Medical Groups That Have Donated: Alvarado: $10,000 Chief of Staff: Frederick M. Howden, MD Chief of Staff Elect: Richard O. Butcher, MD Rady Children’s Specialists of San Diego: $33,000 Chief of Staff: Gail R. Knight, MD Chief of Staff Elect: Mary Hilfiker, MD Scripps Mercy Chula Vista: $33,000 Chief of Staff: Juan M. Tovar, MD Chief of Staff Elect: Thomas C. Lian, MD, PhD Sharp Memorial/Mary Birch: $33,000 Chief of Staff: Ronald C. MacIntyre, MD

So, you can be there for your patients. A leading SBA Preferred Lender in Southern California specializing in: • Real Estate Purchase • New Equipment • Tenant Improvements

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SAN DI EGO PHYSICIAN.org 7

SDCMS Foundation

SDCMS Foundation Recognizes Health Heroes Sept. 26, 2013

by Barbara Mandel, MBA Three 2013 Project Access Health Heroes were recognized at the Héroes de la Salud! event presented by the SDCMS Foundation on Sept. 26 at The Abbey in Bankers Hill.

Wendy M. Buchi, MD 2013 Health Hero Champion Award Gabriela knew it would be almost impossible to continue to care for her young children unless she got medical care. Lifting her 2-year-old had become unbearably painful. She was often unable to leave her home, so walking her children to school was no longer feasible. Then she met Wendy Buchi, MD. Dr. Buchi, an obstetrician/gynecologist in practice at IGO Medical Group since 1993 and SDCMS-CMA member since 1994, regularly volunteers to care for the uninsured women referred to her through the San Diego County Medical Society Foundation’s Project Access San Diego. These patients come to Dr. Buchi after years of untreated medical conditions. “Project Access patients are so appreciative of the care they receive,” says Dr. Buchi. “They want to improve their lives, so they listen and follow through on their care, which is what every doctor wants to see from their patients.” Not only has Dr. Buchi volunteered her own time to care for at least a dozen patients a year, she has also encouraged her partners to join her in these efforts, and now three IGO Medical Group physicians are working to improve the health and lives of uninsured women. “My colleagues saw what I was doing, often assisted me with a surgery, and be8 Oc tober 2013

came inspired themselves,” says Dr. Buchi. “Because we are helping women who have more complicated issues than what our practice normally sees, due to their lack of healthcare access, we are also enhancing our own practice of medicine.” As a Project Access champion, Dr. Buchi has been honored with the 2013 Health Hero Champion Award, presented to a volunteer who has effectively encouraged their peers to participate with Project Access and has played a key role in implementing the program at their organization. “Volunteering for Project Access has been really fun and rewarding for me,” adds Dr. Buchi. “The Project Access staff is great to work with, and I know any follow-up or additional resources will be taken care of, making my role as a volunteer physician easy.” Rosemarie M. Johnson, MD 2013 Health Hero Legacy Award In the early 1970s, at a time when few women were practicing medicine and there were no female anesthesiologists in San Diego, Rosemarie M. Johnson, MD, was a pioneer. Dr. Johnson continues to be a pioneer, encouraging colleagues to volunteer for Project Access San Diego, and cochairing efforts to pair retired physicians with recent veterans needing assistance to navigate a complicated healthcare system. “When I joined Anesthesia Services Medical Group in 1978, I was the 70th physician in the group and the first woman,” says Dr. Johnson. “I always found a way to do something new and different.” Dr. Johnson became involved with

organized medicine through her leadership participation in SDCMS, which she joined in 1978 and where she served as president in 1994, as president of the California Society of Anesthesiologists in 1995–1996, and in numerous committees and commissions for CMA and AMA throughout the 1980s and ’90s. She was involved in advocating for legislation for child safety seats and reducing tobacco use, both of which have had enormous impact on the health and safety of Californians. To support women physicians in a profession dominated by males, she helped form the Roberta Fenlon Society for upand-coming women physician leaders. There she met and bonded with Carol L. Young, MD, a North County rheumatologist, SDCMS-CMA member since 1980, and SDCMS president in 2005. After Dr. Johnson retired from practice, Dr. Young recruited her to join the SDCMS Foundation to launch Project Access San Diego in early 2009. Dr. Johnson became the medical community liaison, talking with community physicians about the need for care for the uninsured, and recruiting literally hundreds of volunteers. Today more than 600 specialty care physicians provide pro bono care to low-income, uninsured adults who would otherwise have no access to needed medical services. “Our physician community believes in putting the patient first, and we get comments all the time from volunteers who say they love seeing a Project Access patient, that this is why they chose a career in medicine,” says Dr. Johnson. Now Dr. Johnson and retired anesthesiologist Harvey M. Shapiro, MD, are

Clockwise from left: (L–R) Dr. Stuart A. Cohen, Dr. Wendy M. Buchi, and Dr. James T. Hay. (L–R) Dr. James T. Hay, Dr. Rosemarie M. Johnson, and Dr. Carol L. Young. Dr. Jon M. Robins, chairman and CEO, Imaging Healthcare Specialists, with Barbara Mandel, executive director of the SDCMS Foundation.

who over the past year displayed an unparalleled level of commitment to the SDCMS Foundation’s mission, has been instrumental in guiding the organization’s work, and has helped to create or strengthen programs to ensure the organization’s success in the years to come. Imaging Healthcare Specialists 2013 Unsung Heroes Award Diagnosing a disease, visualizing an injury, or reviewing evidence of treatment is critical in patient care management. Physicians and patients rely on the skill and expertise of a group of specialists that are often unseen by patients; that is why the radiologists of Imaging Healthcare Specialists are recognized as Project Access’ 2013 Unsung Heroes Award for their dedication to serving the community’s low-income, uninsured patients. Offering more than 30 years of imaging services experience, Imaging Healthcare Specialists has earned an outstanding

reputation for providing the highest quality medical imaging technology, highly specialized expertise, and exceptional customer service to physicians and patients. The 28 physicians providing patient care are all board-certified diagnostic radiologists. Many of the physician members also have nationally recognized qualifications in medical imaging subspecialties such as neuroradiology, musculoskeletal imaging, magnetic resonance imaging, computed tomography, ultrasound, and interventional radiology. Project Access staff and volunteer physician specialists call on Imaging Healthcare Specialists for PET scans to stage a cancer diagnosis, or an MRI to decide on the patient care plan for a joint injury, or for a fine needle aspiration of a potential breast tumor. Imaging Healthcare Specialists has been providing pro bono care to Project Access patients since 2009, and has increased its commitment each year. Chairman and CEO, Jon M. Robins, MD, understands how important the partnership between the two organizations is to the community. “Imaging Healthcare Specialists, and the physician/owners of Physicians Radiology Medical Group and Radiology Medical Group, owe their past and continuing success to the patients and medical community of San Diego,” says Dr. Robins. “We view our commitment to Project Access and the underserved patients of San Diego County as an opportunity to give back to our community and as a privilege.” Ms. Mandel has served as the executive director of the SDCMS Foundation since 2011.

About the San Diego County Medical Society Foundation focused on the needs of young men and women returning from service in Iraq and Afghanistan who need help navigating medical care and understanding their health issues. Retired physicians participated at the July Stand Down, organized by the Veterans Village of San Diego, to gain a better understanding of the needs of recent military personnel. The program, named Physician Advocates for Veterans (PAVE), is set to launch this fall. Dr. Johnson is recognized for her work in all these efforts with the 2013 Health Hero Legacy Award, presented to a volunteer

Founded by SDCMS in 2005 as a 501c3 not-for-profit organization, the SDCMS Foundation addresses the unmet healthcare needs of low-income uninsured or underinsured San Diego County residents. The SDCMS Foundation focuses on increasing healthcare access, improving health education and prevention, and supporting physicians and medical students in improving the quality of care in the community. Through its flagship program, Project Access San Diego, the SDCMS Foundation has assisted more than 2,100 patients with access to specialty healthcare services. Healthcare partners, including nearly 650 specialty medical physicians, 25 hospitals and surgery centers, and numerous imaging, laboratory, and ancillary providers, have provided patients with more than $6.9 million in donated healthcare services. For more information about the SDCMS Foundation, please visit www.SDCMSF.org.

SAN DI EGO PHYSICIAN.org 9

POETRY AND MEDICINE

An Inventory of Days

An Inventory of Days by Daniel J. Bressler, MD

The day is a human-sized unit of time, one we can grasp both intellectually and emotionally. A day typically has a precise beginning (midnight on the clock and “when I wake up” on the screen of consciousness). In contrast, the collection of 365.25 days we call a year blurs into abstraction except in retrospect. At the other end of the spectrum, a second goes by too quickly to apprehend. Oops, there goes another one! Days are colored by moods, appetites, circumstances, events, weather, and, some might say, the stars. These variables can transform even the most predictable daily schedule into an adventure of novelty, of wonder, of discovery. As the great Irish poet W.B. Yeats reminded us, “The world is full of magic things, patiently waiting for our senses to grow sharper.” The beginning of discovery is the practice of noticing. When I teach the medical students physical exam skills, I’m really just teaching them how to notice features on the human body. Did you notice that sound of the wind through a stony crevice? That’s the murmur of aortic stenosis. Did you notice the dark irregularity of that skin mole? That’s a lesion suspicious for melanoma. Did you notice the bouncing of the patella when 10 Oc tob er 2013

you press down sharply? That’s a sign of a knee joint effusion. The clever student will jot down notes on his smartphone knowing that I’ll be asking in a week or two if what got noticed also got absorbed. Days, too, present us with an invitation to observe and incorporate the world in its terrible and beautiful variety. It’s not Jon Stewart’s The Daily Show; it is rather our own personal daily show. Here comes sadness, then joy, awkwardness, gratification, curiosity, embarrassment, wonder, satisfaction, and, if we’re lucky, love. I try to remember that however bad a day may seem, tomorrow is still up for grabs. Too bad that the converse is also true: A good day doesn’t guarantee a good tomorrow. Ah well, that’s just the human condition. This poem — An Inventory of Days — is a reminder to count the days, notice their variety, and to try to fill them to the brim. It’s an attempt to soothe on the “days so wrong” and celebrate on the “days so right.” Dr. Bressler, SDCMS-CMA member since 1988, is chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and a longtime contributing writer to San Diego Physician.

There are feast days and fast days First days and last days Days of valor and disgrace There are death days and birth days Grave days and mirth days Days to savor and erase There are bird days and dog days Sun days and fog days Days of leaping and collapse There are soft days and hard days Smooth days and marred days Days of torpor and dispatch There are my days and your days Sick days and cure days Days to gather and release There are these days and those days Finger days and toe days Days of violence and peace There are yesterdays and todays Golden days and blue days Days of promises and lies There are valley days and mountain days Scorched days and fountain days Days of prison cells and skies There are prose days and poem days Travel days and home days Days of secrecy and light There are open days and closed days Sure days and supposed days Days so wrong and days so right

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PUBLIC HEALTH

Choosing Wisely

An Initiative of the American Board of Internal Medicine (ABIM) Foundation In the coming months and throughout 2014, we will publish in San Diego Physician various Choosing Wisely® lists of “Things Physicians and Patients Should Question.” Choosing Wisely — see page opposite for the second list — is an initiative of the ABIM Foundation to help physicians and patients engage in conversations to reduce overuse of tests and procedures, and support physician efforts to help patients make smart and effective care choices.

12 Oc tober 2013

How the ACC List on Page 13 Was Created

Originally conceived and piloted by the National Physicians Alliance through a Putting the Charter Into Practice grant, leading medical specialty societies, along with Consumer Reports, have identified tests or procedures commonly used in their fields whose necessity should be questioned and discussed. The resulting lists of “Things Physicians and Patients Should Question” will spark discussion about the need — or lack thereof — for many frequently ordered tests or treatments.

The American College of Cardiology (ACC) asked its standing clinical councils to recommend between three and five procedures that should not be performed or should be performed more rarely and only in specific circumstances. ACC staff took the councils’ recommendations and compared them to the ACC’s existing appropriate use criteria (AUC) and guidelines, choosing items for the five things list that had the tightest inappropriate score in the AUCs and were Class III recommendations in the guidelines. The ACC’s Advocacy Steering Committee and Clinical Quality Committee each then reviewed the five items before sending it to the ACC Executive Committee for final review and approval. ACC’s disclosure and conflict of interest policy can be found at www.cardiosource. org/RWI. For more information or to see other lists of Five Things Physicians and Patients Should Question, visit www. choosingwisely.org.

Choosing Wisely: An Initiative of the ABIM Foundation

(For Cardiology) Five Things Physicians and Patients Should Question by the American College of Cardiology (ACC) Note: These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

Don’t perform stress cardiac imaging or advanced noninvasive imaging in the initial evaluation of patients without cardiac symptoms unless high-risk markers are present. Asymptomatic, low-risk patients account for up to 45% of unnecessary “screening.” Testing should be performed only when the following findings are present: diabetes in patients older than 40 years of age; peripheral arterial disease; or greater than 2% yearly risk for coronary heart disease events.

Don’t perform annual stress cardiac imaging or advanced noninvasive imaging as part of routine follow-up in asymptomatic patients. Performing stress cardiac imaging or advanced noninvasive imaging in patients without symptoms on a serial or scheduled pattern (e.g., every one to two years or at a heart procedure anniversary) rarely results in any meaningful change in patient management. This practice may, in fact, lead to unnecessary invasive procedures and excess radiation exposure without any proven impact on patients’ outcomes. An exception to this rule would be for patients more than five years after a bypass operation.

Don’t perform stress cardiac imaging or advanced noninvasive imaging as a pre-operative assessment in patients scheduled to undergo low-risk non-cardiac surgery. Noninvasive testing is not useful for patients undergoing low-risk non-cardiac surgery (e.g., cataract removal). These types of tests do not change the patient’s clinical management or outcomes and will result in increased costs.

Don’t perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms. Patients with native valve disease usually have years without symptoms before the onset of deterioration. An echocardiogram is not recommended yearly unless there is a change in clinical status.

Don’t perform stenting of non-culprit lesions during percutaneous coronary intervention (PCI) for uncomplicated hemodynamically stable ST-segment elevation myocardial infarction (STEMI). Stent placement in a noninfarct artery during primary PCI for STEMI in a hemodynamically stable patient may lead to increased mortality and complications. While potentially beneficial in patients with hemodynamic compromise, intervention beyond the culprit lesion during primary PCI has not demonstrated benefit in clinical trials to date.

SAN DI EGO PHYSICIAN.org 13

Personal & Professional Development

Targeting Greater Life Satisfaction

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14 Oc tober 2013

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It’s been nearly a year since we first talked about living from our values. Values are those principles and priorities that make our life feel exciting, fulfilling, worth living — that make it our life and not someone else’s. (See San Diego Physician October 2012, or http://helanefronekmd.wordpress.com/tools-for-the-lifeyou-want/). Just as helpful as knowing our values is having an effective way of examining our life to see if those values are being reflected in the way we’re living. An easy way of doing this is to use the Wheel of Life (compliments of Coaches Training Institute). Consider each aspect of your life — how satisfied are you with it? If you are 100% satisfied, darken the “10” line in that wedge of the circle. If you are 50% satisfied, darken the “5” line. Although we may not have met our ultimate financial goal, we can still rate it a “10” if we are track to reach the goal. Similarly, if we are not interested in a primary relationship, we might rate that a “10” because we are not in one. It’s all about how satisfied we are with our current circumstances, and not what we believe others think

we should be doing. Having a visual representation of our life is frequently quite startling — how did we allow our lives to become so unbalanced? Fortunately, rebalancing isn’t as difficult as it may seem. Once you have your wheel drawn, select one aspect that you would like to improve. What are three things that you might do to have greater satisfaction with this part of your life? Now pick one of those things and schedule it into your calendar within the next month. If you make this simple commitment to do one thing

each month to improve each of the wedges that you score below 7, you may be surprised at how quickly your life will begin to feel richer and more enjoyable. 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.

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Risk Management

Be Aware of the Risk of Sudden Cardiac Arrest That Killed “Tony Soprano” by SDCMS-endorsed The Doctors Company — For more patient safety articles and practice tips, visit www. thedoctors.com/patientsafety.

The recent death of James Gandolfini, who played mafia boss Tony Soprano in the hit TV series The Sopranos, and recent malpractice cases are reminders that healthcare providers need to be on alert for the risk factors of sudden cardiac arrest (SCA), the unexpected loss of heart function, breathing, and consciousness. In SCA, the electrical system of the heart fails, and, at times, a heart attack may occur concurrently. About half of people who suffer SCA had no previous symptoms, such as fatigue, dizziness, and racing heart rate. Approximately 325,000 people in the United States die from SCA annually. People who smoke or have coronary artery disease, have had a previous heart attack, have high cholesterol, and/or have a family history of heart disease have a higher risk. The following malpractice claims are representative of claims involving SCA: • A 52-year-old patient had heartburn for more than a week, and her physician treated this symptom. The patient 16 Oc tober 2013

had high blood pressure, elevated blood glucose, and normal cardiac enzymes. Her father had died at age 55 from a heart attack, and she had a family history of coronary artery disease. The physician only considered the diagnosis of heartburn and did not order serial cardiac enzymes, an EKG, or a cardiac consult. The patient died the next day from SCA. • An obese patient had elevated triglycerides and complaints of burning in the chest with walking, but no shortness of breath or radiation of the burning sensation into the upper extremities. The physician had done an EKG a year earlier, which was abnormal, and did another EKG, which was also abnormal, with a computer reading of possible left ventricular hypertrophy. The physician thought this EKG was normal, as was his examination, but he did order a cardiology consultation. Prior to the consult, the patient died. The following tips can help providers avoid misdiagnosis of SCA:

• Consider the possibility of advanced cardiac risk in patients who: »» are overweight and unable to control their weight with diet and exercise »» have high blood pressure not responsive to medication »» have evidence of erectile dysfunction »» are glucose-intolerant »» have consistently high cholesterol levels »» have a history of alcoholism • Take into account other factors associated with SCA, including: »» Incidence increases with age — men after age 45 and women after age 55. »» Men are two to three times more likely to have SCA than women. »» Personal or family history of heart rhythm disorders, congenital heart defects, heart failure, or cardiomyopathy. »» Use of illegal drugs (amphetamines or cocaine). »» Nutritional imbalances (low potassium or magnesium levels).

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Practice Management

DocbookMD partners with SDCMS to bring SDCMS-CMA member physicians a free, HIPAA-secure messaging app that uniquely provides you extra security to avoid each of these potential pitfalls. Do not hesitate to reach out to DocbookMD today for more information at www.docbookmd.com or at 1 (888) 930-2048.

Five Inadvertent HIPAA Violations by Physicians by Tracey Haas, DO, MPH Doctors do not plan ahead to violate HIPAA, but in this digital age they may be doing it because they did not plan ahead. The recent final rule of the HITECH Act outlines that even if the physician is unaware of the violation, they may be fined a civil penalty of $100–$50,000 per violation. It is time for even the most resistant doctors to pay attention to how they handle protected health information (PHI). Here, we will outline five common ways 18 Oc tober 2013

physicians are breaking HIPAA/HITECH privacy and security rules, and may not even know it. 1. Texting PHI to Members of Your Care Team It’s a simple scenario: You’ve just left the office and your nurse texts you that Mr. Smith is having a reaction to the medication you’ve just prescribed. She has included his name and phone number in the

text. You may know that texting PHI is not legal but feel justified because it is a serious medical issue. Perhaps you even believe that deleting the text right away will protect you, and Mr. Smith. In reality, this text message with PHI has just passed from your nurse’s phone, through her phone carrier, to your phone carrier, and then to you — four vulnerable points where this unencrypted message could either be intercepted or breached. In a secure messaging app, this type of message must be encrypted as it passes through all four points of contact. Ideally, both sender and recipient should be verified and have signed a business associate agreement (BAA). 2. Taking a Photo of a Patient on Your Mobile Phone To some this will sound silly; to others, it is as common as verifying a rash with a colleague or following the margins of a cellulitis day by day. Simple enough, but if these photos are viewed by eyes they are not intended for, you may be in violation of your patient’s privacy. It’s important to be aware of where and how patient information and images are stored. Apps that allow you to take a secure photo are just as important as sending the message securely. DocbookMD allows photos to be taken within the secure messaging app itself — never stored on your phone or within your phone’s photo album. Always use this type of feature when taking any photo of a patient or patient information.

DocbookMD 3. Receiving Text Messages From Your Answering Service Many physicians believe if they receive a text message from a third party, like an answering service, they are not responsible for any violation of HIPAA; this is simply not true. Many services do send a patient’s name, phone number, and chief complaint via SMS text. The answering service may verify it is encrypted on their end, but if PHI pops onto the physician’s screen, it is certainly not secure on their end — and this is where the physician’s responsibility lies. Talk with your answering service today to see how they are protecting you at both ends of the communication. 4. Allowing Your Child to Borrow Your Phone That Contains PHI Many folks allow their kids to play with their phones, maybe play games on apps while in the car. If your phone has an app that can access PHI, then you may be guilty of a HIPAA breach if the information is viewed by or sent to someone it is not intended for. The simple fix is to utilize the pin-lock feature on your messaging app, and, for double-protection, always password-protect your phone! 5. Not Reporting a Lost or Stolen Device That Contains PHI Losing your smartphone or tablet is a pain for many reasons, but did you know that if you have patient information on that device, you could be held responsible for a HIPAA breach if you do not report the loss right away? The ability to remotely disable an app that contains or handles PHI is an absolute must for technology that handles communications in the medical space. Be sure to ask for this feature from any company claiming to help you be HIPAAcompliant in the mobile world. Remember: Being HIPAA-compliant is an active process. A device can claim to be HIPAA-secure, but it is a person who must ensure compliance. References: The ONC’s official site for mobile devices and HIPAA: www.healthit. gov/providersprofessionals/ your-mobiledevice-and-health-information-privacyandsecurity? gclid=CLvawcuVt7cCFStp7A odZGQAUg. Dr. Haas is co-founder of DocbookMD.

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Infectious Disease

Influenza What Will This Season Bring? By Wilma J. Wooten, MD, MPH Introduction As the summer ends, fall is upon us, and winter months are pending. Public health officials have assessed last year’s moderately severe influenza season and are anticipating this year’s level of influenza activity. According to the Centers for Disease Control and Prevention (CDC), each year influenza affects approximately 5–20% of the United States population (1). Influenza is estimated to cause more than 200,000 hospitalizations (2) and 3,000 to 49,000 deaths annually nationwide (3, 4). A Reflection on the Past Influenza Season During the past influenza season, the County of San Diego local health department reported 65 deaths, the highest number seen in recent times, and certainly the highest seen in this century. This death toll surpassed the 58 persons who succumbed during the H1N1 pandemic three years ago. Most of the deaths involved elderly individuals, most had underlying medical conditions, and, for whom it could be documented, most had not been vaccinated. 74% of the deaths were among those 65 years and older. Many are asking, “What was the contributing factor for this record number of deaths?” Last year, the predominant circulating influenza A virus was the H3N2 strain, which is more virulent and severe than the H1N1 strains. As depicted in the figure opposite (5), the H3N2 strain is responsible for the 1968 Hong Kong influenza pandemic and has been in circulation since then.

The single most effective strategy that a physician can do to prevent influenza is to first obtain an annual vaccination, and then recommend the same for patients, family, and friends. 20 Oc tob er 2013

The coverage among healthcare personnel was surprisingly increased, compared to previous years, but still below the Healthy People 2020 target of 90%.

In addition to a record number of deaths last year, more than 5,400 influenza cases in the San Diego area were confirmed by laboratories — another record number. Not out of the ordinary, however, the peak of the influenza season was near the end of January and early February, but lasted well into April. What Is the Role of the Physician? It is well known that persons with chronic medical conditions, infants and children, seniors, and pregnant women are at greater risk for severe influenza-related illnesses and deaths. While the Advisory Committee on Immunization Practices (ACIP) recommends that everyone six months of age and older should obtain an influenza vaccination (6), the above groups are especially targeted for influenza vaccinations. Additionally, household members or those who care for these target groups, daycare workers, residents of long-term care facilities, and healthcare personnel are also targeted. Given these recommendations, it can be concluded that healthcare leaders have common, shared goals to minimize the spread of communicable diseases, such as influenza or other acute respiratory conditions; provide outstanding healthcare for individuals served in their institutions; and maintain a healthy and robust healthcare workforce. To contribute to these goals during this upcoming influenza season, the single most effective strategy that a physician can do to prevent influenza is to first obtain an annual vaccination, and then recommend the same for patients, family, and friends. The recent issue of the Morbidity and Mortality Weekly Report (MMWR) (7) published several articles examining influenza vaccination coverage among specific groups (e.g., pregnant women, healthcare personnel) during the 2011–12 influenza season. The coverage among healthcare personnel (8) was surprisingly increased, compared to previous years, but still below the Healthy People 2020 target of 90% (9). The article

further cites that improving access to vaccination of HCP across all healthcare settings was the key to increasing vaccination coverage. Such strategies include providing HCP with: 1) information on vaccination benefits and risks; 2) workplace vaccination opportunities at convenient locations and times; and 3) no-cost influenza vaccinations. Some of these strategies already have been used by local healthcare institutions and agencies over the past few years; persistence in these practices is encouraged to reach the recommended national targets. What’s New This Season? As with any influenza season, the severity of a season cannot be predicted! Influenza seasons are unpredictable in a number of ways, including timing, severity, activity, peak, and length of season. While public health officials cannot predict the characteristics of a given season, we do know with certainty what vaccines are available and that the supply is anticipated to be adequate. This year, what is known and new is related to the variety of options for influenza vaccines. In addition, the abbreviations for the vaccines have also changed. The following represents the new formulations and abbreviations for influenza vaccines: • Live, Attenuated Influenza Vaccine (LAIV), Quadrivalent: While the abbreviation is still LAIV, the vaccine is now only quadrivalent and contains one influenza A (H3N2), one influenza A (H1N1), and two influenza B vaccine virus strains — one from each lineage of circulating influenza B viruses. It is indicated for healthy, non-pregnant persons aged 2–49 years. • Inactivated Influenza Vaccine (IIV): The vaccine is available in both quadrivalent (IIV4) and (IIV3) formulations. • Cell Culture-based Trivalent Inactivated Influenza Vaccine (ccIIV3): This vaccine is indicated for persons 18 years of age and older.

• Recombinant Hemagglutinin Influenza Vaccine (RIV): This vaccine is available as a trivalent formulation (RIV3) for 2013–14. RIV is egg-free. It is recommended for individuals who have previously had severe allergic reactions (e.g., angioedema, respiratory distress, lightheadedness, or recurrent emesis), are 18–49 years of age, and have no other contraindications. The U.S. 2013–14 trivalent influenza vaccines are made with the following three viruses: • A/California/7/2009 (H1N1)pdm09like virus; • A(H3N2) virus, antigenically like the cell-propagated prototype virus A/ Victoria/361/2011; and • B/Massachusetts/2/2012-like virus. Quadrivalent vaccines include the above three strains and an additional B virus strain: a B/Brisbane/60/2008-like virus. While there is variety in the vaccine preparations this season, there is no preferential recommendation for any type or brand of licensed influenza vaccine over another. All vaccines are equally safe and effective. For a summary of 2013–14 vaccine recommendations (10) by the Advisory Committee on Immunization Practices (ACIP), go to: www.cdc.gov/flu/professionals/acip/2013summary-recommendations.htm. Of note, while H7N9 influenza and MERS-CoV infections cause respiratory symptoms similar to seasonal influenza, including fever and cough, NO cases of these infections have been reported in the United States. Symptoms and Preventive Measures Symptoms There are numerous types of viral respiratory infections that occur during the winter months and can be confused with influenza; however, as a reminder, the clinical presentation for influenza is as follows: • Symptoms: Mild to severe illness that includes fever, cough, sore throat, SAN DI EGO PHYSICIAN.org 21

Infectious Disease

runny nose, body aches, headaches, and fatigue. • Duration: May last 2 days to 2 weeks; longer if complications (e.g., pneumonia). • Incubation Period: 1–4 days (average 2). • Contagious: 1 day before to 5–7 days after onset of symptoms

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Preventive Measures While this may sound like a broken record, it cannot be emphasized enough that the single most effective strategy for preventing influenza is annual vaccination (11) — whether nasal spray or injection. Other preventive measures people should take include proper hand hygiene that includes washing your hands thoroughly and often; using hand sanitizers; avoiding touching the eyes, nose, and mouth; and cleaning commonly touched surfaces routinely. Individuals — physicians and patients — should stay home from work, school, or other public spaces when ill; cough or sneeze into the arm at the elbow; and wash hands often and after you cough, sneeze, or blow your nose. Key Messages This Influenza Season San Diego physicians are strongly encouraged to promote the following key messages to tackle this year’s influenza season. Promoting these messages to all patients will go a long way to create the herd immunity needed to prevent widespread seasonal illness. • Influenza seasons are unpredictable, so get prepared. • The influenza vaccine is the single best measure to prevent the influenza. • Everyone > 6 months of age should obtain an annual flu vaccine. • Influenza vaccine is safe and effective! The role that physicians and other HCP play in preventing flu-related illness and death is invaluable. Thank you in advance for being a model leader by obtaining your influenza vaccination! Please continue to help stop the spread of influenza and spread the word about influenza facts to your coworkers, patients, friends, neighbors, and communities to help keep our region healthy and safe! To obtain additional influenza information, please access www.flu.gov and www. sdiz.org. For any questions, please contact the County Immunization Program at (866) 358-2966 or at info@sdiz.org. Dr. Wooten, who sits on the SDCMS GERM Commission (Group to Eradicate Resistant Microorganisms), has been an SDCMS-CMA member since 2006 and is the public health officer and director of the Division of Public Health Services in the County of San Diego Health and Human Services Agency (HHSA).

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References: 1. Centers for Disease Control and Prevention (CDC). Seasonal influenza. www.cdc.gov/flu/about/ qa/disease.htm. Accessed Sept. 2, 2013. 2. Thompson WW, Shay DK, Weintraub E, et al. “Influenza-associated hospitalizations in the United States.” JAMA 2004;292:1333–40. 3. CDC. “Estimates of deaths associated with seasonal influenza — United States, 1976–2007.” MMWR Aug. 27, 2010;59:1057–62. 4. Thompson WW, Weintraub E, Dhankhar P, et al. “Estimates of U.S. influenza-associated deaths made using four different methods.” Influenza Other Respi Viruses 2009;3:37–49. 5. European Centre for Disease Prevention and Control. ECDC Risk Assessment. 2009 influenza A(H1N1) pandemic. Version 7. Stockholm:ECDC; 17 December 2009. Available from: http://ecdc. europa.eu/en/healthtopics/Documents/0908_Influenza_AH1N1_ Risk_Assessment.pdf. 6. CDC. “Advisory Committee on Immunization Practices (ACIP) Recommends Universal Annual Influenza Vaccination.” Press Release. Feb. 24. 2010. Accessed Sept. 26, 2013. 7. CDC. MMWR Weekly Sept. 27, 2013 Volume 62, No. 38. www.cdc. gov/mmwr/pdf/wk/mm6238. pdf. Accessed on Sept. 27, 2013. 8. CDC. “Influenza Vaccination Coverage Among Healthcare Personnel — United States, 2012 13 Influenza Season.” MMWR Feb. 1, 2013;62(38);781-786. / Vol. 62. 9. U.S. Department of Health and Human Services. Healthy People 2020. Increase the percentage of healthcare personnel who are vaccinated annually against seasonal influenza. Objective IID-12.9. Washington, DC: U.S. Department of Health and Human Services; 2011. Available at www. healthypeople.gov/2020/topicsobjectives2020/objectiveslist. aspx?topicId=23. Accessed August 28, 2013. 10. CDC. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2013– 14. Sept. 20, 2013/62(RR07);1-43. 11. Cox NJ, Subbarao K. “Influenza.” Lancet 1999;354:1277--82.

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Infectious Disease

24 Oc tober 2013

Recurrent C. difficile Therapy Feces Is Usually Understood As Something to Avoid By Frank Meyers

Even in societies with only a primitive understanding of medicine, feces is usually understood as something to avoid. In the field of infectious disease, unintentional fecal oral transmission is a frequently identified route of transfer of dangerous pathogens. In fact, one of the fastest growing infectious disease scourges, C. difficile, is spread via the fecal-oral route. It is therefore with a certain sense of irony that one of the more successful therapies for recurrent C. difficile is fecal biotherapy. In fact, at the 48th Annual IDSA meeting in 2010, a debate was conducted not on whether to use this novel approach, but when to use it. This resulted in administration of the therapy that varied greatly among those who reported its use in the literature. It is therefore not surprising that this year the FDA stepped in and required those administering these treatments gain informed consent from the patients and functionally required the treatments be done under the review of an IRB (1). C. difficile is an anaerobic gut bacteria whose pathogenic strains produce a toxin that can cause illness varying from mild diarrhea to pseudomembranous colitis to toxic megacolon and death. The bacteria usually causes morbidity and mortality when there is a disruption of the normal gut flora, most commonly by the use of antibiotics. Several studies of C. difficile patients have shown that a significant percentage of these antibiotic therapies preceding C. difficile illness were either unneeded or incorrect.

The theory behind fecal bacteriotherapy is that C. difficile does not cause illness when in the presence of a normal gastrointestinal microbiome. It is only through the disruption of the microbiome that C. difficile can begin to cause illness. A reintroduction of a normal gut microbiome will eliminate the ecological niche that allowed C. difficile to establish itself. While reestablishing normal gut flora has been attempted using less dramatic approaches, such as probiotics, these approaches have not been as successful as fecal bacteriotherapy. The reasons for this are unclear but may be due to ineffective dose of the probiotic surviving oral ingestion and travel to the site of the illness or incorrect choice of a suitable organism to compete with C. difficile, or that the relationship between all of the organisms in a healthy biome cannot be re-created by only selecting one or two organisms for administration. Once C. difficile is diagnosed in a patient with a diarrheal illness, either through the less accurate toxin EIA or more recent PCR technology, the patient, if possible, has the insulting antibiotic discontinued, and a therapy regimen of oral vancomycin

or metronidazole is begun. The choice of oral vancomycin or metronidazole is based on the severity of the patient’s illness. Recently, Fidaxomicin has been added as an effective agent. Although the cost is considerably more when compared to its two generic competitors, it does appear to reduce recurrence (2). It is important to note that C. difficile has not been shown to develop resistance to any of these antibiotics, so recurrence is not due to that cause. Recurrence rates for C. difficile illness vary based on strain and patient characteristics. The usual estimate is that around 20% of patients suffer a recurrence of C. difficile. Recurrence can be debilitating and destroy the patient’s quality of life. It is not surprising then that most patients eagerly accept bacteriotherapy as a potential cure for their recurrence of C. difficile. The growing consensus is that the fecal bacteriotherapy should not be used as a therapy before the third or fourth recurrence. Bacteriotherapy is actually not a new treatment in U.S. medicine for C. difficilelike illness. In 1958 a surgeon described using a fecal enema as an adjunct therapy for pseudomembranous colitis (3). In 1958 C. difficile had yet to be identified. In that

It has also been humorously suggested that spouses or significant others also make a good choice because the patient is used to taking a certain amount of “crap” from them.

SAN DI EGO PHYSICIAN.org 25

Infectious Disease

C. difficile is an anaerobic gut bacteria whose pathogenic strains produce a toxin that can cause illness varying from mild diarrhea to pseudomembranous colitis to toxic megacolon and death.

case, unlike today’s regimens, the donor was the surgeon himself, and it was unclear what screening he underwent before deciding he was an acceptable donor. The donor used most frequently today is generally someone with a significant relationship with the patient and shares the same domicile. The reasoning is that generally their diet should be similar and therefore their gut microbiome should be similar. It has also been humorously suggested that spouses or significant others also make a good choice because the patient is used to taking a certain amount of “crap” from them. The donor is generally screened for various pathogens. This screening varies in the literature but is generally more extensive than those for blood donors. In addition to blood-borne pathogens, hepatitis A, CMV, Epstein Barr virus, and others are generally in the screening panel. Additionally, enteric bacterial pathogens are screened for, and, in some cases, donors are excluded based on irritable bowel syndrome or abdominal complaints. Despite the varying rigor of the screenings in the

literature, no cases of disease transmission from receiving a fecal donation have been documented (4). The mechanism of administration described in the literature also varies widely. Using the nasogastric route (tube), colonoscope, enema, and endoscope have all been reported in the literature. It does now appear that consensus is developing that administering the bacteriotherapy via an endoscope is the preferred approach (5). It is preferred that the patient be off antibiotics at the time of the transplant as this would disrupt the bacteria being transplanted. The method of preparation of the donated material has the greatest variation. The general approach is to get the donor’s stool into a liquid form. There is also a wish to remove much of the nondigested material from the donor stool, so frequent filtering is done using coffee filters and dedicated blenders. Other physicians have reported harvesting specific bacteria from the stool and growing it and transplanting those organisms. Generally, the fresher the stool used, the better it is thought to be as a treatment. Patients speaking about their experience

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Infectious Disease

with this treatment are generally very positive, especially when a cure is obtained. The window period of using fecal transplants for treatment of C. difficile recurrence may be closing just as it is gaining more acceptance. A number of phase 1 and phase 2 trials on the use of nonpathogenic C. difficile or vaccines are promising and may allow for a more conventional, less headline-grabbing therapy that is equally effective. However, that doesn’t mean that fecal bacteriotherapy will necessarily go away. There are some preliminary reports suggesting fecal bacteriotherapy may be effective in treating metabolic syndrome (6), ulcerative colitis (7), autoimmune diseases (8), Parkinson’s (9), and obesity, among others. Mr. Meyers, who sits on the SDCMS GERM Commission (Group to Eradicate Resistant Microorganisms), has worked in the field of infectious disease epidemiology and prevention for more than 25 years, 20 of those in acute care. He is currently an infectious disease preventionist at UC San Diego Health System. Project4:Layout 1

9/22/08

11:22 AM

References: 1. “Important Information About IND Requirements for Use of Fecal Microbiota to Treat Clostridium difficile Infection Not Responsive to Standard Therapies.” U.S. Food and Drug Administration (FDA) website: www.fda.gov/BiologicsBloodVaccines/GuidanceComplianceRegulatoryInformation/Guidances/ Vaccines/ucm361379.htm. 2. Louie, Thomas J.; Miller, Mark A.; Mullane, Kathleen M.; Weiss, Karl; Lentnek, Arnold; Golan, Yoav; Gorbach, Sherwood; Sears, Pamela et al. (2011). “Fidaxomicin Versus Vancomycin for Clostridium difficile Infection.” New England Journal of Medicine 364 (5): 422–31. 3. Eiseman B, Silen W, Bascom GS, et al. (1958). “Fecal Enema as an Adjunct in the Treatment of Pseudomembranous Enterocolitis.” Surgery 44 (5): 854–859. 4. Myers F (2012). “Making the Case for Fecal Bacteriotherapy.” Nursing 2012 Critical Care (7) 4 42-46. 5. Brandt LJ, Borody TJ, Campbell J. “Endoscopic Fecal Microbiota Transplanta-

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tion: ‘First-line’ Treatment for Severe Clostridium difficile Infection?” (Sep 2011). “Endoscopic Fecal Microbiota Transplantation.” J Clin Gastroenterol 45 (8): 655–657. Borody TJ, Khoruts A (20 Dec. 2011). “Fecal Microbiota Transplantation and Emerging Applications.” Nat Rev Gastroenterol Hepatol 9 (2): 88–96. Borody TJ, Torres M, Campbell J, et al. (2011). “Reversal of Inflammatory Bowel Disease (IBD) With Recurrent Fecal Microbiota Transplants (FMT).” Am J Gastroenterol 106: S352 Borody TJ, Campbell J, Torres M, et al. (2011). “Reversal of Idiopathic Thrombocytopenic Purpura (ITP) With Fecal Microbiota Transplantation (FMT).” Am J Gastroenterol 106: S352. Ananthaswamy, Anil (19 January 2011). “Faecal Transplant Eases Symptoms of Parkinson’s.” New Scientist.

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SAN DI EGO PHYSICIAN.org 27

Infectious Disease

Standard Precautions and Respiratory Hygiene/ Cough Etiquette Is It Underestimated? By Shannon Oriola, RN, BSN, CIC, COHN

It’s been 10 years since the SARSCoV (Severe Acute Respiratory Syndrome caused by a novel Coronavirus) pandemic affected the health of 8,098 persons in more than 30 countries, resulted in nearly 800 deaths, and disrupted the economies of Asia and Canada. In the United States, 63 persons were identified as probable SARS patients. Healthcare personnel accounted for 21% of the cases worldwide. The number of deaths in healthcare personnel is not known; however, deaths were reported (there is not a global tracking system to detect fatal occupationally acquired infections in their entirety). The United States does, however, track fatal occupational injuries. No data on occupational SARS deaths is available. Fast-forward a decade to MERS-CoV (Middle East Respiratory Syndrome caused by a novel Coronavirus), which has infected 90 persons to date and has resulted in 45 deaths, with the majority of cases occurring in Saudi Arabia. There are no reported cases in the United States at the time of this writing. How can you protect yourself and your staff from exposure to unknown pathogens that may be harmful? Widespread SARS outbreaks in 2003 prompted the Centers for Disease Control and Prevention (CDC) to create infection control measures intended for healthcare personnel, patients, and accompanying family members at first point of encounters within healthcare settings, such as: reception and triage areas in emergency departments, outpatient clinics, and physician offices. Respiratory Hygiene/ 28 Oc tober 2013

Cough Etiquette is a strategy used to prevent the transmission of undiagnosed transmissible respiratory infections and applies to any person with signs of illness, including cough, congestion, rhinorrhea, or increased production of respiratory secretions. Respiratory Hygiene/Cough Etiquette is a component of Standard Precautions, which include infection prevention practices applied to all patients regardless of suspected or confirmed infection status. The foundation of Standard Precautions is based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents. The practices are to be applied in all settings in which healthcare is delivered, and include hand hygiene, and use of gloves, gown, mask, eye protection, or face shield, depending on the anticipated exposure. Additional practices include safe injection practices and use of masks for insertion of catheters into spinal or epidural spaces via lumbar puncture. The table opposite highlights the CDC’s recommendations for adherence to Standard Precautions. Post visual reminders for cough etiquette in waiting areas — see “Cover Your Cough” example on page opposite. The CDC states that perhaps healthcare personnel infection may have been prevented in the SARS pandemic if Standard Precautions were applied at the time of unprotected exposure to patients unknown to be infectious and later identified as being infectious. Could the death of Dr. Carlo Urbani have been prevented if respiratory

hygiene had been applied? Dr. Urbani, a WHO officer, was the first to identify the outbreak in an American businessman who had been admitted to a hospital in Hanoi, and unfortunately died from the disease. The CDC is currently recommending surveillance and testing for persons who have unexplained severe respiratory illness and a history of travel to countries in the Arabian peninsula or neighboring countries. In particular, persons who meet the following criteria should be reported and evaluated: • A person with an acute respiratory infection, which may include fever (≥ 38°C/100.4°F) and cough; and • Suspicion of pulmonary parenchymal disease (e.g., pneumonia or acute respiratory distress syndrome based on clinical or radiological evidence of consolidation); and • History of travel from the Arabian peninsula or neighboring countries within 10 days of symptom onset; and • Whose illness is not already explained by any other infection or etiology, including all clinically indicated tests for community-acquired pneumonia according to local management guidelines. The CDC website contains additional information on emerging infectious diseases as well as the California Hospital Alert Network or CAHAN. To start receiving the CAHAN alert, send your request to cahaninfo@cdph.ca.gov. Protect yourself, protect your staff, and protect your patients from unknown pathogens. Implement Standard Precautions in your practice and healthcare settings.

Respiratory Hygiene/Cough Etiquette is a strategy used to prevent the transmission of undiagnosed transmissible respiratory infections and applies to any person with signs of illness, including cough, congestion, rhinorrhea, or increased production of respiratory secretions. COMPONENT

RECOMMENDATIONS

Hand Hygiene

• After touching blood, body fluids, secretions, excretions, contaminated items. • Immediately after removing gloves. • Between patient contacts.

Personal Protective Equipment (PPE): Gloves

• For touching blood, body fluids, secretions, excretions, contaminated items. • For touching mucous membranes and non-intact skin.

Personal Protective Equipment (PPE): Mask, Eye Protection, Face Shield

During procedures and patient-care activities likely to generate splashes or sprays of blood, body fluids, secretions.

Personal Protective Equipment (PPE): Gown

During procedures and patient-care activities when contact of clothing / exposed skin with blood / body fluids, secretions, and excretions is anticipated.

Soiled Patient-care Equipment

Environmental Control

• Handle in a manner that prevents transfer of microorganisms to others and to the environment. • Wear gloves if visibly contaminated. • Perform hand hygiene. Develop procedures for routine care, cleaning, and disinfection of environmental surfaces, especially frequently touched surfaces in patient-care areas.

Textiles (Linen and Laundry)

Handle in a manner that prevents transfer of microorganisms to others and to the environment.

Needles and Other Sharps

• Do not recap, bend, break, or handmanipulate used needles. • Use safety features when available. • Place used sharps in puncture-resistant container.

Patient Resuscitation

Use mouthpiece, resuscitation bag, other ventilation devices to prevent mouth contact

Patient Placement

Prioritize for single-patient room if patient is at increased risk of transmission, is likely to contaminate the environment or does not maintain appropriate hygiene, or is at increased risk of acquiring infection or developing adverse outcome following infection.

Respiratory Hygiene/ Cough Etiquette (Source Containment of Infectious Respiratory Secretions in Symptomatic Patients, Beginning at Initial Point of Encounter)

• Instruct symptomatic persons to cover mouth/nose when sneezing/coughing. • Use tissues and dispose in no-touch receptacle. • Observe hand hygiene after soiling of hands with respiratory secretions. • Wear surgical mask if tolerated or maintain spatial separation, greater than 3 feet if possible.

Stop the spread of germs that make you and others sick!

Cover your

Cough Cover your mouth and nose with a tissue when you cough or sneeze or cough or sneeze into your upper sleeve, not your hands.

Put your used tissue in the waste basket.

You may be asked to put on a surgical mask to protect others.

Clean your Hands after coughing or sneezing.

Minnesota Department of Health 625 N Robert Street, PO Box 64975 St. Paul, MN 55164-0975 651-201-5414 TDD/TTY 651-201-5797 www.health.state.mn.us

Wash with soap and water or clean with alcohol-based hand cleaner.

Minnesota Antibiotic Resistance Collaborative IC#141-1428

Download This and Other “Cover Your Cough” Posters in Multiple Languages at www.cdc.gov/flu/protect/covercough.htm

Resources: • Sepkowitz, K., Eisenberg, L., July 2005. “Occupational Deaths Among Healthcare Workers.” Perspective Volume 11, Number 7. • Siegel, J., Rhinehart, G., Chiarello, L., Jackson, M. “Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.” CDC Healthcare Infection Control Practices Advisory Committee. 2007. Retrieved from www.cdc.gov/hicpac/pdf/isolation/ Isolation2007.pdf. • Progress in Global Surveillance and Response Capacity: 10 Years After Severe Acute Respiratory Syndrome. Emerging Infectious Disease Journal. Retrieved from wwwnc.cdc.gov/ eid/pages/sars-10th-anniversary.htm. • World Health Organization Global Alert and Response. Dr. Carlo Urbani of the World Health Organization Dies of SARS. 29 March 2003.

Ms. Oriola, who sits on the SDCMS GERM Commission (Group to Eradicate Resistant Microorganisms), is manager of epidemiology and infection control at Scripps Memorial Hospital, La Jolla. SAN DI EGO PHYSICIAN.org 29

Infectious Disease

Carbapenem-resistant Enterobacteriaceae A Growing Threat By Marie Yu, PharmD, BCPS1 Carbapenem-resistant enterobacteriaceae (CRE) are gram-negative bacteria such as Escherichia coli and Klebsiella with high levels of resistance that can cause various infections, such as pneumonia, urinary tract infections (UTIs), bacteremias, etc. CRE has enzymes such as Klebsiella pneumoniae carbapenemases (KPC) and metallo-beta-lactamases that break down carbapenems. These enzymes are coded on mobile genetic material that allows for transmission of such resistance. CRE often has additional resistance mechanisms that render other classes of antibiotics, such as fluoroquinolones, ineffective. Given its broad resistance, treatment options are very limited with some CRE isolates being non-susceptible to all known antimicrobials. CRE infections are associated with higher rates of mortality (up to 40â&#x20AC;&#x201C;50%) and treatment failure. The incidence of CRE is increasing in the United States and worldwide. CRE has been isolated in California. Risk factors for CRE colonization and infection include severe underlying conditions, prolonged courses of antimicrobials, use of medical devices, such as ventilators and catheters, and extensive exposure to 30 Oc tob er 2013

healthcare settings. Antimicrobials associated with CRE acquisition include previous exposure to carbapenems, cephalosporins, and fluoroquinolones. Judicious use of antiinfectives may help stem CRE rates, and antimicrobial stewardship targeting overall antimicrobial use can play an essential role in potentially preventing CRE and other drug resistance. Few antibiotics retain in vitro activity against CRE (see Table 1), and limited clinical data is available evaluating their efficacy. For all anti-infective agents, confirmation of in vitro sensitivity against CRE is recommended. For CRE infections, combination therapy is recommended over monotherapy due to broad-spectrum resistance, limited efficacy of agents, and potential synergy. Improved outcomes with combination therapy versus monotherapy have also been reported. Combination therapy may prevent the development of further resistance. The best antimicrobial combination for CRE is unknown, given well-designed comparative studies are lacking. The most common combinations are polymyxin with a carbapenem, tigecycline, or aminoglycoside. Given the high rates of treatment failure,

consultation with infectious diseases experts is recommended. Polymyxins, such as colistin and polymyxin B, are bactericidal antibiotics that are frequently used in CRE infections. Higher rates of therapeutic failure were reported with polymyxin monotherapy compared to polymyxin-combination therapy. CRE resistance to colistin is emerging, and development of resistance while on colistin therapy has also been reported. Colistin is available for inhalation via nebulizer for direct administration to the lungs. Limited evidence exists evaluating the efficacy of inhaled antibiotics for pneumonia, whether as monotherapy or in combination with intravenous antibiotics. Tigecycline, a tetracycline antibiotic with bacteriostatic activity, retains activity against CRE. Clinical experience with tigecycline is limited, and treatment failures have been reported. Tigecycline should not be used for bloodstream infections given its low plasma concentrations. Use caution in genito-urinary infections as tigecycline also achieves low urinary concentrations. However, cases of successfully treated KPC UTIs with tigecycline have been reported. Aminoglycosides â&#x20AC;&#x201D; gentamicin, tobra-

Table 1: Antimicrobials With Potential Utility for Treating CRE Infections Drug*

Dose**

Dose Adjustment

Adverse Effects

Colistin

2.5mg/kg IV q12h 75-150mg inh q12h

Adjust for renal function

Nephrotoxicity Inhaled: bronchospasm

Polymyxin B

7,500-12,500units/ kg IV q12h

Adjust for renal function

Nephrotoxicity Elyte abnormalities

None

Nausea/vomiting LFT abnormalities

Tigecycline

Amikacin

Gentamicin

Tobramycin

100mg IV x 1 load then 50mg IV q12h

Comments

Do not use for bacteremia Use caution for UTI

TrusT

5-7.5mg/kg IV q8h 15-20mg/kg IV q24h Consult pharmacy 1.5-2mg/kg IV q8h 4-7mg/kg IV q24h Consult pharmacy

Adjust for renal function

Nephrotoxicity Ototoxicity Inhaled: bronchospasm

Serum level monitoring required

1.5-2mg/kg IV q8h 4-7mg/kg IV q24h Consult pharmacy 300mg inh q12h

Doripenem

500mg IV q8h

Meropenem

1g IV q8h

Adjust for renal function

Well-tolerated

Consider extended infusion

*Combination therapy recommended even with known susceptibilities *For patients with normal renal function

mycin, amikacin — are concentrationdependent antibiotics with activity against some CRE isolates. Amikacin may have the most activity, although higher MICs may be observed. Higher MICs often require different dosing targets in order to optimize outcomes. Consultation with a clinical pharmacist may be prudent. Combination therapy with aminoglycosides is generally recommended. Combination with colistin should be approached with caution due to potential increased risk of nephrotoxicity. Tobramycin and amikacin can also be delivered via the inhalation route. Carbapenems may still have some utility in treating CRE infections. Multiple cases report success using a carbapenem “backbone” in combination with another anti-infective agent such as colistin or an aminoglycoside. Combination therapy may be preferred over carbapenem monotherapy as it is less associated with treatment failure. Maximizing time serum concentrations are above the MIC (%t>MIC) by extending infusion time may be considered, but benefits of attaining this PKPD target in CRE is controversial. Early recognition of CRE and infection control is essential in controlling the spread of CRE infection and colonization. Isolates with high MICs to carbapenems (e.g., MIC = 4) should raise suspicions for CRE. Patients with CRE should be isolated, and hand hygiene and contact precautions should be instituted. All healthcare providers have a role in preventing the transmis-

sion of CRE. Prudent use of anti-infectives and medical devices, participating in antimicrobial stewardship, and practicing infection control may curb the rate of CRE. A CRE Toolkit is available on the CDC website. References: 1. Carbapenem-Resistant Enterobacteriaceae (CRE). CDC. www.cdc.gov/hai/ organisms/cre. Accessed Aug 12, 2013. 2. Gupta N, Limbago BM, et al. Carbapenem-resistant Enterobacteriaceae: Epidemiology and Prevention. CID, 2011; 53(1):60-7. 3. Kani SS and Kanafani ZA. Current Concepts in Antimicrobial Thearpy Against Resistant Gram-Negative Organisms: Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae, Carbapenem-resistant Enterobacteriaceae, and Multidrugresistant Pseudomonas aeruginosa. Mayo Clin Proc, 2011; 86(3):250-9. 4. Lee GC and Burgess DS. Treatment of Klebsiella Pneumoniae Carbapenemase (KPC) infections: a review of published case series and case reports. Annals of Clinical Microbiology and Antimicrobials, 2012; 11(32):1-9 Ms. Yu, who sits on the SDCMS GERM Commission (Group to Eradicate Resistant Microorganisms), is infectious diseases and antimicrobial stewardship clinical pharmacist at Sharp Grossmont Hospital.

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

San Diego County Medical Society Foundationâ&#x20AC;&#x2122;s Mission Is To Improve Health, Access To Care, And Wellness For Patients And Physicians Through Engaged Volunteerism.

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SAN DI EGO PHYSICIAN.org 33

classifieds PHYSICIAN POSITIONS AVAILABLE SEEKING INTERNIST FOR PART-TIME WORK IN THE SOUTH BAY: The work will consist of ambulatory medicine, SNF medicine, and hospital medicine. Excellent location at the Veterans Home Chula Vista and Sharp Chula Vista Medical Center. Please send a cover letter and CV to Dr. Paul Wagner, Chief Medical Officer, at paul.wagner@calvet. ca.gov. [171] JOIN HOUSE CALL DOCS INC., a dynamic group of pioneering healthcare practitioners striving for excellence while developing sound socioeconomic models of healthcare delivery. Our mobile primary care / specialty practice complements our panoramic outpatient practices in primary care, oncology, cardiology, gastroenterology, gynecology, infectious diseases, and psychiatry. Pay is among the best in the country, with part-time income in the $150K range (exclusive of incentives / bonuses). A good fit is essential. Interview questions should be directed to Dr. Wolfram Forster, Senior Partner, House Call Docs Inc. (1855 First Avenue, Suite 200, San Diego, CA 92101, phone 619-793-7988) [167] INTERNAL MEDICINE OR FAMILY PRACTICE, FULL-TIME OR PART-TIME, FLEXIBLE HOURS: National Health Service Corps — Loan Repayment Eligible Site Imperial Beach Community Clinic. A community-focused health center committed to being responsive to the healthcare needs of our area. Physician needed with license to practice medicine in the state of California. Board-certified. Imperial Beach Health Center Attention: Jorge Gutierrez — Human Resources Director, 949 Palm Ave., Imperial Beach, CA 91932. Phone (619) 628-5564. Email jorgeg@ibclinic.org. [166] PHYSICIAN OR NURSE PRACTITIONER TO PERFORM HOUSECALLS: In North San Diego County Monday through Friday. 10–12 patients per day. Please forward CV. Full time. Excellent time management skills required. Pager one week per month, no hospital rounds. Established patient base. Independent contractor position with great income potential. NPs: Home health experience a plus. Please respond by email only to mobiledoctor@sbcglobal.net. Thank you. [165a] ADULT PRIMARY CARE OPPORTUNITIES: Family medicine, internal medicine, and urgent care openings throughout Southern California. The Southern California Permanente Medical Group (SCPMG) boasts nearly 60 years of experience in delivering high-quality, innovative healthcare. With sub-specialists in virtually every area of medical and surgical practice, SCPMG is home to more than 6,000 physicians serving over 3.3 million members. SCPMG prides itself on attracting outstanding physicians and offers them the opportunity to have sustained, fulfilling careers in their practices while enjoying the benefits of a large, stable medical group. Fulltime physicians have access to a compensation and benefits package that’s designed to impress you. Per diem opportunities offer flexible schedules as well as the chance to earn supplemental income. For consideration, please visit and apply at our website at http://physiciancareers.kp.org/ scal, call (877) 608-0044, or email professional. recruitment@kp.org. We are an AAP/EEO employer. [164]

FULL-TIME OR PART-TIME URGENT CARE PHYSICIAN: Busy practice in El Cajon, established in 1982, seeks a full-time and/or part-time physician. Good hours (mostly 9:00am–5:30pm weekday shifts with some weekends from 9:00am–4:00pm and closed on major holidays) plus good pay. Please send CV to jeff@eastcountyurgentcare.com or fax to (619) 442-2245. [161] PSYCHIATRIC CENTERS AT SAN DIEGO (PCSD) IS LOOKING FOR A PSYCHIATRIST: to work for the George F. Bailey Detention Facility, full-time, Monday–Friday, 8:00am–4:30pm. Must be licensed to practice medicine in the State of California by the Medical Board / Osteopathic Board of California. Must maintain a BLS and DEA. Must have a valid certificate in psychiatry. Salary DOE. PCSD will cover malpractice insurance. Medical, dental, 401k offered. If you are interested in making a difference and becoming part of the PCSD team of professionals, please fax your cover letter and CV to Jada Brathwaite, director of operations, at (619) 528-4625. EOE (157) PSYCHIATRIC CENTERS AT SAN DIEGO (PCSD) IS LOOKING FOR A PSYCHIATRIST: to work for the Las Colinas Detention Facility, part-time, Monday–Friday, 1:00pm–4:30pm, and every other Saturday 8:00am–4:00pm. Must be licensed to practice medicine in the State of California by the Medical Board / Osteopathic Board of California. Must maintain a BLS and DEA. Must have a valid certificate in psychiatry. Salary DOE. PCSD will cover malpractice insurance. If you are interested in making a difference and becoming part of the PCSD team of professionals, please fax your cover letter and CV to Jada Brathwaite, director of operations, at (619) 528-4625. EOE (158)

PHYSICIANS NEEDED: Family medicine, pediatrics, and OB/GYN. Vista Community Clinic, a private nonprofit outpatient clinic serving the communities of North San Diego County, has opening for part-time, per diem positions. Must have current CA and DEA licenses. Malpractice coverage provided. Bilingual English/Spanish preferred. Forward resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. Visit our website at www. vistacommunityclinic.org. EOE/MF/D/V [912] SEEKING BOARD-CERTIFIED PEDIATRICIAN FOR PERMANENT FOUR-DAYS-PER-WEEK POSITION: Private practice in La Mesa seeks pediatrician four days per week on partnership track. Modern office setting with a reputation for outstanding patient satisfaction and retention for over 15 years. A dedicated triage and education nurse takes routine patient calls off your hands, and team of eight staff provides attentive support allowing you to focus on direct, quality patient care. Clinic is 24–28 patients per eight-hour day, 1-in-3 call is minimal, rounding on newborns, and occasional admission, NO delivery standby or rushing out in the night. Benefits include tail-covered liability insurance, paid holidays/vacation/sick time, professional dues, health and dental insurance, uniforms, CME, budgets, disability and life insurance. Please contact Venk at (619) 504-5830 or at venk@gpeds. sdcoxmail.com. Salary $ 102–108,000 annually (equal to $130–135,000 full-time). [778] PRACTICE WANTED

PHYSICIANS WANTED FOR OUR GROWING ORGANIZATION: Full, part time or per diem, flexible schedules available at locations throughout San Diego. As the second largest community health organization in the nation, Family Health Centers of San Diego is a private, nonprofit community clinic organization that is an integral part of San Diego’s healthcare safety net. Since 1970, our mission has been to provide caring, affordable, high-quality healthcare and supportive services to everyone, with a special commitment to uninsured, low-income, and medically underserved persons. Every member of our team plays an important role in improving the health of our patients and community. We offer an excellent, comprehensive benefits package that includes malpractice coverage, NHSC loan repay eligibility, and much, much more! For more information, please call Anna Jameson at (619) 906-4591 or email ajameson@fhcsd.org. If you would like to fax your CV, fax it to (619) 8764426. To apply, visit our website and apply online at www.fhcsd.jobs. [046] FAMILY PRACTICE / INTERNAL MEDICINE PHYSICIAN NEEDED to help two physicians in Chula Vista. Reasonable salary and package, four weeks’ leave, light call commitments, and cheerful work environment. Nursing home, hospital, and teaching opportunities optional. Please send CV or questions to geriatricpractice@gmail.com. [156] PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com) is a fastgrowing group of house-call doctors. Great pay ($140–$220+K), flexible hours, choose your own

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

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days (full or part time). No ER call or inpatient duties required. Transportation and personal assistant provided. Call Chris Hunt, MD, at (619) 9925330 or email CV to drhunt@thehousecalldocs. com. Visit www.thehousecalldocs.com. [037]

WE BUY URGENT CARE OR READY MEDCLINIC: 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 Sublease Medical Suite in Encinitas: Ready to lease 1,120-square-foot suite with a beautiful reception area and waiting room, three exam rooms, lab and conference room. Plenty of parking space in complex. Some furniture available in suite. Available November 1, 2013, or sooner if needed. Please contact Cristina at (760) 9441000, ext. 106, for more information. [175] Poway office space for sublease: Private exam room or rooms available for one day a week or more. Ideal for physician, chiropractor, massage therapist. Low rates. Email inquiries to kathysutton41@yahoo.com. [173] LEASING MEDICAL OFFICE SPACE IN ESCONDIDO: 2,450 square-foot office building in downtown Escondido, adjacent to large imaging center. Three examining rooms, two consulting rooms, and an office designed to be completely HIPAA compliant. Also, a leaded room suitable for radiographic services. Available for rent February 1, 2014. Apply to Physicians’ Medical Building, 355 E. Grand Ave., Escondido, CA 92025. [169] ENCINITAS OFFICE SPACE TO SUBLEASE — 345 SAXONY ROAD, ENCINITAS: Shared office space available, 1700 square feet total. Occupied by one dermatologist. Easy-to-find location just off the I-5 with all new decor. Spa-like waiting room and friendly, professional front desk staff.

Will sublease one or two exam rooms, half or full day. Exam rooms complete with electronic fully adjustable chair, cabinets, and sink, and great windows provide ocean views and plenty of light in the rooms. Plenty of free parking. For more information, call Elizabeth at (760) 230-2537. [163]

CLASS “A” MEDICAL OFFICE, ENCINITAS Join over 250 doctors and dentists representing nearly 50 specialties in North County’s leading outpatient health center. Office being fully renovated to Class “A” standard at owner’s expense. Strong referral potential. 2,300 SF including: 4 exam rooms, large office, lab, nurse station, ADA bathroom, back office, wait/reception, dual entry, and more. For more information, including a floor plan, please call Greg Petree at (858) 792-0696 x112 or visit www.northcoasthealthcenter.com/leasing

CLASS “A” MEDICAL OFFICES, VISTA Upgrade to a new Class “A” medical office at no cost in TriCity’s leading outpatient health center. Collegial environment with more than 40 physicians in 15+ specialties. Strong primary care referral base. Fully renovated offices with today’s modern finishes. Close hospital proximity. Multiple sizes available ranging from 1200, 1600, 2400, 4000-5700. For more information, including floor plans, please call Greg Petree at (858) 792-0696 x112 or visit www.vistamedicalplaza.com/ leasing

NORTH COAST HEALTH CENTER OFFICE SPACE TO SUBLEASE — 477 EL CAMINO REAL, ENCINITAS: Beautiful office space available, 2100 square feet, at the 477/D Building. Occupied by vascular and general surgeons. Great window views and location with all new equipment and furniture. New hardwood floors and exam tables. Full ultrasound lab with tech on site, doubles as procedure room. Will sublease partial suite, one or two exam rooms, half or full day. Will consider subleasing the entire suite, totally furnished, if there is a larger group. Plenty of free parking. For more information, call Irene at (619) 840-2400 or (858) 452-0306. [153] SCRIPPS XIMED MEDICAL CENTER BUILDING OFFICE SPACE TO SUBLEASE — LA JOLLA: Occupied by vascular and general surgeons. One room consult office available, with one or two exam rooms, to a physician or team. Located on the campus of Scripps Memorial Hospital, Scripps XiMed Medical Center Building is the office space location of choice for anyone doing surgeries at the hospital or seeking a presence in the La Jolla area. Support staff may be available if needed. Full ultrasound lab on site / procedure room. For more information, call Irene at (619) 840-2400 or (858) 452-0306. [154] SUBLEASE IN PRESTIGIOUS UTC BUILDING: Sublease beautifully appointed 2100-square-foot office in prestigious building in UTC, starting on July 1, 2014. Ideal for plastic surgeon, urologist, orthopedic surgeon, or pain specialist. Direct access to AAAASF-certified surgical center with existing contracts with Blue Cross, UnitedHealthcare, work-

ers’ compensation, and Aetna. Fraxel repair laser, hand fluoro, endoscopic and power-assisted liposuction equipment available at premises. Please call or email Ines Ustare at (858) 457-8686 or ines@solteromd.com. [145] LUXURIOUS / BEAUTIFULLY DECORATED DOCTOR’S OFFICE NEXT TO SHARP HOSPITAL FOR SUB-LEASE OR FULL LEASE: The office is conveniently located just at the opening of Highway 163 and Genesee Avenue. Lease price if very reasonable and appropriate for ENT, plastic surgeons, OB/GYN, psychologists, research laboratories, etc. Please contact Mia at (858) 279-8111 or at (619) 823-8111. Thank you. [836] 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] 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] 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 PART-TIME PA OR NP NEEDED FOR FAMILY PRACTICE: Located in Eastlake / Chula Vista area. Must have 1–2 years experience in family practice. Will perform complete physical exams, including pap smears, must be able to diagnose and treat acute and chronic problems. This includes ordering and interpreting diagnostic tests. Patients of all ages. We are open Monday through Friday, 8:00am to 5:00pm. Seeking part time, 16+ hours. Days and times are negotiable. Hourly rate is competitive. Physician may require more coverage if out of office. Please contact Norma at (619) 946-4073. [170] FULL-TIME PHYSISIAN’S ASSISTANT: Looking for a physician’s assistant to join a busy academic private spine surgeon’s practice in La Jolla area. Preferred candidate should have 3–5 years of previous experience. Responsibilities to include but are not limited to: Examine patients to obtain information about their physical condition; provide physicians with assistance during surgery or complicated medical procedures; interpret diagnostic test results for deviations from normal; visit and observe

patients on hospital rounds or house calls; update charts; order therapy; and report back to physician. Compensation based on experience. Please send CV to icuellar@sandiego-spine.com. [168] PHYSICIAN OR NURSE PRACTITIONER TO PERFORM HOUSECALLS: In North San Diego County Monday through Friday. 10–12 patients per day. Please forward CV. Full time. Excellent time management skills required. Pager one week per month, no hospital rounds. Established patient base. Independent contractor position with great income potential. NPs: Home health experience a plus. Please respond by email only to mobiledoctor@sbcglobal.net. Thank you. [165b] PART-TIME NURSE PRACTITIONER: A concierge internal medicine practice in La Jolla is hiring a part-time nurse practitioner, to ultimately transition to full-time with benefits. 20% clinical visits + 20% health coaching + 30% phone calls / emails + 30% care coordination. Preferred Skills: excellent bedside manner, articulate communicator, electronic charting experience, detail-oriented, ability to function autonomously, and experience in geriatric medicine. Requirements: current California registered nurse license and nurse practitioner certificate from the State of California, with furnishing license; DEA number; American Heart Association Healthcare Provider BLS card required by hire date; participation in after-hours call. Salary is based on qualifications; long-term commitment rewarded. Email Kirstin at admin@pambrarmd. com. [160] 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 / résumé to paindoctorstaff@hotmail.com. [094] PART-TIME OR FULL-TIME NP OR PA: Island Family Medicine is looking for a part-time or fulltime NP or PA who loves primary care and wants to work with both adults and children of all ages. Busy practice in Coronado with a small-town feel. Experience preferred, but I am willing to consider a motivated new graduate. Compensation based on experience. 401K for PT and FT. Vacation pay and health insurance for FT. Apply by sending resume to CoronadoMedPeds@gmail.com. [155] NURSE PRACTITIONER: Needed for house-call physician in San Diego. Full-time, competitive benefits package and salary. Call (619) 992-5330 or email drhunt@thehousecalldocs.com. Visit www. thehousecalldocs.com. [152] PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Needed for house-call physician San Diego. Part-time, flexible days / hours. Competitive compensation. Call (619) 992-5330 or email drhunt@thehousecalldocs.com. Visit www.thehousecalldocs.com. [038] MEDICAL EQUIPMENT NEOMATRIX HALO BREAST PAP TEST CONSOLE: Excellent condition. One owner in private GYN practice. Call (619) 220-0999. [174] SAN DI EGO PHYSICIAN.org 35

San Diego Physician Celebrates 100 Years!

The Bulletin of the San Diego County Medical Society January 1962 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.

the bulletin

Chargers San Diego M. Smith, M.D. By Walter

SociMany members of the San Diego County Medical ns. ety have unusual and interesting extra-time positio the for ian physic the , Martin One of these is Dr. Worth San Diego Chargers. In this position, Dr. Martin is required to travel, o, and this past season’s trips included Houston, Buffal not duties his ian, physic team As Boston and Denver. in the only require his presence at the game (often pacing he that also but n), Gillma Sid Coach restless shadows of e administer to the team during the week in the practic are s throat sore and Colds s. period and in the off-time one frequent among the fellows. One Charger, and only ulcer. nal duode a has ), writer the to (this was a surprise , are Two cases of porphyria, one picked up by Dr. Martin obmena pheno al medic ting listed among the interes served. Much of Dr. Martin’s time is taken up [word illegteam’s ible] physiotherapy, usually administered by the some spent trainer the says Martin excellent trainer. Dr. Angefive years with U.S.C. before going to the Los often les Rams with Coach Sid Gillman. Dr. Martin is the busy at half-time suturing minor lacerations so that e requir ankles ntly, Freque . action players can return to the xylocaine injections before a game. Jackie Kemp, ed star quarterback of the Chargers, for example, requir during shoulder injections before each game and later rethe season for both shoulders because of a new injury t ceived in practice. Practice injuries apparently accoun ins injurie do as ers Charg ed bench for almost as many curred during the heat of battle. One of the typical busy days for Dr. Martin was near two the end of the season during the Boston game when

36 Oc tob er 2013

injury Boston players were injured. One had a severe head the and was unconscious, convulsing and cyanotic when owed “swall a of e Becaus . arrived ian trainer and physic of an tongue,” immediate laryngoscopy and insertion He ance. ambul by al remov t’s patien the ed airway preced alleviregained consciousness as soon as the anoxia was pain in ated. The other man was near collapse because of Subthe lower left chest and was removed by ambulance. more than rather ribs ed fractur ted indica s sequent studie serious abdominal or thoracic injury. Dr. Martin lists other injuries which he was called arm upon to attend during the season such as one broken ion; reduct open ing requir radius the of ird in the midth ssions; one Bennett’s fracture of the thumb; two concu a one kidney stone passed the night following a game; season sever fracture dislocation of the ankle early in the susin Charger linebacker Allen; a fractured mandible sepatained in training camp, preseason; two shoulder al disc rations; numerous torn knee cartilages; one cervic with biceps loss on one side; etc. Dr. Martin’s closing remarks about his interestseason ing season with the Chargers who finished their Chamn Divisio rn Weste the and s defeat with only two proud pionship of the American Football League, were Diego San the with n positio “My part, in ones. He said as a Chargers was an interesting one. I am proud of them graducollege all men, young ent, intellig group of fine, d. I am ates, all in excellent health and all highly inspire for them with ation associ my to d forwar g eagerly lookin the another season.” All who enjoyed the games during ing the year surely share Dr. Martin’s sentiments regard past season and his hopes for future ones.

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We fight frivolous claims. We smash shady litigants. We over-prepare, and our lawyers do, too. We defend your good name. We face every claim like it’s the heavyweight championship. We don’t give up. We are not just your insurer. We are your legal defense army. We are The Doctors Company. The Doctors Company built its reputation on the aggressive defense of our member physicians’ good names and livelihoods. And we do it well: Over 82 percent of all malpractice cases against our members are won without a settlement or trial, and we win 87 percent of the cases that do go to court. So what do you get for your money? More than a fighting chance, for starters. The San Diego County Medical Society has exclusively endorsed our medical malpractice insurance program since 2005. To learn more about our program benefits for SDCMS members, call (800) 852-8872 or visit www.thedoctors.com.

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