December 2013

“Physicians United for a Healthy San Diego”

official publication of SDCMS Dec 2013

The Importance of Not Forgetting

NORCAL Mutual is owned and directed by its physicianpolicyholders, therefore we promise to treat your individual needs as our own. You can expect caring and personal service, as you are our first priority. Contact your broker or call 877-453-4486 today. Visit norcalmutual.com/start for a premium estimate.

A N o r c A l G r o u p c o m pA N y

N o r c A l m u t u A l .c o m

B

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

Beginning with San Diego’s first open heart surgery, our history of providing leading-edge cardiovascular care spans more than five decades and has earned Sharp a regional and worldwide reputation for excellence.

Cardiovascular cases are challenging.

Finding the right specialist doesn’t have to be.

Each year, thousands of cardiovascular patients are referred to Sharp HealthCare for diagnosis and treatment. From high-risk cases needing immediate intervention to rehabilitation, your patient will be treated with the clinical skill, leading-edge technology and compassion that are hallmarks of The Sharp Experience.

At Sharp, it’s easy to find the specialist who matches your patient’s individual needs. Each of our hospitals has a head of cardiovascular services who will work personally with you on a referral recommendation.

Central San Diego, Coastal and Inland North County: Cindy Walsh, Sharp Memorial Hospital, (858) 939-5009 South Bay: Barry Taylor, Sharp Chula Vista Medical Center, (619) 502-5353 East County: Joyce McGinty, Sharp Grossmont Hospital, (619) 740-4123

CORP571A ©2013 SHC

Dec.

Contents

Volume 100, Number 12

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

SDCMS BOARD OF DIRECTORS 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)

THE IMPORTANCE OF NOT FORGETTING

24 Retired Physician Leaders of SDCMS Take a Look Back

BY MATTHEW C. GLEASON, MD, KEVIN P. GLYNN, MD, ALLAN H. GOODMAN, MD, JOHN S. HATTOX, MD, RALPH R. OCAMPO, MD, ANTHONY J. PIERANGELO, MD, DAVID M. PRIVER, MD, and LYNN SHEFFEY, MD

14

Avoid the Medicare Quality Reporting Penalty in 2015

departments

BY THE ALAMEDA-CONTRA COSTA MEDICAL ASSOCIATION

4 Briefly Noted: Welcome New & Rejoining Members! • Covered California FAQs • Featured Member • Commercial Real Estate Tips & Trends • And More …

10 Happy Holidays From Your SDCMS and SDCMS Foundation Support Teams

18

12

Choosing Wisely: Five Things Physicians and Patients Should Question

BY THE AMERICAN COLLEGE OF PHYSICIANS

cIMT and the Eternal Now

BY DANIEL J. BRESSLER, MD

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

BY THE DOCTORS COMPANY

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

Malpractice Case Shows Risk From Physician Not Dating and Initialing Reports

22 The Inspiration of the Holidays — and Every Day — at Our Fingertips

BY HELANE FRONEK, MD, FACP, FACPH

34 Physician Marketplace Classifieds

NOMINATED BY THE PHYSICIANS OF INTERNAL MEDICINE ASSOCIATES: PAUL F. SPECKART, MD, RAYMOND G. PIGEON, MD, DEANNA K. PRICE, MD, BRIAN J. LENZKES, MD, AND THERESA R. BOHUN, MD

Cover: Horton’s Hall, located on the southeast corner of 6th Avenue and F Street, was the first meeting place of the San Diego County Medical Society. It had shops downstairs and a meeting hall above when it opened around Christmas in 1869. It burned in 1897 and was torn down shortly thereafter. The national census of 1870 gave San Diego 2,300 inhabitants and 915 houses.

2 decem b er 2013

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)

20

36 Congratulations to San Diego County’s Outstanding Medical Office Manager for 2013: Pat Russell

10

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)

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

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.]

/////////briefly ///////////////////noted ////////////////////////////////////////////////////////////////////// 11th Annual Natural Supplements: An Evidencebased Update JAN 29, 30, 31, FEB 1 (www. scripps.org/events/11thannual-natural-supplementsjanuary-29-2014)

calendar Cma Webinars CMAnet.org/events Avoiding Embezzlement: A Physician’s Guide to Protecting Your Practice JAN 15: 12:15pm–1:15pm Medicare: 2014 New Rules JAN 16: 12:15pm–1:15pm Update on Medicare Physician Incentives: What’s New for 2014 JAN 22: 12:15pm–1:45pm Transitioning Your Practice: Retiring, Selling, or Buying a Practice FEB 19: 12:15pm–1:15pm Fraud and Abuse: Dangers and Defenses FEB 26: 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.

Health IT Program Held by the Institute for Health Technology Transformation JAN 21–22 (ihealthtran.com) 14th Annual UCSD Heart Symposium for Primary Care and Internal Medicine Physicians JAN 25 (www.ccmmeetings.com) Melanoma 2014: 24th Annual Cutaneous Malignancy Update JAN 25, 26 (www.scripps.org/ events/melanoma-annualcutaneous-malignancyupdate-january-25-2014)

“

Structural Heart Intervention and Imaging 2014: A Practical Approach FEB 6, 7 (www.scripps.org/ events/structural-heartintervention-and-imagingfebruary-6-2014) Scripps 34th Annual Conference: Clinical Hematology & Oncology 2014 FEB 15, 16, 17, 18 (www.scripps. org/events/scripps-34thannual-conference-clinicalhematology-oncologyfebruary-15-2014) CTEPH: State of the Art 2014 — A Multidisciplinary Symposium FEB 28–March 1 (www.ccmmeetings.com) The Future of Genomic Medicine VII MAR 6, 7 (www.scripps.org/ events/the-future-of-genomicmedicine-vii-march-6-2014) The SDCMS Foundation’s 2nd Annual Aces for Health Golf Tournament MAR 13 at the Del Mar Country Club. Benefitting Project Access, providing healthcare to those who need our help most.

Foursome: $1,000. Individual players: $300. Sponsorship opportunities available.

Contact (858) 565-7930 or visit www.sdcmsf.org/golf.

19th Annual Primary Care in Paradise MAR 24, 25, 26, 27 (www.scripps.org/events/ primary-care-in-paradisemarch-24-2014) 29th Annual New Treatments in Chronic Liver Disease MAR 28, 29, 30, 31 (www. scripps.org/events/newtreatments-in-chronic-liverdisease-march-28-2014)

Things won are

done, joy’s soul lies in the doing.

4 decem b er 2013

— William Shakespeare

get in touch

Your SDCMS and SDCMSF Support Teams Are Here to Help!

SDCMS Contact Information 5575 Ruffin Road, Suite 250, San Diego, CA 92123 T (858) 565-8888 F (858) 569-1334 E SDCMS@SDCMS.org W SDCMS.org • SanDiegoPhysician.org CEO • EXECUTIVE DIRECTOR Tom Gehring at (858) 565-8597 or Gehring@SDCMS.org COO • CFO James Beaubeaux at (858) 300-2788 or 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

SDCMSF Contact Information 5575 Ruffin Road, Suite 250, San Diego, CA 92123 T (858) 300-2777 F (858) 560-0179 (general) W SDCMSF.org EXECUTIVE DIRECTOR Barbara Mandel at (858) 300-2780 or Barbara.Mandel@SDCMS.org project access PROGRAM DIRECTOR Francesca Mueller, MPH, at (858) 565-8161 or Francesca.Mueller@SDCMS.org RESOURCE DEVELOPMENT DIRECTOR Kristina Starkey at (858) 565-7930 Kristina.Starkey@SDCMS.org Patient Care Manager Rebecca Valenzuela at (858) 300-2785 or Rebecca.Valenzuela@SDCMS.org Patient Care Manager Elizabeth Terrazas-Olivera at (858) 565-8156 or Elizabeth.Terrazas@SDCMS.org Office Manager Liz Brave at (858) 300-2789 or at Liz.Brave@SDCMS.org IT PROJECT MANAGER Victor Bloomberg at (619) 252-6716 or Victor.Bloomberg@SDCMS.org IT PROJECT MANAGER Rob Yeates at (858) 300-2791 or Rob.Yeates@SDCMS.org

///////////////////////////////////////// /////////// ////// ///////to////yours, ////////////////////////////// From our home www.vibrabank.com

we wish you a Happy Holiday season and New Year

micra defense

Individuals and Groups Donating to Defend MICRA The MICRA fight is on. The initiative to eviscerate MICRA has been rolled out for signature gathering! Thank you to the following hospitals for contributing toward its defense: Alvarado: $10,000 • Chief of Staff: Frederick M. Howden, MD • Chief of Staff Elect: Richard O. Butcher, MD Grossmont: $33,000 • Chief of Staff: Brian S. Moore, MD • Chief of Staff Elect: C. Eric Orr, MD Palomar: $33,000 • Chief of Staff: Richard C. Engel, MD Paradise Valley: $10,000 • Chief of Staff: Paul J. Manos, DO • Chief of Staff Elect: Dorothy E. Hairston, MD Pomerado: $33,000 • Chief of Staff: Roger J. Acheatal, MD Rady Children’s: $33,000 • Chief of Staff: Gail R. Knight, MD • Chief of Staff Elect: Mary Hilfiker, MD San Diego Imaging: $12,000 San Diego Pathologists Medical Group: $10,000 Scripps Encinitas: $10,000 • Chief of Staff: Ron J. MacCormick, MD • Chief of Staff Elect: Scott A. Eisman, MD Scripps Memorial: $33,000 • Chief of Staff: Shawn D. Evans, MD • Chief of Staff Elect: M. Jonathan Worsey, MD Scripps Mercy Chula Vista: $33,000 • Chief of Staff: Juan M. Tovar, MD • Chief of Staff Elect: Thomas C. Lian, MD, PhD Sharp Chula Vista: $10,000 • Chief of Staff: Errol R. Korn, MD • Chief of Staff Elect: Sharp Coronado: $20,000 • Chief of Staff: Kevin C. Considine, DO • Chief of Staff Elect: Roger Oen, MD Sharp Memorial: $33,000 • Chief of Staff: Ronald C. MacIntyre, MD Tri-City: $5,000 • Chief of Staff: Juan C. Deza, MD • Chief of Staff Elect: The California Hospital Association matches hospital medical staff contributions 2:1! In other words, medical staffs have raised $888,000, plus the $22,000 from San Diego Imaging and San Diego Pathologists Medical Group, or almost $1 million for San Diego!

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

SAN DI EGO PHYSICIAN.org 5

/////////briefly ///////////////////noted ////////////////////////////////////////////////////////////////////// Commercial Real Estate Tips & Trends

Special Leasing Report What to Look for When Your Building Changes Hands

By Chris Ross With medical building investment sales activity near all-time highs, the news that an owner is selling a building has become more common. This can trigger many questions among tenants. Is the owner going bankrupt? Will the buyer pump up rents as soon as possible? Will the new owner scale back on the maintenance of the building or make upgrades to the property, and for what purpose?

While transfer of your building’s ownership is nothing to take lightly, neither is it a cause for panic. The best defense is a good offense, and you can start by digging up your lease agreement and other related documents.

Ignore the Rumors, Get the Facts If you suspect that your building is going to be sold, try not to jump to conclusions based on market speculation you may have heard from fellow tenants or others. When in doubt, the best approach is to go straight to the owner and inquire about what you have heard. Though some landlords might be reticent, most would rather share the truth and quash rumors among occupants.

Though less common today than two to three years ago, if you think the building is at risk for foreclosure, work with your commercial real estate provider or legal counsel who can help determine the reason and likely outcome. Is the ownership trying to restructure or refinance in order to keep the building? Is there a threat that the maintenance of your building is going to suffer? Will the building likely be put on the market for sale?

Whatever the answers may be, it is wise to revisit and review your lease file. It is a good idea to have an experienced broker assist with your review sooner rather than later, as sometimes a building sale creates a window of opportunity to restructure your lease with certain terms and provisions that would otherwise be difficult to obtain. These terms may be something the selling party would consider, or they may be terms that are particularly attractive to the buyer.

If you occupy a significant amount of 6 decem b er 2013

space in the building, if your credit rating is particularly strong, if your lease expires soon, or if your current rental rate is notably higher or lower than market, your chances of a lease restructure improve dramatically.

Through assertive negotiation you may be able to gain short-term benefits such as capping rent or your share of operating expenses, which can be ideal if the building’s assessed value — and in turn the property taxes — are expected to go up when the building trades.

Consider the timing of financing from the new owner’s lender. If it coincides with the expiration of your current lease, your clout in any negotiations will multiply.

What Will the New Owner Do? Regardless of the type of investor that acquires your building, a new owner usually pays more for the property than the previous one, has a larger investment to repay, and will in turn look for ways to increase the building’s rental income. More often than not the new landlord will heighten the building’s curb appeal in an effort to attract higher-paying occupants.

For the immediate future, a new owner must adhere to all provisions in the lease agreement, which protects you from unwanted adjustments during the duration of your current lease such as unscheduled rent increases. A new owner will typically take the initiative to set up a courtesy meet and may want to review the agreement or listen to any concerns or suggestions you may have about the lease or property. Use this opportunity to make sure the new landlord will honor previously promised concessions or resolve outstanding issues that the prior

owner may have avoided or put off.

Lastly, try to determine what the owner’s plans may be regarding capital improvements and next-cycle rent increases. If it appears that rents may be substantially raised or out of touch with the market, express your concerns at the appropriate time and in a professional and organized manner. No new landlord wants unhappy tenants, especially from the outset.

If your leverage position is less than strong, the real moment of truth may not come until the first time your lease comes up for renewal. Be realistic, but if you feel that a rent increase is unfair, benchmark the landlord’s asking terms against comparable vacancies and recently completed lease and renewal transactions in your market. Such research can be provided by a qualified broker and will provide potent ammunition to demonstrate your understanding of market conditions and relocation alternatives.

Depending on where your office is located, many landlords are still struggling to attract and retain occupants, which makes your negotiating position better than you may think (even though you probably want to avoid moving if at all possible!). Owners who may have displayed somewhat of a cavalier attitude during years of space shortages may now need to show some flexibility in order to keep their current occupants happy.

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.

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

Welcome New and Rejoining SDCMS-CMA Members!

New Members Marc K. Akashi, MD Pediatrics Chula Vista (619) 482-3090 Preeti Bansal, MD Ophthalmology San Diego (858) 309-7702 Brian J. Bigoni, MD Diagnostic Radiology Imperial (760) 545-0340 Maya G. Borso, MD Diagnostic Radiology San Diego (858) 658-6500 Elizabeth B. Burgamy, MD Pediatrics San Diego (858) 457-0030 William R. Carr, MD Anesthesiology San Diego (858) 565-9666 Achal Dhupa, MD Pulmonary Disease La Jolla (858) 625-7200 Elainie De Villena Doringo, MD Pediatrics El Cajon (619) 442-2560 Kristopher L. Downing, MD Orthopaedic Surgery, Hand Surgery Chula Vista (619) 421-3400 Sheetal N. Gandhi, MD Pediatrics San Diego (858) 457-0030 Chris Glenn, MD Transplantation Surgery San Diego (831) 796-3740

Vy U. Hoang, MD Pediatrics El Cajon (619) 442-2560 Norbert Kased, MD Radiation Oncology Vista (760) 599-9545 April M. Kranz, MD Internal Medicine San Diego (909) 963-6343 Jonathan M. Meyer, MD Psychiatry San Diego (858) 642-3570 Alexandra L. Pinon, MD Pediatrics Temecula (951) 699-3299 Michele C. Rochelle, MD Diagnostic Radiology Escondido (760) 739-5400 Rong Shi, MD Internal Medicine San Diego (619) 278-3300 Vikram M. Udani, MD Neurological Surgery San Diego (619) 297-4481 Rejoining Members Dennis E. Amundson, DO Pulmonary Disease San Diego (760) 230-8994 Scott A. Eisman, MD Pulmonary Disease Encinitas (760) 230-8994 Bret R. Gerber, MD Pediatrics San Diego (619) 278-3300

Steven L. Higgins, MD Clinical Cardiac Electrophysiology La Jolla (858) 658-0088 Matthew J. Horn, MD Pulmonary Disease Encinitas (760) 230-8994 Martha E. Lozano, MD Internal Medicine Chula Vista (619) 482-7301 Afsaneh Maghsoudy, MD Diagnostic Radiology Imperial (760) 545-0340 Robert E. Neveln, MD Internal Medicine La Jolla (858) 452-7040 Sabiha Pasha, MD Internal Medicine Escondido (442) 281-4047

Medical Professional Liability Protection, and more!

David M. Priver, MD Obstetrics and Gynecology San Diego Suneil R. Ramchandani, MD Internal Medicine San Diego (619) 532-5548

800-356-5672 www.caPphysicians.com

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Charles J. Sarosy, MD General Surgery La Mesa (619) 697-1325

orange LoS angeLeS PaLo aLTo

Robert T. Savage, MD Pulmonary Disease Encinitas (760) 230-8994

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Peter M. Seymour, MD Psychiatry San Diego (858) 576-1788 Henry C. Yeager, MD Internal Medicine San Diego (619) 278-3300

SAN DI EGO  PHYSICIAN.org 7 CAP_1402.indd 1

2/5/13 11:13 AM

/////////briefly ///////////////////noted ////////////////////////////////////////////////////////////////////// COVERED CALIFORNIA

FAQs for Clinicians and Their Staff Q: How will Covered California impact my practice?

A: The impact on physician practices will vary greatly depending on the mix of patients in your practice and the extent to which you contract with Covered California plans. Millions of previously uninsured Californians will now be eligible for health insurance. Your patients with employer-sponsored coverage are not likely to see significant changes in their coverage.

Small and medium-size physician practices with 50 employees or fewer are also eligible to participate in the Small Business Health Options Program (SHOP). For more information, visit www.CoveredCA.com.

Q: Will my patient insured through Covered California be able to continue to see me?

A: You will have to be contracted with a Covered California plan and your patient will have to select that plan. Each health insurance plan has a specific list of doctors and hospitals that are considered innetwork providers for covered services. Directories of doctors and hospitals will be available at www.

CoveredCA.com. Patients should be advised to verify with each plan that a particular doctor’s or hospital’s services will be covered under that plan.

Covered California is providing a searchable online directory so that patients can see which health plan networks contain a particular doctor or hospital.

Q: How can a patient apply for Covered California coverage or Medi-Cal? A: Open enrollment for Covered California will continue until March 31, 2014, but patients must enroll in a plan by Dec. 15, 2013, for coverage to begin Jan. 1, 2014. Patients can apply for a Covered California health insurance plan online at www.CoveredCA. com or by calling (800) 300-1506, by mail, or through a Certified Enrollment Counselor. Patients can be directed to their nearest Certified Enrollment Counselor by calling (800) 300-1506. Medi-Cal enrollment is continuous throughout the year.

Q: What if I have questions about how my business may be impacted by Covered California or health plan contracting under Covered California?

A: If you have questions related to your business or contracts for providing services to Covered California patients, please refer to the California Medical Association’s (CMA) resource page, “Health Insurance Exchange Resources for Physicians,” at www. cmanet.org/exchange. For further assistance, please contact CMA’s Physician Hotline at (800) 786-4262.

8 decem b er 2013

Featured Member

James W. Ochi, MD Helping Kids Heal For years, Dr. Ochi — SDCMS-CMA member since 1991 — has been using medical acupuncture to decrease pain in children who need to undergo surgery. He is the only pediatric ENT doctor in Southern California trained in medical acupuncture and one of just a handful nationwide. Dr. Ochi is boardcertified in both medical acupuncture and otolaryngology, and has been in private practice for more than 20 years.

Dr. Ochi recently completed a study that showed medical acupuncture reduced pain in children after tonsillectomy. His article has undergone peer review and has been accepted for publication by the International Journal of Pediatric Otorhinolaryngology, the only medical journal entirely devoted to the specialty of pediatric ENT. Dr. Ochi has an office in Encinitas but also drives two hours east into the desert to serve children in El Centro every week. El Centro, which struggles with the highest unemployment, worst air quality, and greatest rate of childhood asthma in California, has very few doctors but a huge number of children with severe respiratory disease, including enlarged tonsils.

“I’ve been very encouraged by the improvement in pain from acupuncture in the children after surgery,” says Dr. Ochi. Acupuncture is quickly being incorporated into mainstream medicine. Recent research has shown acupuncture is effective in reducing pain and safer than many drugs. Another benefit is acupuncture costs very little, which is no small matter during this time of soaring healthcare costs.

Dr. Ochi hopes to do more research projects to further refine the improvement from acupuncture in his patients: “It’s exciting to be able to offer an effective and safe way for my patients to suffer less pain.”

www.SanDiegoSafePrescribing.org The No. 1 cause of unintentional deaths in San Diego County is from drugs, with almost one person a day dying in our county from this preventable cause.

The San Diego and Imperial County Prescription Drug Abuse Medical Task Force is a coalition of medical leaders who have joined efforts to reduce deaths and addiction due to prescription drugs. The task force includes pain specialists, internal medicine physicians, emergency physicians, psychiatrists, dentists, pharmacists, hospital administrators, health department administrators, and our local DEA. The task force also includes broad health partners, including Kaiser Permanente, Scripps Health, Sharp HealthCare, UC San Diego Health System, Palomar Health, and the Community Clinics. The task force encourages all medical practitioners to use the materials provided at www.

SanDiegoSafePrescribing.org to improve patient care.

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Helping you deliver quality care, one square foot at a time.

In today’s competitive market, we leverage our extensive experience and exclusive specialization in healthcare real estate to achieve valuable savings and provide optimal solutions for our clients.

We share your commitment to enhancing the patient’s experience, maximizing resources and planning for the future. As San Diego’s trusted leader in medical office and healthcare properties, we thrive on saving our clients time and money through our persistent and strategic negotiating style.

Whether negotiating a 2,000-square-foot lease renewal or acquiring a 50,000-square-foot building, you will always be in good hands.

Put our experience and expertise to work. Contact us today: Paul Braun Managing Director +1 858 410 6388 paul.braun@am.jll.com

Chris Ross Vice President +1 858 410 6377 chris.ross@am.jll.com

www.us.joneslanglasalle.com/healthcare Leases ▪ Renewals ▪ Sales ▪ Strategic Planning ▪ Demographic & Patient Analysis

SAN DI EGO PHYSICIAN.org 9

Happy Holidays From Your SDCMS and SDCMS Foundation Support Teams!

Describe Your Ideal Holiday Vacation

An ideal vacation would be riding bikes with my wife in a faraway countryside of a place I have never been where surprises of beauty would be found around each corner. We have spent three weeks riding through the Loire Valley of France, traveling from chateau to chateau. We also rode for almost a month on Prince Edward’s Island near Nova Scotia, taking in the beauty and amazing seafood. Where would we go next? Hmm … something to dream about!

As soon as the plane touches down on the sun-baked lava fields of Kona, I know that I am home for the holidays. The winds on the lanai shift around 10 a.m. It reminds me that it’s time for snorkeling with the family and then some paddleboarding. Or maybe it’s a reminder that it’s time for a cup of coffee and a good book. Kona, the tropical sun, and no schedule. This is my Christmas in paradise.

My ideal holiday vacation is any tropical island. I love to watch the ocean with my toes in the sand. Bliss.

I really don’t have an ideal holiday vacation.

I have one each year at home, all cozied up with my family.

Pictured Left to Right: Janelle Kistler, Liz Brave, James Beaubeaux, Rebecca Valenzuela, Victor Bloomberg, Elizabeth TerrazasOlivera, Brandon Ethridge, Jennipher Ohmstede, Barbara Mandel, Francesca Mueller, Kyle Lewis, Marisol Gonzalez, Brian Gerwe, Kristina Starkey, Betty Matthews, and Tom Gehring

10 decem b er 2013

My holiday dream vacation would be to take my parents to a small village in Italy so that we can all experience an authentic Italian Christmas, have delicious food, and make memories to last a lifetime!

Encarnacion, Paraguay, because the land and people are wonderful. I would love to see my friends from the time I served in the Peace Corps.

My ideal holiday vacation would be to spend three days skiing on fresh, powdery snow. On the last run of the third day, I’d like the run to end on a beach, and then spend another three days relaxing in the sunshine.

I would love to spend Christmas with family in a cabin by a small lake, maybe in northern Minnesota where they get plenty of snow.

There would be a big fireplace with lots of wood to burn, good cheer, and goodwill all around. There would be, as well, lots of libations and rooms to escape to, cuz, ya know, I’d be trapped with my family in a cabin in the middle of nowhere for who knows how long. Merry Christmas, Mom :-)

Skiing in the Alps. I love Europe — as I grew up there — and the major European resorts are much more spread out (albeit not as high), so you can go for many, many miles and not see the same runs. The only thing better is walking in the Alps — for the same reasons — and the villages are close enough together than you can hop from one village (bakery) to next (bakery).

My ideal holiday vacation would start by surfing an undisclosed Puerto Rican surf spot with excellent wave conditions. I would follow up by traveling to Sao Paulo, Brazil, to race the Autodromo Jose Carlos Pace Circuit in the Infiniti Red Bull Racing Team’s F1 car.

My ideal holiday vacation would include three things: sun, sand, and my fab husband, Marty … in an area with no cellular phones or laptops!

White sands, warm weather, a calm, beautiful ocean to standup paddleboard on all day with my soul mate, away from all the hustle and bustle of everyday life. The only sounds we’d hear are the sounds of the ocean, each other, and the beautiful tropical creatures all around us.

SAN DI EGO PHYSICIAN.org 11

PUBLIC HEALTH

Choosing Wisely

How The List on Page 13 Was Created

An Initiative of the American Board of Internal Medicine (ABIM) Foundation SDCMS is publishing various Choosing Wisely® lists of “Things Physicians and Patients Should Question.”

Choosing Wisely — see page opposite — 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 decem b er 2013

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 Physicians (ACP) formed a workgroup of 11 experienced internal medicine physicians with specific skills in the assessment of evidence. Members of this workgroup included physicians who were current members of the ACP Clinical Guidelines Committee, the Education and Publication Committee, the Board of Governors, and the Board of Regents, as well as three ACP staff physicians. The group collaboratively identified and narrowed down screening or diagnostic tests commonly used in clinical situations where they are unlikely to provide high value or improve patient outcomes. The results were further reviewed and narrowed by clinically active ACP staff physicians before being placed for review into a randomly selected internal medicine research panel. Representing 1% of ACP members, the panel selected five scenarios that represented the greatest potential for overuse or misuse of a diagnostic test leading to low value care. Based upon this process, the final top five scenarios were identified. ACP’s disclosure and conflict of interest policy can be found at www.acponline.org.

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

Five Things Physicians and Patients Should Question by the American College of Physicians (ACP) 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.

1 2 3

4

5

Don’t obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary heart disease.

In asymptomatic individuals at low risk for coronary heart disease (10-year risk <10%) screening for coronary heart disease with exercise electrocardiography does not improve patient outcomes.

Don’t obtain imaging studies in patients with nonspecific low-back pain.

In patients with back pain that cannot be attributed to a specific disease or spinal abnormality following a history and physical examination (e.g., nonspecific low-back pain), imaging with plain radiography, computed tomography (CT) scan, or magnetic resonance imaging (MRI) does not improve patient outcomes.

In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI).

In patients with witnessed syncope but with no suggestion of seizure and no report of other neurologic symptoms or signs, the likelihood of a central nervous system (CNS) cause of the event is extremely low and patient outcomes are not improved with brain imaging studies.

In patients with low pretest probability of venous thromboembolism (VTE), obtain a high-sensitive D-dimer measurement as the initial diagnostic test; don’t obtain imaging studies as the initial diagnostic test.

In patients with low pretest probability of VTE as defined by the Wells prediction rules, a negative high-sensitivity D-dimer measurement effectively excludes VTE and the need for further imaging studies.

Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.

In the absence of cardiopulmonary symptoms, preoperative chest radiography rarely provides any meaningful changes in management or improved patient outcomes.

SAN DI EGO PHYSICIAN.org 13

Quality of Care

Avoid the Medicare Quality Reporting Penalty in 2015

by The Alameda-Contra Costa Medical Association

14 decem b er 2013

Note: Thank you to the Alameda-Contra Costa Medical Association for allowing us to reprint this article.

exhaustive discussion of PQRS â&#x20AC;&#x201D; resources are listed at the end of the article for those desiring additional information.

As part of the Physician Quality Reporting System (PQRS), Medicare will impose a 1.5% penalty in 2015 on physicians and other providers who do not successfully report at least one individual quality measure for at least one patient in 2013. The purpose of this article is to help physicians avoid the penalty in 2015 by providing guidance on how to report at least one measure for at least one patient using Medicare claims. Since most physicians already submit Medicare claims for reimbursement, adding the additional PQRS reporting information to the claim will be the least burdensome way for most physicians to avoid the penalty. This article also touches upon how physicians can qualify for a quality reporting bonus and discusses some additional PQRS reporting options.

However, this article is not intended to be an

Avoid the Penalty in 2015 Through Claims-based Reporting For many physician practices not yet participating in PQRS, the simplest way to avoid the penalty in 2015 will be to report on one quality measure for at least one patient (preferably a few patients) on your Medicare claims. The process can be broken down into three steps: 1. Select an appropriate measure.

2. Identify your Medicare patients to whom the measure applies.

3. Report the quality measure on your Medicare claims after an applicable patient encounter.

Step One: Select an Appropriate Measure Quality measures form the basis of the PQRS program, and are intended to provide information to Medicare about an aspect

Since most physicians already submit Medicare claims for reimbursement, adding the additional PQRS reporting information to the claim will be the least burdensome way for most physicians to avoid the penalty.

of care, such as prevention, chronic- and acute-care management, procedure-related care, resource utilization, and care coordination. For purposes of avoiding the penalty in 2015, physicians should select a quality measure relating to an aspect of care that you will encounter in your Medicare patient population. Review the list of individual measures that are reportable by claims [SDCMS members may email Editor@ SDCMS.org to obtain the list], and select the most frequent measure that applies to your Medicare patients. Although there are many individual measures that can be reported via claims, some physicians may not find specialty-specific measures.

Nevertheless, there may be a measure that reflects a general aspect of care that is not specialty-specific that may be applicable and can be reported for purposes of avoiding the penalty.

Step Two: Learn the Details for Each Measure After you have selected which measure to

report, it is important to review the specifications for the measure with your billing staff. This will help ensure that eligible Medicare patients are appropriately identified and quality measures are accurately reported on claims. Measure specifications are developed by the Centers for Medicare and Medicaid Services (CMS), and can be accessed online at www.cms.hhs.gov/ PQRS. Although the details vary across measures, each measure specification developed

by CMS shares a common format and provides important information about which Medicare patients are eligible for reporting the measure based on patient demographics (age and gender), diagnosis (ICD 9 codes), and primary service(s) provided (CPT codes); the various “quality codes” that are used for reporting on Medicare claims; and, the clinical rationale and information about the measure. It is important to review this information carefully since compliance with these specifications is required for measures you report to be counted. For example, you will not get credit for reporting if the Medicare patient is outside of the age range indicated or whose diagnosis code is not listed on the measure specification.

Step Three: Start Reporting on Your Medicare Claims Once you understand which Medicare patients are eligible and the “quality codes” and modifiers that may be used to report the measure, you are ready to start reporting.

The final step is to establish a process in your office to ensure that you consistently identify eligible patients, correctly document the correlating clinical information in the patient’s chart, and accurately report the information on your Medicare claims.

To ensure you successfully report for at

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Quality of Care

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least one patient, ACCMA recommends that you overshoot the target and report the quality measure you select for at least several patients.

With claims-based reporting, a quality code is billed like any other procedure or E/M code (on Line 24 of the CMS 1500 form or electronic equivalent); however, quality codes are billed at a $0.00 charge (or $0.01 if your billing system will not accept zero), and are denied by Medicare with remark code N365 indicating the code is not payable but is counted for tracking purposes. Quality codes are only counted when submitted in combination with an eligible diagnosis and service. Quality codes submitted by themselves or along with services that have already been paid will not be counted (i.e., no retroactive claims-based reporting).

As with any other “billed” Medicare service, quality measures should be supported by documentation in the medical record, which will provide some protection in the event of an audit. Documentation should indicate in clinical terms the basis for the quality code that is reported; it is not sufficient to simply write the code in the medical record.

Earning PQRS Incentives Physicians and other eligible providers may earn an incentive equal to 0.5% of allowed charges for 2013 and for 2014.

To qualify, physicians must report at a higher frequency on at least three different individual measures (instead of just the one measure required to avoid the penalty) or one measures group (consisting of three or more related individual measures).

Individual measures must be reported for at least 50% of eligible Medicare patient encounters, and all individual measures within a measures group must be reported for at least 20 unique Medicare patients.

For claims-based reporting, the process for earning the incentive is similar to the process outlined above for avoiding the penalty: Select measures, learn the reporting requirements, and start reporting on Medicare claims. To qualify for the incentive bonus, you should identify the three most frequently occurring measures (or the most applicable measures group) and you should report the measures as frequently as you can for eligible Medicare patients. Because the threshold to receive the incentive is so high, it is advisable for physician practices to implement processes that enable 100% reporting, which will maximize your chances of receiving the incentive bonus. This might include training your front-office staff or medical assistants to screen patients for reporting

eligibility prior to each visit based on demographic and diagnosis information, and placing some sort of flag in the patient’s record to indicate eligibility. Some practices may even find it helpful to use tracking forms that can be placed in the eligible patient’s chart prior to the visit, completed by the physician and clinical staff during the encounter, and then used by billing staff to complete the reporting process. (AMA has developed tracking forms for many measures, which can be accessed directly through ACCMA’s PQRS webpage, located at www.ACCMA.org under “Practice Tools”). Also, physicians should be advised that the reporting period is Jan. 1 to Dec. 31, and it may be challenging or even impossible to meet the 50% reporting threshold for the 2013 incentive.

Regardless of whether you report individual measures or measure-groups, it is important to choose measures that occur frequently in your practice. By choosing relatively common measures or measuregroups, you will improve the likelihood of meeting the reporting thresholds. CMS encourages physicians to also consider your own quality improvement goals when selecting measures. While a physician’s goals for their patients should always be the primary driver behind any quality improvement initiative, they are unfortunately not even considered by CMS when determining penalties or incentives. Rather, avoiding the penalty in 2015 and obtaining incentives in 2013 and 2014 is entirely contingent on selecting measures that occur with enough frequency to ensure accurate reporting at or above PQRS minimum thresholds.

More Info About PQRS Reporting EHR and Registry Reporting: In addition to claims-based reporting, physicians and other eligible providers can report PQRS measures through EHR systems (either directly or through a data-submission vendor) or through approved registries.

Practices utilizing EHR systems should consult your vendors about implementing PQRS reporting in your practice, either for purposes of avoiding the penalty or earning the incentive bonus.

One advantage of utilizing registry reporting is the ability to “retroactively” report quality measures for patient encounters for which the Medicare claim has already been submitted. Registry reporting provides a mechanism for physicians to report quality measures separate from the claims process. However, registry reporting may be an additional process or system in your medical practice, and you may prefer to utilize claims-based reporting.

Doctor’s recommend Group Practice Reporting Option: The PQRS Group Practice Reporting Option (GPRO) is open to medical groups of any size, and provides different options depending on the size of the medical group. For example, in 2013, group practices ranging in size from 25 to 99 eligible professionals will report 29 quality measures for 218 consecutive Medicare patients, or 411 consecutive patients for group practices with 100 or more professionals. Practices wishing to use GPRO must submit a self-nomination letter indicating interest in participation. The next opportunity for GPRO participation will be for the 2014 reporting period.

Validation Process if Less Than Three Measures Can Be Reported: If fewer than three quality measures can be reported, physicians may still earn the incentive.

CMS uses a “measure-applicability validation process” to verify whether a physician could have reported on additional measures before determining whether reporting requirements for the bonus have been met. CMS analyzes claims to determine if other measures could have been reported (based on ICD-9 and CPT codes). If CMS finds that 30 or more patients/encounters during the reporting period were eligible for reporting another measure, then the physician practice will not have met the reporting requirements.

Financial Incentive Paid to TIN: PQRS tracks compliance with the reporting requirements at the individual provider level (using the NPI number), but the PQRS payment will be made to the Taxpayer Identification Number (TIN) used by the reporting physician. Participating physicians within the same practice (using a common TIN) should expect to receive the physicians’ incentives in a lump sum. Likewise, physicians who see patients on behalf of more than one practice (and, therefore, use more than one TIN when submitting Medicare claims) should expect their PQRS payment to be made to the respective TIN under which the services were reported.

Additional PQRS Resources • For more information about PQRS, the California Medical Association has published a guide that is available online at www.cmanet.org.

• For official PQRS information, please visit the CMS website at www.cms. gov/pqrs.

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SAN DI EGO PHYSICIAN.org 17

POETRY AND MEDICINE

cIMT and the Eternal Now

by Daniel J. Bressler, MD

Carotid Intima-Medial Thickness (cIMT) is an ultrasound-obtained measurement of the inner two layers of the carotid artery. It is a test that has been validated in hundreds of studies as a risk factor for heart disease independent of the other classic risk factors such as cholesterol, blood pressure, and smoking.

I explain cIMT to patients as a “running tally” of vascular risk. It reflects not only their current clinical factors and behaviors, but summarizes their entire life history as far as their arteries are concerned. Did they smoke for 20 years starting in the Navy?

The arteries remember. Were they once a star athlete? The cIMT reflects that, too. In a graphic and useful way this tests reminds patients of a basic universal truth: At every moment we are the sum total of every past moment. The ellusive, accumulative past lives on in us. We call it the present.

We have a paradoxical relationship with the past. It seems real in memories and photographs. It invites us to visit and change it through fantasy and speculation. (What 18 decem b er 2013

A Lesson From My Candle

if I had gone to med school in San Francisco instead of Boston? What if my wife and I had had a second child after all? What if I had bought Google at 15?) On the other hand, our logical mind tells us that the past is fixed and immutable. When Shakespeare’s Macbeth quips, “What’s done is done,” the phrase is both obvious and ironic.

In medicine and in life, one of the “tricks” seems to be to comprehend the past as an “iteration machine” that has made us exactly who we are while at the same time not allowing that understanding to turn us fatalistic. Like so many things, the past makes for a good servant but a bad master.

To the extent that our past helps us, we must capitalize on it. To the extent that our past haunts us, we must — as the poem says — let it burn.

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.

This moment’s vanished down the hatch Like every now before it Distracted by our daily catch We mortal fools ignore it.

Our human cloth unraveling To lastly leave us naked The show with which we’re traveling Bestows life then retakes it.

The candle on my tabletop First flickers smart and cheerful When exhausted to its final drop Leaves me bereft and tearful The message of this meter isn’t To carouse or practice Spanish Whether hedge fund king or peasant All you adore will vanish.

The lesson from my candle A moment at a turn The present we can handle The past we must let burn.

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Risk Management

Malpractice Case Shows Risk From Physician Not Dating and Initialing Reports

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

20 decem b er 2013

Physicians must be certain that there is a process in place to ensure that no imaging, laboratory, or consultant’s report is ever filed unless it has been dated and initialed by the physician as proof that it was reviewed. Many medical liability claims would be prevented by this simple policy.

It is also important to create a suspense file or EHR followup list for all ordered imaging studies, laboratory tests, diagnostic procedures, and consultations to ensure that they were completed and that the physician reviewed the reports.

The following case is an example of a “perfect storm” that led to a malpractice claim: A patient over the age of 50 was referred by the primary care physician to an orthopedist for evaluation of a two-year history of low-back pain. The orthopedist ordered X-rays, which showed a questionable

lytic lesion measuring 6cm in diameter in the right iliac bone just superior to the acetabulum.

The orthopedist’s routine was to personally review his patients’ X-rays, which he did in this case, but he focused on the lumbar spine and did not see the lytic lesion. The radiology report was sent to the orthopedist’s office and filed without his review. No office policy existed to ensure that reports were to be filed only after he had initialed and dated them.

An X-ray taken eight months later again showed the large lytic lesion in the pelvis. The orthopedist reviewed the films and again missed the lytic lesion. The radiology report was not found in the orthopedist’s file.

Four months later, the orthopedist performed an L5 laminectomy. Follow-up X-rays again noted the expansile lytic lesion. These films were reviewed by the orthopedist, who focused on the operative site in the lumbar spine and failed to see the lesion. The radiologist’s report was faxed to his office and filed; it had not been brought to his attention.

An MRI done one month later showed a lobulated, expansile lesion in the pelvis, suspicious for low-grade chondrosarcoma. The radiologist phoned the orthopedist to discuss the findings — it was the first time the orthopedist realized that an abnormality was present.

The patient was immediately referred to a major medical center, where the patient underwent partial resection of the pelvis and hip with amputation of the right leg. A claim was filed alleging failure to appreciate the presence and significance of a lesion diagnosed as chondrosarcoma more than three and a half years after it was first noted in the filed radiology reports.

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Personal & Professional Development

The Inspiration of the Holidays — and Every Day — at Our Fingertips

by Helane Fronek, MD, FACP, FACPh

The holidays are upon us — complete with parties galore, gifts to give and receive, warm times with family and friends.

Images of festive gatherings with good food and joyful moments fill our minds.

So why is it that so many of us dread the holidays?

Whether we have a religious or spiritual orientation or perceive the season to simply be a time to exchange presents, it’s easy to become overwhelmed with the sheer number of events, the stress of finding the “right” gift for the many special people on our lists, the heartache of missing loved ones who are no longer with us, and the inescapable, nonstop marketing. How can we restore a sense of the wonder of the season and find the enjoyment and magic that the holiday season is supposed to hold?

Actually, it’s simple. When the very wise physician Rachel Naomi Remen, MD, realized that she and her colleagues had become estranged from the reasons they had decided to become physicians, from the heart of medicine, she devised three questions that have the potential to bring us back to the joys and meaning that surround us each day. As we wind down each evening, we can ask ourselves:

What surprised me today?

What moved me or touched my heart today?

What inspired me today?

22 decem b er 2013

Recently, I was surprised when a grocery store checker declined to charge me for a box of firelogs. I had purchased the same box 30 minutes earlier but forgot to put it in my car, leaving it at the bottom of my grocery cart. Frustrated upon realizing what I had done, I drove back to the store to find the cart where I left it, but someone had taken the firelogs. Although I insisted that I should pay because it had been my error, the checker simply smiled and handed the new box to me. What kindness and compassion from someone who clearly understood that we all have distracted moments.

Later, I worked with a physician client as she struggled to find the best way to help one of her residents communicate more effectively with patients.

I was touched that she felt so passionate about helping this doctor-in-training become the best physician she could be, and was willing to spend extra time and risk having an uncomfortable conversation in order to accomplish this. What a noble profession we are part of!

Finally, I spoke with a medical student who had overcome his initial discomfort speaking with patients and had become a sincere, present, caring medical professional whose patients now felt safe sharing their vulnerabilities. It was inspiring to watch his bravery and concern as he inquired about his patient’s safety, and offered his help and reassurance. It made me wonder where I might stretch my own capabilities. His effort gave me the inspiration and courage to leap into some new things myself.

So why not take a few moments each evening to consider these three simple questions? It just might make for your happiest holiday season ever.

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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//////////////////////////////////////////////// The Importance of Not

Forgetting Retired Physician Leaders of SDCMS Take a Look Back

Roundtable Participants: Ralph R. Ocampo, MD (SDCMS-CMA member since 1967) Allan H. Goodman, MD (SDCMS-CMA member since 1970) Anthony J. Pierangelo, MD (SDCMS-CMA member since 1954) Lynn Sheffey, MD (SDCMS-CMA member since 1974) David M. Priver, MD (SDCMS-CMA member since 1980) John S. Hattox, MD (SDCMS-CMA member since 1952) Kevin P. Glynn, MD (SDCMS-CMA member since 1971) Matthew C. Gleason, MD (SDCMS-CMA member since 1959)

24 decem b er 2013

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O

On Nov. 5, 2013, San Diego Physician invited eight retired SDCMS physician leaders to meet for lunch and take a look back at their careers in medicine, recalling exciting medical developments they witnessed, discussing how the doctor-patient relationship has changed, commenting on current trends they believe to be important, and imparting words of wisdom to their younger colleagues. The following is a transcript of that discussion.

DR. OCAMPO: Welcome all. For the benefit of our admiring public, I think we need to go one by one, introducing ourselves.

Tell us who you are, what you specialize in, and how long you worked in San Diego.

DR. GOODMAN: Allan Goodman. I’m in the field of cardiovascular and thoracic surgery. I’ve been in San Diego all my life — I literally grew up here. In fact, I always remember my very first exposure to medicine was my tour of this brand-new hospital they had just built — it was Sharp Memorial — and my junior high school class took a tour of that building.

DR. PIERANGELO: I’m Tony Pierangelo, and I did general practice in South Bay since 1952. I came here first with the Navy in 1944, but I didn’t really know anything about San Diego at the time. I came back in ’52 to do a year’s residency in OB at Mercy Hospital — at that time, they had the largest OB service in the country, taking care of the Navy.

DR. SHEFFEY: My name is Lynn Sheffey, and I came to town in 1969. I was in family practice in Escondido for just about 40 years. I’ve been retired about six years now. I was involved in the Medical Society mainly in the ’80s and early ’90s and was president in 1989.

DR. PRIVER: I’m David Priver. I’m an OB-GYN. We came here from Michigan in 1979, and one of the very first things I did was to find out how you joined the Medical Society; I’ve always felt that we need to work together if we’re going to improve

what we do and interact well. I was president in ’96. Well, actually, no, ’97, but my predecessor moved away about a month or two into his term.

DR. HATTOX: I’m John Hattox, anesthesiologist. My first exposure to San Diego was as an intern at the Naval Hospital in 1945. Never dreamed I’d be back some day, but I came back in ’51 for good and practiced here for what ultimately was a very large group of anesthesiologists: Anesthesia Services Medical Group. I feel so fortunate to have been a part of San Diego and the medical world.

DR. GLYNN: I’m Kevin Glynn, and my field was pulmonary medicine. I came here in 1969 and practiced in the Hillcrest area mostly, Mercy Hospital, until I retired from seeing patients in 2003. I’ve never been the president of the Medical Society. All the things that I did were as an appointed chairman or editor of San Diego Physician or something like that, so I feel like I’m with the brass today.

DR. GLEASON: I’m Matt Gleason. After my internship and residency over at the old County Hospital, before it was UCSD, I looked around. There were two neurosurgeons in town, and there was only one plastic surgeon, so I thought, well, they got plenty of neurosurgeons — I’ll just pick plastic surgery. I remember being on the 9th floor of the old medical-dental building at 233 A Street, looking out, and saying, “Here I am San Diego.” At that time the emergency rooms did not have full-time physicians, so it was very easy to get started by going to the emergency rooms. I became president of the County Medical Society in ’74.

DR. OCAMPO: It’s fitting that you should end this, Matt. You were one of my attendings when I started my first year of surgical residency at the old County Hospital in 1960.

DR. GLEASON: I remember you were a smart aleck then.

DR. OCAMPO: I was born at Paradise Valley Hospital, delivered by a physician, J.W. Erkenbeck, who became a member of this Society in 1918. I’m a general and vascular surgeon, and I practiced from about 1966 to 2002. I worked 20 hours a week for UCSD’s new medical school transitioning

SAN DI EGO PHYSICIAN.org 25

//////////////////////////////////////////////// years ago, out “40 of every 1,000

residents that were in the general surgeon programs, about 200 went into subspecialties like neurosurgery, plastic surgery, etc., and today it’s just exactly the opposite. Now you have 200 general surgeons left out of 800 who go into all of the lifestylebeneficial surgical specialties.”

from the old County Hospital to UCSD. That’s enough of these formal introductions. Now, even though you have a list of topics to look at, feel free to interrupt anybody, to switch topics, anything that comes to your head. Kevin, lead off on the first question, which is: What are the most exciting medical developments you’ve seen during your career?

DR. GLYNN: Well, on the diagnostic side, endoscopy. Then the development of respiratory care, which went from some guys in work overalls with a monkey wrench unscrewing the valves on oxygen cylinders to very complicated ventilator management. Pulmonary medicine has changed so much. They now have what they call invasive pulmonologists who, through various endoscopic devices, do biopsies and things like that.

Another trend has been the evolution of biomedical ethics, which was mostly, did you split fees or advertising, things like that. Now there are very complex decisions relating to what’s right and what’s just, what people are entitled to, what’s going to prolong pain, and what’s really best for the patient.

The final trend is that, when we started out, we did what the people who trained us taught us to do. And lots of times that just went back to whoever trained them. Obviously, a lot of it didn’t really work, but nobody knew — you just did what you had been taught to do. Now the emphasis is on doing things that have been validated by forwardlooking trials and so-called evidence-based medicine. That’s a double-edged sword because each human being is unique, and some people just don’t fit into the mold, but certainly the thrust has been toward socalled evidence-based medicine.

DR. OCAMPO: The second question is, how have patients changed over the time you’ve been in practice? How have you seen the doctor-patient relationship change?

That is absolutely key to what a family physician does — maybe Lynn wants to chime in on that.

DR. SHEFFEY: I think patients are definitely more educated now, probably less likely to just accept the doctor’s word for things. A few generations ago, the doctor may have been the only educated

26 decem b er 2013

person around, and the doctor’s word was accepted. The doctor wasn’t always right, but I think patients understood that he or she couldn’t be perfect. I think doctors now are not considered as having the final word necessarily because patients have the Internet. We come into the office and they tell us, “Oh, I’ve researched this on the Internet, and this is what I need.” Basically, a lot of patients come in and tell the doctor what they need, so the doctor is not the authority as in past years.

DR. PRIVER: The evolution that I’ve been impressed with, and I’m not sure always in a positive sense, has been the development of group practices. I would almost guess that all of us started off as solo practitioners because that’s pretty much what you were trained to do. And almost nobody does that anymore. Now there are group practices, and so, the question is, is this a good thing or a bad thing?

I can tell you that in my particular specialty, OB, the hours were deadly, and a lot of people burned out at a much younger age than they should have because of that. Getting into a group enabled a little bit more division of labor. Sometimes the patients didn’t care for that, you know, they come to your office, they see you every month, they just naturally assume, comes the labor, you’ll be there. But I will tell you, I don’t think any OB practices work that way anymore. In a way, I kind of miss it because you develop that close rapport.

DR. OCAMPO: How do you perceive the economics as working out in the transition from individual practitioners to groups?

Favorably or unfavorably for physicians, for instance?

DR. PRIVER: Probably favorably because you can be more efficient at what you do, presumably. At least I’m talking mostly about my area.

DR. GLYNN: What David brings up has a lot to do with a megatrend that I forgot to mention and that’s the advent of female physicians. When all of us went through medical school, probably 1% of our class were women, and now it’s the majority.

And OB-GYN, I don’t know the statistics, David, but what percentage of contemporary obstetricians are women themselves?

//////////////////////////////////////////////// DR. PRIVER: I do a little bit of teaching of the residents at UCSD, and at least 90 to 95% are female now.

DR. HATTOX: The advent of nonphysicians into the medical decision-making process is a major thing that I predict is going to only accelerate. And you’re going to see in the next 10 or 15 years some amazing things from creating a whole competitive atmosphere.

I’ll give you an example of what I’m talking about. We don’t have in San Diego nurse anesthetists except at UCSD and Kaiser. Now, nationally, there is a huge push by the American Association of Nurse Anesthetists to change all of this, and one of the things that they’re doing, for example, is they’ve been able to persuade the Veterans Administration that there is absolutely no need for doctor input into the process of anesthesia. We’re having a big battle nationally because of this, and that’s Project4:Layout 1

9/22/08

11:22 AM

going to accelerate, in my opinion, not just in anesthesiology but across the board.

DR. GOODMAN: It might even be more accelerated by the current economics because the way they’re designing healthcare — and we’re hearing about it very actively now — there’s going to be less dollars available, and how can they pay less dollars?

They can pay the dollars to allied health professionals instead of the doctor.

DR. GLEASON: Along this line, for the past seven years now I’ve been working for the state of California Social Security Administration, and as part of that I belong to the union of physicians and dentists, which has really done a very good job for the physicians who work for the state and federal government. I can see this as something that physicians are going to do more and more, in other words, to start forming into some kind of unions like that because it’s Page 1

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//////////////////////////////////////////////// only when you have a large group behind you that you’re able to sit down with the one person who tells you what to do, which is usually the government, and come to something at least that protects physicians, including no podiatrists doing hip surgeries, no dentists doing facelifts and noses. The only way we are going to make it is really by joining together.

DR. OCAMPO: One of the topics that I should comment on, because it’s happening to general surgeons more than any others federally, is the great decrease in numbers of general surgeons, now, in San Diego. Because we’re such a large urban society, that’s not a problem, but in communities of 60 to 80 to 100,000 people, you just can’t have all the subspecialties. It’s become a real problem.

In terms of general surgeons, 40 years ago, out of every 1,000 residents that were in the general surgeon programs, about 200 went into subspecialties like neurosurgery, plastic surgery, etc., and today it’s just exactly the opposite. Now you have 200 general surgeons left out of 800 who go into all of the lifestyle-beneficial surgical specialties.

Obviously, when you’re a general surgeon, you have a role to play in an urban community, but a lot of that has turned out to be trauma. A lot of what general surgeons were trained for, which is to provide a general service to relatively rural communities, now they’re becoming more and more trauma surgeons. This is a big concern

for the national organization, the College of Surgeons, in terms of how is the United States going to service local communities with adequate, good-quality services if they’re not turning out people that are more generalists, family physicians, and so on?

DR. GOODMAN: My proudest accomplishment as a doctor is that I conceived the idea that in cardiovascular surgery, cardiac surgery in particular, we needed what I call centers of excellence. I went into Dean Crowder’s office — he was the administrator at Sharp — and said, “Dean, we’ve got to become a center of excellence in cardiac disease.” And Dean said to me, “You know, I’ve got to find out what is a center of excellence. I’ve got to go to a place that is a center of excellence.”

Because he had a friend who was an administrator, he went back to the Peter Bent Brigham in Boston, now the Brigham and Women’s Hospital, spent two weeks there, came back, and he said, “You’re right, let’s do it.” That was the root of the development of the cardiac program at Sharp.

I initiated the same idea at Rady Children’s Hospital, and am very proud of the wonderful cardiac disease program there, which is known as one of the outstanding programs in our country.

In terms of medical developments, the field of cardiovascular disease has so changed and become so excellent that you wouldn’t recognize it if you went back to our original times. Witnessing that has been a thrill.

told me once that engineers in the “Somebody 19 century were mostly solo practitioners, so to th

speak. They had offices where they offered their services, but with the late Industrial Revolution, with skyscrapers, automobiles, and railroads, these big companies began to hire engineers, and independent engineers now are a very small group. I think medicine is headed that way.”

DR. PRIVER: I’d like to change the topic a little bit and talk about organized medicine in general and the San Diego County Medical Society specifically. You know, some of us served in leadership capacities, and I mentioned a while ago the evolution of group practices. When I was president, we were really up against the issue of how are we going to sustain our membership?

Because, as these groups congealed, they began to see less need for organized medicine. They had their reinforcements with one another through their groups to the exclusion of organized medicine.

We began to see our membership dropping, so I and some of the councilmembers decided that the time was right to approach groups and talk about the concept of group membership. This was very, very controversial, and did not sit well. Anesthesia Services Medical Group was the original one, and they still are group members, but they are such at a reduced dues payment. Those of us who were in a solo practice were not getting a reduced dues payment; you were still paying the full freight. I got a lot of grief from this, and all I can say in response to it is, if we get enough increased volume of members, and we have an increase overall in our income, everybody can pay less. That’s been 20 years ago. Group membership is a reality nowadays, and you could argue that it’s unfair to the solo affiliated, but I don’t see how else organized medicine can survive.

DR. GLYNN: I never saw Anesthesia Services Medical Group as the same thing as Rees-Stealy or the Mayo Clinic. [Pointing to Dr. Hattox] You guys were all anesthesiologists. You covered most of the hospitals in town, but it was in that one specialty. The fees, how many dollars an hour you got per case, was pretty much uniform. I’ve tried to get a multispecialty medical group going at Mercy, and it fell on its face.

DR. GOODMAN: That’s what the Mayo Clinic learned in Jacksonville. They didn’t want to experience that in San Diego, when I tried to encourage them to come.

DR. GLYNN: But at the Mayo Clinic I think the doctors are paid by salary, and, as far as I know, they worked as hard as anybody else.

DR. GOODMAN: But they grew up with that philosophy.

28 decem b er 2013

//////////////////////////////////////////////// they leave residency and they come into the group, and that’s what they know — they can live with it. If they leave residency and go into practice and then join a group, it’s a different ballgame.

DR. GLYNN: That is important too, isn’t it? It’s a culture.

DR. GOODMAN: Well, doctors are sometimes difficult to deal with as a group [Everyone laughs].

DR. HATTOX: I’d like to talk about the development of outpatient surgery. You know, that was almost unheard of when we went into practice. There were two guys by the name of Wally Reed and John Ford in Phoenix — both of them I knew. They had started the first ambulatory surgical center, and they did it because for a simple DNC the hospital required that they be admitted the day before, operated, and you couldn’t be discharged until the second day for a simple DNC. Well, my two friends said, “This is ridiculous; let’s build a place and do it.” And they really made it work.

I visited them about a year after they opened. I said, my God, this is the way to go! So I came home and I had the bright idea

DR. GLYNN: I think that this is something that has changed, and that the younger physicians, the generation after us, or two generations after us maybe, don’t see it that way. Somebody told me once that engineers in the 19th century were mostly solo practitioners, so to speak. They had offices where they offered their services, but with the late Industrial Revolution, with skyscrapers, automobiles, and railroads, these big companies began to hire engineers, and independent engineers now are a very small group. I think medicine is headed that way.

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//////////////////////////////////////////////// that the way to make this work would be within the hospital, and I did that at Sharp.

We set aside a single operating room. Separate admission. Got everybody to cooperate, including pathology to get the lab done early so the patient would be admitted about an hour before surgery, get all the work done, have their surgery, and they can go home!

Well, that worked fine within the hospital, but I finally discovered that the hospital was in charge of what the patients got charged. I discovered that the patients weren’t saving any money. The insurance companies weren’t saving any money. They still got charged full board as though they had been in the hospital. I remember going to the executive medical board meeting and explaining to the president what had happened — they had appointed me chair of the committee to deal with this. I said I’m offering my resignation.

I laid out why we got this all started, in addition to basic convenience, and that’s when I began to deemphasize the hospital.

I had all these people like Hugh Dickinson, people across the street, say, “Come on build one over here.” Well, before we could do that, I decided we’d build one — I was practicing at Pomerado Hospital those days.

We’d set aside a single operating room in an office building and see if we could make it work. We were able to make it work, and went of course across the street from Sharp.

We ultimately had an eight-operating-room facility. Anyhow, I think that was a pretty significant change in the way medicine was

practiced, and certainly in the way surgery was practiced.

DR. SHEFFEY: Tony and I were both in family practice, general practice, and I was thinking back to when I started, and when you started, Tony, many years before me. I was thinking of how medicine changed for us in family practice, some of the things that we did. We delivered babies and took care of newborns. We took care of orthopedic problems, set bones, put casts on, treated leg fractures, ankle fractures, finger fractures, foot fractures, clavicle fractures. We took care of very sick patients in the hospital. We had consultations when necessary. We took care of poisonings in the office, concussions.

It’s not like that anymore. These patients, when they get sick, they head straight for the emergency room, and the family practitioner is kind of out of it.

DR. HATTOX: Do you miss those days when you were doing everything? That had to be the most satisfying time in your professional life when you were taking care of all of the patient.

DR. SHEFFEY: Yes. DR. PIERANGELO: One of the bigger problems we had in the South Bay is we couldn’t get specialists to come down. As an anecdote, a colleague and I one time had a fellow admitted with a perforated ulcer on New Year’s Eve. We could not get a surgeon

thinking of how medicine changed for us “Iin was family practice, some of the things that we did.

We delivered babies and took care of newborns.

We took care of orthopedic problems, set bones, put casts on, treated leg fractures, ankle fractures, finger fractures, foot fractures, clavicle fractures.

We took care of very sick patients in the hospital.

We had consultations when necessary. We took care of poisonings in the office, concussions. It’s not like that anymore.”

30 decem b er 2013

to come down to Chula Vista to see this guy. And we’re stuck! What do we do? Tom looks at me and says, “Have you ever done a perforated ulcer?” I says, “No. How ‘bout you?” “No.” We’d assisted. But, anyway, we ended up having to do it. Luckily the perforation was staring us right in the face when we cut through the skin. We fixed it, and the guy recovered. And we never got paid. He was admitted to the hospital 30 minutes before his insurance went out.

DR. OCAMPO: We’ve only got about five minutes left. Maybe each one of you can express your hope for the future — both of the profession and the patients we serve.

Let’s start with Allan.

DR. GOODMAN: My hope is that the quality of the doctors will remain good.

That the principle that the patient is the important thing will remain. I think I see too much of this business, I got to do procedures, I got to do procedures. I think it’s the focus on the patient that’s important.

I hope, as well, that we see the development of sophisticated work as much as I’ve seen it in my specialty. I was there at the beginning of heart surgery, and I see what it is today, and I hope that we’ll see that in a lot of work in the hospitals — and with the support of the hospitals. The thing that concerns me is the hospitals today have a goal to take over medicine, and I hope that doesn’t destroy the …

DR. OCAMPO: That was their goal a hundred years ago too by the way.

DR. GOODMAN: But they’re closer to accomplishing it today. I just hope we can continue to see the doctors driving the ship.

DR. PIERANGELO: That’s been the mantra of medicine forever, and forever the nonmedical people encroach on medicine all the time.

DR. SHEFFEY: If I could give advice to young doctors, it would be when you go into the room to see the patient, don’t stare at the computer the whole time. Look at the patient. Get to know the patient. Talk to the patient about their family. You might even make it easier for patients to talk to the doctor or the nurse when the patient is at home.

//////////////////////////////////////////////// And remember that medicine is an exciting profession. Keep the excitement.

Be eager to learn more. Spend time trying to figure out what’s causing your patients’ problems. Study and try to learn. Don’t just automatically refer a patient that is a difficult diagnosis. Don’t be paralyzed by malpractice concerns, but make sure your decisions are logical and well thought out.

DR. PRIVER: I’m by nature an optimist.

Despite some of the huge challenges we face, I actually think things are going to get better, in two ways. I don’t know whether this Affordable Care Act is going to work, but we have to achieve universal coverage somehow, and I don’t care much how we achieve it. But I think that is going to happen in some way, shape, or form.

The other thing that I would encourage younger people who are now our leaders to do is communicate better with one another.

During my presidency I wrote an editorial

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to that effect. I don’t want to get a phone call from a ward clerk that says such and such doctor would like you to come up here and do a consult. There was a time that that doctor used to pick up the phone, and he actually called you and would tell you a little bit about the case. That does worry me that this sort of closeness and collegiality is not what it once was, but it needn’t disappear.

I say I’m optimistic because of my observation of the current leadership of this Medical Society. I think it’s attracting extraordinarily talented people, very committed people, who really do work extremely well with one another. I didn’t go to the CMA meeting this year, but in past years SDCMS has been the leadership of the CMA because they get together, they work, they figure out their strategies, and they communicate well to their colleagues around the state. So, I’m actually fairly optimistic about the future.



“My fondest wish for the men and women who succeed us is that they in fact pay a little attention to our history, that they use scientific medicine practiced in an ethical environment, and that they not forget who all of you are and what you did.”

DR. HATTOX: I recall a former president of the American Society of Anesthesiologists had a very famous quote that’s worth listening to. What it said was, “It’s all about the patient.” That’s why we exist. And I think sometimes we tend to forget that.

Save time on paperwork so Keep you canthat put uppermost in your minds, it’s all quality back into patient care. about the patient. We wouldn’t be around otherwise. And the idea of developing a tight relationship with your patient, I especially have a very limited opportunity Speak tranScribe create to doautomatically that. When you seerobust a patient, you’ve directly into your EHR patient records got to make every word count. Pay strict attention to the patient, and look them The fasT Track To a straight in the eye every second of the time. more profitable practice Make them believe that you’re interested Achieve meaningful in usewhat criteria, increase reimbursement levelsthey’re they’re thinking, and how going to react to the surgery they’re about to undergo. ® • More than 99% accurate out Dragon Medical Practice Edition 2 of the box the most efficient way for medical DR. GLYNN: The wheels have medical been turn• Over 90 specialty professionals to speech-enable their ing as to the comments vocabularies EHR and create more accurate andI’ve been listening trend that I haven’t • 3x faster than typing complete documentation. by everybody. Another

talked about is the hospitalists, and • Accelerates adoption of Iallsee that continuing. For that work there remajor EHRtosystems ally need to be large multispecialty groups.

• Reduces unnecessary mouse clicks and keystrokes doctors The separation of the office-based and the surgical specialists and medical

SAN DI EGO PHYSICIAN.org 31

//////////////////////////////////////////////// find that the “Istudents are really

very well educated, very brilliant, well spoken, who have the optimism that we all had at one time. And I think that they are going to do whatever they’re going to do to make surgery, and medicine in general, continue to thrive.”

specialists and so forth, they have to be in the same group and have the opportunity to communicate, I think, because medicine is much more complicated than it was when we entered practice 40 or 50 or 60 years ago.

But I’m optimistic because of the fact that as long as there are people that want to help people that are sick, physicians are always going to be needed. I think the outlook is good. Although right now it sounds like the pressures that are on office-based primary care physicians are awful, and I don’t know that I’d want to do that right now. But I have to be optimistic that something will happen that will make it work.

DR. GLEASON: I think that one of the advantages that I have is that I continue to go to UCSD and the Division of Plastic Surgery, and give the occasional lecture to the students that are going through the plastic surgery division. I find that they are really very well educated, very brilliant, well spoken, who have the optimism that we all had at one time. And I think that they are going to do whatever they’re going to do to make surgery, and medicine

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32 decem b er 2013

in general, continue to thrive.

They’ll learn how to do it. They’ll get out into practice, whether it’s for a big organization or for individuals, they’re all going to do the same thing that we did.

I think that they’re learning to live with government — that’s all they’ve known about is the government. And that doesn’t mean they’ll go along with it. I think physicians are always going to resist things, and that’s what brings us together. When we get a problem, usually a government problem, we join hands and then find a way out of it. We have a lot of experience here. The students will kind of think this is where the future is and it is. I don’t worry about the future.

DR. OCAMPO: Thanks, Matt. My fondest wish for the men and women who succeed us is that they in fact pay a little attention to our history, that they use scientific medicine practiced in an ethical environment, and that they not forget who all of you are and what you did.

Now I want to give you all a hand of applause.

//////////////////////////////////////////////// Second Annual

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Efficient, hard working, team player with compassion towards patient care is expected. Ability to use computerized EHR is important. Weekly / biweekly education program, including specialists’ topic discussion as well as patient case presentation are provided. Hard work, dedication, compassion, and communication skills are required. Job satisfaction will be guarantied. Willingness to participate in patient care at Grossmont Hospital and skilled nursing facilities is preferred. Internal medicine work experience is desired; compensation is competitive. You can apply with your CV to vprabaker@yahoo.com. [176] 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] 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, highquality 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) 876-4426. To apply, visit our website and apply online at www.fhcsd.jobs. [046] 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 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] 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 For Sale EVER DREAM OF BEING YOUR OWN BOSS? Private practice internal medicine physician on the campus of Scripps Memorial La Jolla looking for board-certified internist to take over his practice when he retires. Currently sharing campus office

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

34 decem b er 2013

space and overhead with another internist who will be continuing to practice. Exciting opportunity, as the campus is expanding and building a new stateof-the-art Cardiovascular Institute set to open in 2015. Various arrangements available. Please email nev@san.rr.com for information. [189] PRACTICE WANTED WE BUY URGENT CARE OR READY MED-CLINIC: We are interested in purchasing a preexisting urgent care or ready med-clinic anywhere in San Diego County. Please contact Lyda at (619) 4179766. [008] OFFICE SPACE / REAL ESTATE AMAZING PRIMARY CARE OPPORTUNITY IN OLD DEL MAR: Available suites with 1,000–6,000 sq. ft. of doctor-ready medical space located one block south of the Del Mar Plaza on Hwy. 101. Location boasts a 50-year medical office history.

Current primary care with over 12,000 patients is moving, providing the opportunity to coattail and capture a significant patient load. Building complex currently includes numerous specialists, PT, X-ray, and dentists. Parking is ample and lease rates are extremely competitive. Establish yourself in this proven location in the desirable community of Del Mar. Contact Richard at richcardow@yahoo.com or call (858) 755-2345 for more information. [183]

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

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 UTC/LA JOLLA MEDICAL OFFICE SPACE TO SUBLEASE: Spacious, modern, brand new and fully furnished medical suite with beautiful reception area and waiting room, two exam rooms, and one window doctor’s office / consultation room.

(Also space for 2 office staff and 1 med tech of your own.) Available for sublease either half day or whole day. Ideal for primary care or specialist.

Some space available for storage of your materials. Amazing location across from the UTC Mall on Executive Drive near the 5, 15, and 805. Reasonably priced. Please contact Miriam at (858) 9979727. Available November 1, 2013. [179]

SPACE AVAILABLE TO SUBLET: Space available in suite with busy internal medicine practice located in Escondido. Exam rooms and office space. Call (760) 432-6886, ext. 354. [178] BANKERS HILL PRIMARY CARE AND RESEARCH OFFICE SPACE TO SUBLEASE: 50year established primary care practice and clinical research office with currently two internists has space to sublease to another primary care MD (internal medicine or subspecialties / family practice) to help curb overhead and see acute overflow patients. Also can provide opportunity to get involved with clinical research. Flexible terms/space. Free parking, close to hospital, easy access to freeways.

Contact Cindy at allmedgrp@hotmail.com. [146] 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) 944-1000, 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] 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] 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]

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) 5210806 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) 5045830. [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]

1-2 days per week in our Encinitas office. Experience with coding details and orthopedic/pain billing a plus. Please reply with resume and letter of interest: ssbunyak@hotmail.com. [182] PSYCHIATRIC NURSE PRACTITIONER OPPORTUNITY: South Bay private practice seeking licensed psychiatric NP with a minimum three years experience to work with psychiatrist in hospital and nursing home settings. Current license is required. Please submit CV to (619) 327-0164 or send to drbhatia@phwsd.com. [180] LOOKING FOR NP OR PA: Busy internal medicine practice located in Escondido looking for NP or PA. Call (760) 432-6886, ext. 354. [177] 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]

NONPHYSICIAN POSITIONS AVAILABLE / WANTED MEDICAL EQUIPMENT EXPERIENCED, PART-TIME BILLER/CODER FOR SPORTS/SPINE/PAIN PRACTICE (ENCINITAS): Growing medical practice seeks experienced, motivated, consistent biller/coder to work

NEOMATRIX HALO BREAST PAP TEST CONSOLE: Excellent condition. One owner in private GYN practice. Call (619) 220-0999. [174]

Place your ad here Contact Dari Pebdani at 858-231-1231 or DPebdani@sdcms.org

POWAY / RANCHO BERNARDO — OFFICE FOR SUBLEASE: Spacious, beautiful, newly renovated, 1,467 sq-ft furnished suite, on the ground floor,

SAN DI EGO PHYSICIAN.org 35

Office Manager Advocacy

Congratulations Pat Russell San Diego County’s Outstanding Medical Office Manager for 2013!

Nominated by Internal Medicine Associates: Paul F. Speckart, MD, Raymond G. Pigeon, MD, Deanna K. Price, MD, Brian J. Lenzkes, MD, and Theresa R. Bohun, MD

L–R: Brian Gerwe (SDCMS Director of Recruiting and Retention), Katie McLaughlin, DNP, Paul Speckart, MD, Brian Lenzkes, MD, Pat Russell, Theresa Bohun, MD, Raymond Pigeon, MD, and Deanna Price MD

Dear SDCMS, When we read the SDCMS “News You Can Use” newsletter that detailed the search for the Office Manager of the Year, we were immediately compelled to nominate our office manager, Ms. Pat Russell. Pat has been an absolute blessing to our office and staff and has played a key role in our recovery from a financially

Previous Medical Office Manager Winners

36 decem b er 2013

and emotionally devastating embezzlement case.

Ms. Russell accepted the position of office manager at a very difficult time in our office’s illustrious history.

Unknowingly, within days of her hire, Pat would help us to discover long-term fraudulent behavior executed by our previous office manager. Pat’s new job acceptance placed her in the midst of an extremely

difficult financial storm almost immediately. Accounting irregularities, wasteful purchasing policies, low staff morale, poor staff management, and more would have made any new hire flee. However, Pat’s commitment to us never wavered, even when more bad news surfaced seemingly on a daily basis.

Hoping to simplify her life, Ms. Russell left a large healthcare system desiring to work in a small office environment like ours. When the unexpected happened, she met this burdensome challenge head-on. We witnessed Pat incorporate basic survival skills, industry knowledge, grace, and a degree of professionalism we have rarely seen. Pat accomplished much of this task with a fierce determination that our patients would not suffer from this taxing distraction.

Many of the complicated tasks Pat was involved in included: • assisting with a timeconsuming criminal investigation • reviewing and streamlining every existing business/ purchasing contract • working with forensic accountants to repair the

fraudulent habits of our previous office manager • working with our bank and pension officials to meet our pension obligations • improving employee evaluation procedures, job descriptions, salaries, and vacation/sick-time ledgers After months of daily bad news and heartbreaking discoveries, we have returned to a financially secure office with a confident and content staff. With Pat’s assistance, we were able to accomplish this in a remarkably short timeframe, something that was inconceivable to us last year. Our office is running with tremendous efficiency, our employees are happy to have a consistent and stable advocate, and, most importantly, we have been able to maintain the high level of patient care we pride ourselves in. Pat Russell has played a vital role in the revitalization of our office.

In summary, the nomination of Ms. Pat Russell for Office Manager of the Year is an easy one. She entered into a situation that she did not sign up for but has displayed all of the characteristics of an exemplary professional, a talented and capable office manager, and a genuine friend.

We appreciate her takecharge attitude, her fair and compassionate approach, her tireless professionalism, and her unwavering commitment to our patients’ well-being. We cannot imagine anyone more deserving of this honor.

Sincerely, The Physicians of Internal Medicine Associates

2012 Carol Carney

2011 Robert O’Meara

2010 Sue Rose

2009 Anne Billeter

Nominated by E.L. Sakas, MD (SDCMS Member Since 2005)

Nominated by Irwin Goldstein, MD (SDCMSCMA Member Since 2007)

Nominated by David J. Bodkin, MD (SDCMS-CMA Member Since 1990)

Nominated by John A. LaFata, MD (SDCMS-CMA Member Since 1981)

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

PRSRT STD U.S. POSTAGE

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[ Return Service Requested ]

We reward loyalty. We applaud dedication. We believe doctors deserve more than a little gratitude.

We do what no other insurer does.

We proudly present the Tribute® Plan.

We honor years spent practicing good medicine. We salute a great career.

We give a standing ovation. We are your biggest fans. We are The Doctors Company.

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

You deserve more than a little gratitude for a career spent practicing good medicine. That’s why The Doctors Company created the Tribute Plan. This one-of-a-kind benefit provides our long-term members with a significant financial reward when they leave medicine. How significant? Think “new car.” Or maybe “vacation home.” Now that’s a fitting tribute. To learn more about our medical malpractice insurance program, including the Tribute Plan, call our Los Angeles office at (800) 852-8872 or visit www.thedoctors.com/tribute.

www.thedoctors.com Tribute Plan projections are not a forecast of future events or a guarantee of future balance amounts. For additional details, see www.thedoctors.com/tribute.