January 2014

“Physicians United for a Healthy San Diego”

official publication of SDCMS January 2014

San Diego County’s

Emergency Departments Getting Bigger and Better

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

B

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

Gregory Stein, M.D., MBA ‘06 Curtana Pharmaceuticals, Inc. Chief Executive Officer “The Rady School gave me the requisite tools and know-how I needed to be successful in business as a life sciences executive and entrepreneur. My Rady experience got me plugged into the life sciences community and on my way to a new career.”

Jan.

Contents

Volume 101, Number 1

features SAN DIEGO’S EMERGENCY DEPARTMENTS: 2013 SURVEY RESULTS

24 The Results of San Diego’s 2013 Emergency Department Survey

BY RONEET LEV, MD

departments 4 Calendar • Welcome New & Rejoining Members! • In Memoriam • And More …

8 Physicians Stand to Defend MICRA as Threat Re-emerges

BY RICHARD THORP, MD

12

New Health Laws for 2014

BY THE CALIFORNIA MEDICAL ASSOCIATION

18

Choosing Wisely: Five Things Physicians and Patients Should Question

8

BY THE AMERICAN COLLEGE OF RADIOLOGY

20

Medical Clearance Does Not Clear the Patient or Physician of Risks

BY THE DOCTORS COMPANY

22 Three Simple Questions to Start the New Year off Right

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 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) GEOGRAPHIC AND GEOGRAPHIC ALTERNATE DIRECTORS EAST COUNTY: Venu Prabaker, MD, Alexandra E. Page, MD, Jay P. Mongiardo, MD (A: Susan Kaweski, MD (CALPAC Treasurer)) HILLCREST: Gregory M. Balourdas, MD, Thomas C. Lian, MD (A: Sunny R. Richley, MD) KEARNY MESA: Jason P. Lujan, MD, John G. Lane, MD (A: Anthony E. Magit, MD, Sergio R. Flores, MD) LA JOLLA: Geva E. Mannor, MD, Wayne Sun, MD (A: Lawrence D. Goldberg, MD) NORTH COUNTY: James H. Schultz, MD, Eileen S. Natuzzi, MD, Michael A. Lobatz, MD (A: Anthony H. Sacks, MD) SOUTH BAY: Reno D. Tiangco, MD, Michael H. Verdolin, MD (A: Elizabeth Lozada-Pastorio, MD) AT-LARGE DIRECTORS Jeffrey O. Leach, MD (Delegation Chair), Karrar H. Ali, MD, Kosala Samarasinghe, MD, David E.J. Bazzo, MD, Mark W. Sornson, MD (Board Representative), Peter O. Raudaskoski, MD, Vimal Nanavati, MD (Board Representative) AT-LARGE ALTERNATE DIRECTORS Karl E. Steinberg, MD, Phil Kumar, MD, Holly B. Yang, MD, Samuel H. Wood, MD, Elaine J. Watkins, DO, Carl A. Powell, DO, Theresa L. Currier, MD OTHER VOTING MEMBERS COMMUNICATIONS CHAIR: Theodore M. Mazer, MD (CMA Vice Speaker) YOUNG PHYSICIAN DIRECTOR: Edwin S. Chen, MD RESIDENT PHYSICIAN DIRECTOR: Jane Bugea, MD RETIRED PHYSICIAN DIRECTOR: Rosemarie M. Johnson, MD MEDICAL STUDENT DIRECTOR: Jason W. Signorelli OTHER NONVOTING MEMBERS YOUNG PHYSICIAN ALTERNATE DIRECTOR: Renjit A. Sundharadas, MD RESIDENT PHYSICIAN ALTERNATE DIRECTOR: Erin Whitaker, MD RETIRED PHYSICIAN ALTERNATE DIRECTOR: Mitsuo Tomita, MD SDCMS FOUNDATION PRESIDENT: Stuart A. Cohen, MD, MPH CMA PAST PRESIDENTS: James T. Hay, MD (AMA Delegate), Robert E. Hertzka, MD (Legislative Committee Chair, AMA Delegate), Ralph R. Ocampo, MD CMA TRUSTEE: Albert Ray, MD (AMA Alternate Delegate) CMA TRUSTEE (OTHER): Catherine D. Moore, MD CMA SSGPF Delegates: James W. Ochi, MD, Marc M. Sedwitz, MD CMA SSGPF ALTERNATE DELEGATES: Dan I. Giurgiu, MD, Ritvik Prakash Mehta, MD AMA ALTERNATE DELEGATE: Lisa S. Miller, MD

BY HELANE FRONEK, MD, FACP, FACPH

34 Physician Marketplace Classifieds

36 2 jan uary 2014

36 Rain, Moonlight, and a Secret Password

BY DANIEL J. BRESSLER, 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.]

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

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

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

Covered California: What You Need to Know to Inform Your Patients (seminar/ webinar) FEB 13: 12:00pm–1:00pm Covered California for Physicians: What You Need to Know to Inform Your Patients and How to SHOP for Insurance for Your Practice (seminar) FEB 13: 5:30pm–7:00pm (dinner served) Covered California: How to SHOP for Health Insurance for Your Practice (webinar) FEB 19: 12:00pm–12:30pm Cal MediConnect From a Billing Perspective (seminar/ webinar) FEB 27: 11:30am–1:00pm C.U.R.E.S. Sign-up Event FEB 28: 9:00am–5:00pm

Cma Webinars CMAnet.org/events 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 HIPAA Security Risk Analysis: How to Make Sense of This Requirement MAR 5: 12:15pm–1:15pm

get in touch Community Healthcare Calendar

To submit a community healthcare event for possible publication, email KLewis@ SDCMS.org. Events should be physician-focused and should take place in or near San Diego County.

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 (taking place at the Del Mar Country Club; benefitting Project Access, which provides healthcare to those who need our help most; foursome: $1,000; individual players: $300; sponsorship opportunities available; contact (858) 565-7930 or visit http:// 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) 29 Annual New Treatments in Chronic Liver Disease MAR 28, 29, 30, 31 (www. scripps.org/events/newtreatments-in-chronic-liverdisease-march-28-2014) th

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

4 jan uary 2014

/////////////////////////////////////////Doctor’s /////////recommend ///////////////////////////////////////////////// micra defense

Individuals and Groups Donating to Defend MICRA

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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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SAN DI EGO PHYSICIAN.org 5

/////////briefly ///////////////////noted ////////////////////////////////////////////////////////////////////// SDCMS-CMA Membership

Welcome New and Rejoining SDCMS-CMA Members!

New Members Leonard R. Allmond, MD Anesthesiology San Diego (858) 565-9666 David J. Barnette, MD Dermato-pathology La Jolla (858) 554-9274 Timothy J. Barounis, MD Family Medicine San Diego (858) 657-7785 Adriana A. Bedoya, MD Anatomic Pathology San Diego (619) 528-5000 Chad M. Bernhardt, MD Emergency Medicine Carlsbad (760) 439-1963 William R. Bertucci, MD General Surgery San Diego (619) 528-5000 Krista G. Bockstahler, MD Anesthesiology San Diego (858) 565-9666 Dorothy W. Brown, MD Emergency Medicine Carlsbad (760) 439-1963 Abigail Buhain, MD Family Medicine San Diego (619) 528-5000 Kan P. Chen, DO Internal Medicine La Mesa (619) 528-5000 Stanley G-C Cheng, MD Diagnostic Radiology San Diego (619) 528-5000 Philip D. Cheung, MD Anesthesiology San Diego (858) 565-9666 Pengta A. Chiang, MD Emergency Medicine Carlsbad (760) 439-1963 Chien-Hsiang Chow, MD Anesthesiology San Diego (858) 565-9666

6 jan uary 2014

Reid F. Conant, MD Emergency Medicine Carlsbad (760) 439-1963 Brian M. Dicks, MD Urology San Diego (619) 297-4707

Ellyn S. B. Levine, MD Internal Medicine La Mesa (619) 567-6914

Don D. Palencia, DO Family Medicine Escondido (760) 741-1224

Julie W. Martin, MD Cardiovascular Disease San Diego (619) 528-5000

Yogesh V. Patel, MD Pain Management (Anesthesiology) San Diego (760) 753-7127

Sonali S. Master, MD Internal Medicine San Marcos (619) 528-5000 Cary R. Mells, MD Emergency Medicine Carlsbad (760) 439-1963

Beau V. Duwe, MD Pulmonary Critical Care Medicine San Diego (619) 528-5000

Wilford B. Mitchell, MD Emergency Medicine Carlsbad (760) 439-1963

Preston S. Gable, MD Hematology Oncology San Diego (619) 532-7300

Firoozeh Motamedi, MD Rheumatology San Diego (619) 528-5000

Steven M. Gabriel, MD Emergency Medicine Carlsbad (760) 439-1963

Donald H. Ngo, MD Anesthesiology San Diego (858) 565-9666

Judd L. Glasser, MD Emergency Medicine Carlsbad (760) 439-1963

Khoa H. Nguyen, MD Internal Medicine San Diego (619) 528-5000

Scott E. Greenway, MD General Surgery San Diego (619) 528-5000

Bismark Youngmin Oh, MD Emergency Medicine Carlsbad (760) 439-1963

Virgil A. Hilliard, MD Anesthesiology San Diego (619) 528-5000

Raveen T. Raviendran, MD Pediatric Critical Care Medicine San Diego (858) 565-9666 Eric J. Roeland, MD Hospice and Palliative Medicine La Jolla (858) 534-7079 Edward H. Sherer, MD Anesthesiology San Diego (858) 565-9666 Mona Singh, MD Nephrology San Diego (619) 528-5000 Alissa G. Speziale, MD Gastroenterology San Diego (858) 939-6531 Neil Tomaneng, MD Emergency Medicine Carlsbad (760) 439-1963 Gail T. Tominaga, MD, FACS General Surgery La Jolla (619) 270-4910

Juan C. Zorrilla, MD Emergency Medicine Carlsbad (760) 439-1963 Rejoining Members Ben DuBois, MD Orthopedic Surgery La Mesa (619) 462-3131 Sonya K. Christianson, MD Hospice and Palliative Medicine San Diego (858) 748-3030 Sieu P. Truong, MD Obstetrics and Gynecology Encinitas (760) 635-3777 Richard P. Burruss, MD Emergency Medicine Carlsbad (760) 439-1963 Paul F. Balen, MD Diagnostic Radiology San Diego (619) 528-5000 Diane L. Hutchison, MD Family Medicine Encinitas (760) 634-6922 Eva M. Runnman, MD Hospice and Palliative Medicine San Diego (619) 528-5000

Robert C. Huang, MD Infectious Disease San Diego (619) 528-5000 Stephen T. Kajdasz, MD Anesthesiology San Diego (858) 565-9666 Cynthia L. Kao, MD Hospitalist Encinitas (760) 230-2251 Stephen Karas, MD Emergency Medicine Carlsbad (760) 439-1963 Zachary T. Kneass, MD Otolaryngology Vista (760) 726-2440 Michael J. Lee, MD Anesthesiology San Diego (858) 565-9666

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.

/////////////////////////////////////////////////////////////////////////////////////////////////// In Memoriam

William “Bill” Yancey, MD William Albert Yancey joined the San Diego County Medical Society in 1956. He was born Feb. 2, 1922, son of William Paul Yancey and Lydia Cenac, and passed away on Saturday, Jan. 4, 2014, at Sharp Coronado Hospital at the age of 91. Born in Davenport, Iowa, he was a graduate of Warren Easton High School of New Orleans, Loyola University of New Orleans, and Louisiana State University Medical School. Concentrating in ophthalmology, he attended Tulane University and Kreage Eye Institute in Detroit, Michigan.

In 1956 he established an ophthalmology practice in San Diego, where he attended the needs of patients for more than 35 years. Through the years he published a number of medical papers and donated his time to local charities such as Father Joe’s Village.

He enlisted in the U.S. Army in 1943. He served as public health officer in Nagasaki, Japan during the postwar occupation. He served as a resident ophthalmologist at the VA hospital in Detroit and Army Reserve at the rank of lieutenant colonel until 1965.

He is survived by his sister, Marian Yancey Landry of New Orleans; his four children, William Yancey Jr. of Pioneer Town, Calif., John Paul Yancey of San Diego, Barbara Yancey Franklin (John) of San Diego, and Mark Yancey of San Diego; his grandchildren, Emily Franklin, Erin Franklin Bokhoven (Eric), and Krista Yancey; and his great-grandchildren, Logan Bokhoven and Blake Bokhoven.

He was an assistant clinical professor in the Department of Surgery at UC San Diego and on staff at Scripps Mercy Hospital and Sharp Memorial Hospital.

In lieu of flowers, the family asks that donations be made to Father Joe’s Village and the San Diego Maritime Museum. A military service will be held at Fort Rosecrans National Cemetery at noon on Jan. 31, 2014.

Become an SDCMS Featured Member!

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

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SAN DI EGO PHYSICIAN.org 7

MICRA

Court and his followers eventually made good on their threat of introducing a ballot measure, submitting language in early July that calls for MICRA’s cap on subjective noneconomic damages to be raised from $250,000 to $1.1 million, with automatic annual increases every year thereafter.

Physicians Stand to Defend MICRA As Threat Re-emerges

by Richard Thorp, MD

8 jan uary 2014

When trial lawyers announced last year that they were working to scrap California’s Medical Injury Compensation Reform Act (MICRA), CMA warned that the campaign would be riddled with lies, misdirection, and below-the-belt shots designed to fool the public into thinking the trial lawyers’ efforts were anything more than an outright money grab.

Unfortunately, we didn’t know how right that warning would prove to be.

Since its passage, MICRA has been under near-constant attack from those who place the prospect of a higher payday above the overall health and wellbeing of California’s residents. While time and again MICRA has weathered the storm, the law is under siege once more. This time MICRA is facing the greatest threat yet as trial lawyers aim to put more money in their own pockets at the expense of patients across the state.

Driven by greed and the promise of inflated attorney fees, California trial lawyers have renewed their fight to lift MICRA’s cap on speculative, non-economic damages, presenting ballot language that seeks to more than quadruple the maximum award for non-economic damages to roughly $1.1 million.

While trial lawyers have postured and threatened major action on MICRA before, this latest effort is made credible by the nearly $1 million the lawyers put into a ballot measure committee. The proposed ballot language, put forward by a trial lawyer front group inappropriately named Consumer Watchdog, was cleared by the Attorney General for MICRA opponents to begin collecting signatures to place the measure on the Nov. 14 ballot. Trial lawyers and their allies are bankrolling the proposed initiative.

With money on the table and signature gatherers on the street, it’s clear that MICRA opponents are serious about overturning the law in 2014.

If successful, these efforts would be devastating to California’s healthcare system. More meritless lawsuits will lead to reduced patient access to our healthcare professionals — and fewer options for affordable, quality healthcare — especially in rural and underserved communities. With federal healthcare reform expanding coverage for millions of additional patients, California is already struggling to provide access to care for the neediest and most vulnerable patients. If this ballot initiative is successful, it will only make the situation worse — even longer lines in emergency rooms, extended waits for appointments with specialists, and reduced access to women’s services like OB-GYNs. This measure will make healthcare professionals, including doctors, nurses, and other

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MICRA

These cheap shots continued, however, when representatives from Consumer Watchdog crashed CMA’s annual House of Delegates conference in Anaheim, hosting a press conference outside of the conference center before circling the streets with a video truck broadcasting the message that “doctors should pee in a cup.” providers, less accessible — not more accountable, as claimed by the trial lawyers.

A broad-based coalition of nearly 1,000 groups and organizations led by CMA — including doctors, nurses, dentists, hospitals, Planned Parenthood, and community health centers and clinics, among others — has emerged to protect access to care across the state.

While the latest fight over MICRA has now taken its first steps toward the ballot box, CMA and its allies have already notched several key victories in this fight, and remain committed to defeating the initiative push in its entirety.

The Threat Emerges This latest assault on MICRA began with all the theatrics and deception that has come to be expected from California trial lawyers and their faux-grassroots front group, Consumer Watchdog.

In early May, Consumer Watchdog President Jamie Court held a press conference in front of the California Capitol announcing his organization’s intent to overturn MICRA, either through legislation introduced in the final months of the 2013 legislative session, or through a ballot initiative brought before California voters. During the conference, Court nefariously painted physicians as believing they were above the law, and, in some cases, completely apathetic to the pain and suffering experienced by victims of medical malpractice.

Despite drawing only a small crowd and 10 jan uary 2014

being unable to expand much upon their intentions during the May press conference, Court and his followers eventually made good on their threat of introducing a ballot measure, submitting language in early July that calls for MICRA’s cap on subjective non-economic damages to be raised from $250,000 to $1.1 million, with automatic annual increases every year thereafter. The ballot measure came only after Consumer Watchdog and others unsuccessfully tried to pressure the Legislature to address the issue.

The central intent of the proposed ballot language is nothing more than a thinly veiled money grab by California’s trial attorneys, who stand to make hundreds of thousands of additional dollars on every malpractice case should the cap be changed. However, since most voters would not support that provision, it also calls for physician drug testing and a bolstering of the state’s Controlled Substance Utilization Review and Evaluation System (CURES).

Currently, MICRA protects patients involved in medical liability lawsuits by allowing unlimited economic compensation for any and all economic or out-of-pocket costs, including past and future lost income and earning capacity, all necessary medical care, as well as unlimited punitive damages.

Under MICRA, patients can also receive up to $250,000 for non-economic pain and suffering damages. This allows legitimate medical liability cases to move forward while discouraging lawyers from filing frivolous suits. MICRA also limits how much lawyers can take as payment, ensuring more money goes to patients, not lawyers.

The trial lawyers’ measure would not only nearly quadruple MICRA’s non-economic damages cap from $250,000 to $1.1 million, it would also triple the legal fees that lawyers receive.

While the trial lawyers get rich, everyone else pays. More lawsuits mean higher healthcare costs for everyone. An analysis

by California’s former independent legislative analyst found that this measure would increase healthcare costs for consumers and taxpayers in California by nearly $10 billion annually.

Pandering in the Capitol MICRA opponents also attacked the Capitol, where members of the Legislature were returning from their summer recess and preparing to begin the final legislative push for the 2013 session.

Knowing that legislation attempting to scrap MICRA would never survive the vetting process typical of a full session, op-

ponents sought to find an author willing to use the so-called “gut-and-amend” action to avoid public scrutiny provided through the regular legislative process to push an anti-MICRA bill through the Legislature in the final days, or even hours, before the Assembly and Senate adjourned for the year.

In its effort to locate an author, as well as drum up opposition to MICRA, Consumer Watchdog began conducting daily mail drops featuring their “38 is too late” campaign to legislative offices. The canvassing project targeted physicians as being unsympathetic to their patients’ needs, and portrayed MICRA as a barrier to victims seeking restitution for medical malpractice. Nowhere in Consumer Watchdog’s literature did it mention that medical malpractice victims are entitled to unlimited economic damages — such as lost wages, earning capacity, and medical expenses — under California law. Nor did it mention that lawyers would stand to make more money should MICRA be overturned.

To combat this effort, CMA and a host of allies — including labor groups, public safety entities, allied healthcare professionals, and municipal interests — inundated members of the Legislature with facts supporting MICRA’s efficacy, warning that altering the cap would adversely impact local governments, community clinics, and insurance premiums for all Californians.

In the end, MICRA’s supporters emerged victorious, as trial attorneys were unsuccessful in getting anti-MICRA legislation introduced during the most recent session.

Cheap Shots and Scare Tactics

An analysis by California’s former independent legislative analyst found that this measure would increase healthcare costs for consumers and taxpayers in California by nearly $10 billion annually.

Shortly after being defeated in the state Capitol, MICRA opponents decided it was time to start playing dirty.

In late September, Consumer Watchdog distributed a mail piece featuring the names of hundreds of California physicians who it claims are afraid to “pee in a cup,” while also personally targeting CMA past president Paul Phinney, MD, asking what he had to hide by opposing the trial attorneys’ greed-fueled initiative to gut MICRA. Oddly enough, the trial attorneys’ mailer makes no mention of the proposed initiative’s attempt to nearly quadruple MICRA’s cap on non-economic damages and exponentially increase their fees, and sticks to the more voter-friendly provisions regarding substance abuse in the workplace.

The attack was a brazen one, illustrating that the state’s trial lawyers and their puppet organization, Consumer Watchdog, will stop at nothing to line their pockets through the inflated attorney fees that would be generated from MICRA’s cap being lifted.

These cheap shots continued, however, when representatives from Consumer Watchdog crashed CMA’s annual House of Delegates conference in Anaheim, hosting a press conference outside of the conference center before circling the streets with a video truck broadcasting the message that “doctors should pee in a cup.”

While these attacks may sting for those who are personally targeted, they also illustrate one fact: MICRA opponents are desperate.

In the months since trial lawyers launched their latest assault against MICRA, California physicians and other allies have rallied to MICRA’s defense at a near-historic rate. Funds are being raised at record numbers, and physician engagement with the issue grows every day. As a result, Consumer Watchdog and other MICRA opponents are stooping to new lows in an attempt to intimidate those who have come to MICRA’s defense.

These deceitful attacks by MICRA opponents will continue, and will get worse as the November 2014 election cycle ramps up. Physicians, however, must continue to advocate for MICRA and ensure that our patients and practices are not jeopardized by the greed of those who would like to see MICRA fall.

Rest assured, CMA will win this fight, but we will need all physicians in order to do so. To find out how you can help, visit www.cmanet.org/micra today.

Dr. Thorp is president of the California Medical Association.

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Healthcare Legislation

New Health Laws for 2014

by The California Medical Association

Note: This is just a sampling of the new laws impacting healthcare in 2014 and beyond. For a complete list, see “Significant New California Laws of Interest to Physicians for 2014,” in the California Medical Association’s online resource library at www.cmanet.org/resource-library.

12 jan uary 2014

T

The California Legislature had an active year passing many new laws affecting healthcare. Below are highlights of the new laws likely to impact physicians next year and beyond. For more details, see “Significant New California Laws of Interest to Physicians for 2014,” in the California Medical Association’s online resource library at www.cmanet.org/ resource-library.

ALLIED HEALTH PROFESSIONALS: • PHYSICAL THERAPISTS: DIRECT ACCESS TO SERVICES (AB 1000) (CMA Position: Support / Co-sponsor): Allows physical therapists to treat patients for 45 days or 12 visits without first seeing a physician. Requires a physical therapist to refer a patient to a physician if the condition is beyond the therapist’s scope of practice or if the patient is not progressing, to disclose to the patient any financial interest he or she has in treating the patient, and, with the patient’s authorization, notify the patient’s physician that the physical therapist is treating the patient. Specifies that professional corporations, including medical corporations, are not limited to employing those licensed professionals that are listed in Corporations Code §13401.5.

• MIDWIFERY (AB 1308): Removes physician supervision over licensed midwives. Specifies conditions of a normal pregnancy and childbirth and requires a licensed midwife to refer clients who do not meet these conditions to a physician for examination. Requires the Medical Board to adopt regulations specifying those certain conditions. Authorizes a licensed midwife to directly obtain supplies and devices, obtain and administer drugs and diagnostic tests, order testing, and receive necessary reports consistent with the scope of practice.

Requires disclosure to prospective clients of the specific arrangements for referral of complications to a physician and surgeon, and to obtain consent of those disclosures.

CONFIDENTIAL INFORMATION: • PERSONAL INFORMATION: PRIVACY (SB 46): Amends existing law that requires notification to individuals whose unencrypted computerized personal information was or is reasonably believed to have been acquired by an unauthorized person due to a breach of security of a computerized system or data. Revises certain data elements included within the definition of personal information by adding certain information that would permit access to an online account.

Imposes additional requirements on the disclosure of a breach of security of the system or data in situations where the breach involves personal information that would permit access to an online or email account.

• CONFIDENTIALITY OF MEDICAL INFORMATION (SB 138): Specifies the manner in which a healthcare service plan or health insurer would be required to maintain confidentiality of information regarding the treatment of an insured, including a requirement to accommodate requests to receive requests for confidential communication of medical information in situations involving sensitive services, including requests by dependents insured under a health insurance policy held by another person, or situations in which disclosure would endanger the individual. Authorizes a healthcare provider to communicate information regarding benefit cost-sharing arrangements to the healthcare service plan or health insurer.

Prohibits health plans from conditioning enrollment in the plan or eligibility for benefits on the waiver for certain rights provided for in the bill.

DRUG PRESCRIBING AND DISPENSING: • DRUG OVERDOSE TREATMENT: LIABILITY (AB 635) (CMA Position: Support): Authorizes a licensed healthcare provider, who is permitted by law to prescribe an opioid antagonist and is acting with reasonable care, to prescribe and subsequently dispense or distribute an opioid antagonist for the treatment of an opioid overdose. This is permitted to treat a person at risk of an opioidrelated overdose or a specified person in a position to assist a person at risk of an opioid-related overdose. Authorizes these licensed healthcare providers to issue standing orders for the distribution of an opioid antagonist.

SAN DI EGO PHYSICIAN.org 13

Healthcare Legislation • CONTROLLED SUBSTANCES: REPORTING (SB 809) (CMA Position: Support): Funds the Controlled Substance Utilization Review and Evaluation System (CURES) for the electronic monitoring of the prescribing and dispensing of controlled substances by assessing an annual fee on practitioners authorized to prescribe, order, administer, furnish, or dispense controlled substances, non-governmental clinics, and non-governmental pharmacies. Establishes the CURES Fund within the State Treasury.

Requires the Medical Board to periodically develop and disseminate education materials relating to the assessment of a patient’s risk of abusing or diverting controlled substances and information related to CURES to physicians and general acute care hospitals. Eliminates notarization requirement for application process and requires healthcare practitioners and pharmacists to apply to obtain approval to access CURES after Jan. 1, 2016. Requires the Department of Justice in conjunction with the Department of Consumer Affairs and relevant licensing boards to develop a streamlined application and approval process to access CURES and enable healthcare practitioners and pharmacists with access to CURES to delegate their authority to order reports from CURES. HEALTH BENEFIT EXCHANGE: • CALIFORNIA HEALTH BENEFIT EXCHANGE (SB 28): Requires the California Major Risk Medical Insurance Board to provide the California Health Benefit Exchange (Covered California) with specified information to assist in conducting outreach to subscribers to notify them that they may be eligible for coverage through the Exchange or MediCal. Implements various provisions of the Affordable Care Act relating to determining eligibility for the Medi-Cal program.

Requires the Department of Health Care Services (DHCS) to authorize individuals to select Medi-Cal managed care plans via the California Healthcare, Enrollment, and Retention System.

• HEALTHCARE COVERAGE: BRIDGE PLAN (CA SBX1 3): Requires the California Health Benefit Exchange (Covered California), by means of selective contracting, to make a bridge plan product available to specified eligible individuals, as a qualified health plan (QHP). Exempts the bridge plan product from certain requirements that apply to QHPs, relating to making the product available and marketing and selling to all individuals equally (guaranteed issue) outside the Ex14 jan uary 2014

change and selling products at other levels of coverage. Requires the Department of Health Care Services to include provisions relating to bridge plan products in its contracts with Medi-Cal managed care plans. Requires Covered California to evaluate three years of data from the bridge plan products, as specified.

HEALTHCARE COVERAGE: • STOP-LOSS INSURANCE COVERAGE (SB 161) (CMA Position: Support): Prohibits a stop-loss insurer from excluding any employee or dependent on the basis of specified actual or expected health status-related factors. Establishes regulatory requirements for stop-loss insurance policies for small employers, including requiring a stop-loss insurer to renew all stop-loss insurance policies at the option of the small employer and prohibiting setting individual attachment point of $40,000 or greater and an aggregate attachment point of the greater of $5,000 times the total number of group members, 120% of expected claims, or $40,000 for a policy year or providing coverage for an employee or his or her dependents. Exempts small employer stop-loss insurance issued prior to Sept. 1, 2013, from these attachment point requirements.

• HEALTHCARE COVERAGE (CA ABX1 2) (CMA Position: Support if Amended): Establishes health insurance market reforms contained in the Affordable Care Act specific to individual purchasers, such as open enrollment, prohibiting insurers from denying coverage based on preexisting conditions, insured claims experience as part of a single risk pool, the use of certain factors in determining individual plan rates, insurance advertising and marketing, small employer enrollment periods and coverage effective date and premium rates, a risk adjustment program, insurance data reporting, and insurer disclosure requirements; and makes conforming changes to small employer health insurance laws resulting from final federal regulations.

HEALTHCARE FACILITIES AND FINANCING: • PRIMARY CARE CLINICS: ABORTION (AB 980): Imposes the same licensing and building standards to all primary care clinics, including those that provide abortion services. Grants the Office of Statewide Health Planning and Development emergency regulatory authority to implement these provisions and requires the Department of Public Health to repeal certain regulations relating to abortion services in primary clinics by July 1, 2014.

• OCCUPATIONAL SAFETY AND HEALTH STANDARDS (AB 1202) (CMA Position: Support): Requires the Occupational Safety and Health Standards Board to adopt a standard for the handling of antineoplastic drugs, primarily cancer drugs, in healthcare facilities regardless of the setting. Requires the standard to be consistent with and not exceed specific recommendations adopted by the National Institute for Occupational Safety and Health for preventing occupational exposures to those drugs in healthcare settings.

• EMERGENCY MEDICAL SERVICES (SB 191) (CMA Position: Co-sponsor): Extends the operative date to Jan. 1, 2017, of existing law that establishes the Maddy Emergency Medical Services Fund, which authorizes each county to establish an emergency medical services fund for reimbursement of costs related to emergency medical services and funding for pediatric trauma centers, and authorizes county boards of supervisors to elect to levy an additional penalty upon fines, penalties and forfeitures collected for criminal offenses. Makes technical, nonsubstantive changes to the provisions.

MEDI-CAL: • MEDI-CAL: MANAGED CARE: LONGTERM SERVICES AND SUPPORTS (SB 94) (CMA Position: Oppose): Amends existing law regarding the Coordinated Care Initiative (CCI) and separates CCI provisions to allow the mandatory enrollment of Medi-Cal and Medicare beneficiaries (dual eligibles) into Medi-Cal managed care, the integration of longterm supports and services into managed care plans, and the commencement of the In-Home Supportive Services Statewide Public Authority, to proceed separately from the CCI Duals Demonstration Project (now called Cal MediConnect).

• HEALTHCARE PROVIDERS (SB 494) (CMA Position: Support ): Increases the number of beneficiaries assigned to the panel of a full-time equivalent primary care physician under a Medi-Cal managed care plan. Requires a health service plan to ensure that there is at least one full-time primary care physician for every 2,000 enrollees. Authorizes the assignment of up to an additional 1,000 enrollees to the primary care physician for every full-time non-physician medical practitioner supervised by that physician. Requires the Medi-Cal program to evaluate the location, hours, and language capabilities of practitioners and adds nonphysician medical practitioners (physician assistant or a nurse practitioner) to the definition of a primary care provider.

Healthcare Legislation MEDICAL EDUCATION: • EDUCATION FINANCE: HIGHER EDUCATION (AB 94): Higher education budget trailer bill that allocated $15 million dollars to the regents of the University of California, Riverside School of Medicine.

• CALIFORNIA PHYSICIAN CORPS PROGRAM (AB 565) (CMA Position: Sponsor): Amends the Steven M. Thompson Physician Corps Program to require the guidelines for the selection and placement of program applicants to include criteria that would give priority consideration to program applicants with experience providing healthcare services to medically underserved populations or in a medically underserved area. Gives priority to applicants who agree to practice in those areas and serve a medically underserved population, and give priority consideration to applicants from rural communities who agree to practice in a physician owned and operated medical practice. Amends the definition of “practice setting” to include a physician owned and operated medical practice setting

that provides primary care located in a medically underserved area.

PROFESSIONAL LICENSING AND DISCIPLINE: • STATE MEDICAL BOARDS: LICENSING: APPLICATION PROCESSING (AB 1288) (CMA Position: Sponsor): Requires the State Medical Board and the Osteopathic Medical Board of California to develop a process to give priority review status to the application of an applicant who can demonstrate that he or she intends to practice in a medically underserved area or serve in a medical underserved population.

• HEALING ARTS: BOARDS (SB 304): This bill is the sunset extension bill for the Medical Board containing statutory and technical changes to provisions relating to Medical Board review by appropriate legislative committees, issuance of a license to a physician and surgeon who has acquired any part of his or her education from an unrecognized medical school who has held licensure in another state or Canada, reporting an electronic

address to the Board, licensed midwives, adverse event reporting, fines for failure to provide healthcare records by a facility, and Medical Board investigations.

• PHYSICIANS AND SURGEONS: DRUG PRESCRIBING PRIVILEGES (SB 670) (CMA Position: Support): Authorizes the Medical Board, in any investigation that involves the death of a patient, to inspect and copy the records of the deceased patient without authorization of the beneficiary or personal representative of the deceased patient or a court order to determine the extent to which the cause of death was the result of the physician and surgeon’s violation of the Medical Practice Act, if the board provides a written request to the physician that includes a declaration that the board was unsuccessful in locating or contacting the deceased patient’s beneficiary or personal representative after reasonable efforts. Revises definition of unprofessional conduct to include repeated failures by a licensee who is the subject of an investigation, in absence of good cause, to attend and participate in an interview

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by the board. Clarifies the authority of the administrative law judge to issue an interim order limiting the authority to prescribe, furnish, administer or dispense controlled substances.

PUBLIC HEALTH: • HIV TESTING (AB 446) (CMA Position: Support): Requires a medical care provider or a person administering a HIV test to provide a patient with information about risk reduction strategies and information regarding test results. Requires oral or written informed consent as specified for the HIV test except when a person independently requests an HIV test from an HIV counseling and testing site and requires the person administering the test to document the person’s independent request for the test. Exempts clinical laboratories from the informed consent requirements. Requires an HIV test to be offered to any patient having blood drawn at a primary care clinic and consents to the test. Authorizes disclosure of HIV test results by secure Internet website posting.

REPRODUCTIVE ISSUES: • ABORTION (AB 154) (CMA Position: Support): Allows nurse practitioners, certified nurse midwives and physician assistants to perform an abortion by medication or aspiration techniques in the first trimester of pregnancy if he or she completes training and validation of clinical competency and is working pursuant to specified standardized procedures that specify the extent of physician supervision, and procedures for transferring patients to the care of a physician or a hospital, obtaining assistance and consultation of the physician and providing emergency care until physician assistance and consultation is available. Deletes references to nonsurgical abortions.

• HEALTHCARE COVERAGE: INFERTILITY (AB 460) (CMA Position: Support): Requires that healthcare service plan and health insurer coverage for the treatment of infertility be offered and, if purchased, provided without discrimination on the basis of age, ancestry, color, disability, domestic partner sta-

tus, gender, gender expression, gender identity, genetic information, marital status, national origin, race, religion, sex or sexual orientation.

• PRENATAL TESTING PROGRAM: EDUCATION (SB 460) (CMA Position: Support if Amended): Requires the Department of Public Health to include prescribed information regarding environmental health in the California Prenatal Screening Program patient educational information and to post that information on the department’s website. Requires the Department of Public Health to send a notice to all distributors of the patient educational information that informs them of that change and encourages obstetrician-gynecologists and midwives to discuss environmental health with their patients.

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PUBLIC HEALTH

Choosing Wisely

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 19 — 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.

18 jan uary 2014

How The List on Page 19 Was Created

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

The American College of Radiology (ACR) initially solicited expert opinion from physician leaders with its Board of Chancellors. A working group was then formed to further identify common clinical scenarios in which imaging may be misused and should be reconsidered.

Members of the group included the physician chairs or vice chairs of seven ACR commissions, such as Quality and Safety, Appropriateness Criteria, and Metrics. An initial list of topics was narrowed down based on the highest potential for improvement, representing a broad range of tests and the availability of strong guidelines. Members then researched specific recommendations and evidentiary statements based on their expertise. Recommendations that were too general or were well covered by other existing measures and initiatives were eliminated to identify the final five things list.

ACR’s disclosure and conflict of interest policy can be found at www.acr.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 Radiology Note: These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional.

Patients with any specific questions about the items on this list or their individual situation should consult their physician.

Don’t do imaging for uncomplicated headache.

1

Imaging headache patients absent specific risk factors for structural disease is not likely to change management or improve outcome.

Those patients with a significant likelihood of structural disease requiring immediate attention are detected by clinical screens that have been validated in many settings. Many studies and clinical practice guidelines concur. Also, incidental findings lead to additional medical procedures and expense that do not improve patient well-being.

Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability.

2

3

4

While deep vein thrombosis (DVT) and PE are relatively common clinically, they are rare in the absence of elevated blood d-Dimer levels and certain specific risk factors. Imaging, particularly computed tomography (CT) pulmonary angiography, is a rapid, accurate and widely available test, but has limited value in patients who are very unlikely, based on serum and clinical criteria, to have significant value. Imaging is helpful to confirm or exclude PE only for such patients, not for patients with low pre-test probability of PE.

Avoid admission or preoperative chest X-rays for ambulatory patients with unremarkable history and physical exam.

Performing routine admission or preoperative chest X-rays is not recommended for ambulatory patients without specific reasons suggested by the history and/or physical examination findings. Only 2% of such images lead to a change in management. Obtaining a chest radiograph is reasonable if acute cardiopulmonary disease is suspected or there is a history of chronic stable cardiopulmonary disease in a patient older than age 70 who has not had chest radiography within six months.

Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until after ultrasound has been considered as an option.

Although CT is accurate in the evaluation of suspected appendicitis in the pediatric population, ultrasound is nearly as good in experienced hands. Since ultrasound will reduce radiation exposure, ultrasound is the preferred initial consideration for imaging examination in children. If the results of the ultrasound exam are equivocal, it may be followed by CT. This approach is cost-effective, reduces potential radiation risks and has excellent accuracy, with reported sensitivity and specificity of 94%.

Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts.

5

Simple cysts and hemorrhagic cysts in women of reproductive age are almost always physiologic. Small simple cysts in postmenopausal women are common, and clinically inconsequential. Ovarian cancer, while typically cystic, does not arise from these benignappearing cysts. After a good-quality ultrasound in women of reproductive age, don’t recommend follow-up for a classic corpus luteum or simple cyst <5 cm in greatest diameter. Use 1 cm as a threshold for simple cysts in postmenopausal women.

SAN DI EGO PHYSICIAN.org 19

Risk Management

“Medical clearance”

Medical Clearance Does Not Clear the Patient or Physician of Risks SDCMS-endorsed The Doctors Company — For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

20 jan uary 2014

is when a surgeon requests clearance from an assessing physician before performing surgery on a patient. Cardiac risk is the No. 1 reason to request medical clearance, but other risks that call for medical clearance include congestive heart failure, pulmonary embolism, anticoagulation, obesity, and high blood pressure.

Anticoagulants, for example, are often an issue in surgical claims. If the patient is taking anticoagulants, the surgeon and the physician should agree on the best approach for that specific patient. They may discuss changes in medical management that should be made to decrease risk. If they believe the patient is at risk from a respiratory perspective, the focus may be on early mobilization, incentive spirometry, and respiratory treatment.

To avoid malpractice risks, consider the following tips when dealing with medical clearance: • Determine Which Patients Need Medical Clearance: The surgeon should assess the type of

surgery and its associated risks and the health of the patient. Healthy patients with no underlying conditions who are undergoing fairly low-risk procedures don’t routinely need medical clearance.

• Provide Appropriate Information: Problems can arise when the surgeon does not provide enough information to the assessing physician about the surgery being proposed.

The surgeon should provide information to the assessing physician about the type of surgery, how long it will take, what kind of anesthesia is anticipated, how long the patient will be immobile, what is involved in rehabilitation, and what the recovery period looks like. The assessing physician should take that information into consideration, along with exam results and knowledge of the patient, to determine if the patient is at increased risk.

• Develop a Plan to Mitigate Risks: The surgeon and the assessing physician should work together to determine the steps to take to mitigate risk preoperatively, intraoperatively, and postoperatively. For example, they should agree about which medications to stop preoperatively and which to continue.

There is no standard medical clearance process. Physicians should be aware of when a medical clearance would be indicated and have a good process to ensure it’s done.

Medical clearance is a misnomer because it implies that the patient is cleared and there are no risks. No patient is free of risk when undergoing a procedure.

The goals of the assessment are to determine the level of risk and to identify opportunities to mitigate risk — with the surgeon and the assessing physician working in concert. The decision about whether to proceed with the operation belongs to the surgeon and the patient.

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Personal & Professional Development

Three Simple Questions to Start the New Year off Right

by Helane Fronek, MD, FACP, FACPh

22 jan uary 2014

It’s a new year, filled with promise and possibility. Yet many of us feel oppressed by the hours we spend entering data into EHRs, the increased documentation we must provide for insurance reimbursement, and the pressure of having to see more patients in less time while being held responsible not only for accurate diagnosis and treatment of their medical condition but also for their satisfaction with us and our practice. Our system of medical care delivery is undergoing enormous change, leaving us with even greater insecurity. So you might be wondering … where exactly is the promise and possibility?

Rachel Naomi Remen, MD, founder of the Institute for the Study of Health and Illness, and creator of courses that focus on the wellbeing of physicians and medical students, recently observed, “Our system is broken.” She then went on to emphasize that, in spite of and perhaps because of that reality, it is even more important that we take care of ourselves as physicians.

We can do that by examining our lives to make sure we are giving adequate time and attention to our values, those principles and activities that give our life meaning (See http://helanefronekmd.wordpress.com/ tools-for-the-life-you-want). By adding

one new activity each month that brings us true joy, nurtures our soul, creates closer connections, or brings us closer to exciting goals we have set, we can create a life that has more balance and feels right to us.

But without changing or adding anything new, we can consciously look at the interactions and events in our lives to find the meaning and connection that is already there.

Dr. Remen tells of a physician who sought her guidance, complaining of disillusionment with his practice and life in general.

She suggested one simple thing: Each night, he was to write the answers to three questions in a journal: 1. What surprised me today?

2. What moved me or touched me today?

3. What inspired me today?

He returned, lamenting that no answers had been forthcoming, and he had noticed no change in his life. Rachel requested that he continue to ask the three questions each night. On his next visit, he was a changed person, surprised by what he had found in his own life. He was astonished at the many moving and inspiring things he had not noticed before, and he realized that his life was actually extremely rich and meaningful.

Recent psychological studies have shown that we create more of what we put our attention on in our lives. By focusing daily on these three things — what surprised us, what moved or touched us, and what inspired us — we cannot help but be more connected to our lives, more in touch with the hope and love that we encounter each day, and happier with our practices and relationships. It just might be the antidote to the many stressors that are weighing us down, and would be a powerful way to begin the New Year.

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

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San Diego County’s Emergency Departments

San

Getting Bigger and Better »San Diego County’s emergency departments constitute one of the most collaborative groups of EDs in the nation.

SDCMS’s Emergency Medicine Oversight Commission (EMOC) brings together emergency department physicians, nurses, administrators, and paramedics on a monthly basis. Despite practicing in a highly competitive market, these professionals join on a regular basis to improve the quality of emergency care in our county. Each year, all emergency departments complete a voluntary, confidential, and extensive survey about their departments. The total number of hospitals in the survey is 21, with the addition of El Centro Hospital and Palomar West. The graphs in this article are a sampling of the results from our 2013 survey. To view the complete results of our 2013 San Diego Emergency Department Survey, visit www.SDCMS.org and search for “EMOC,” or email Editor@SDCMS.org.

9,000

8,000 9,000

7,000

8,000

7,000

6,000

6,000

5,000 5,000

4,000

4,000

3,000

3,000 2,000 2,000

1,000

1,000

980

1,020

980

1,020

0 Sharp Fallbrook Coronado

980

1,020

UCSD La Jolla

2,000

0 Sharp Fallbrook Coronado

By Roneet Lev, MD

2,130

2,000 2,000

2,300

980

1,020

UCSD La Jolla

2,000

Palomar Alvarado Downtown Po (old) 2,130

2,300

Monthly 24 jan uary 2014

Sharp Fallbrook Coronado

980

1,000

Palomar Alvarado Downtown Pomerado (old)

UCSD La Jolla

Scripps La Jolla

PVH

Scripps Encinitas

UCSD Hillcrest

2,727

2,954

3,475

3,530

El Centro Scripps CV Sharp CV

El Centro Scripps CV Sharp CV

P

Scripps Mercy

Naval

Tri-City

5,121

5,604

5,669

1,020 1,020

980

2,000

2,130

2,300

2,300

Scripps La Jolla

PVH

Scripps Encinitas

UCSD Hillcrest

2,727

2,954

3,475

3,530

4,119

4,210

4,788

0 Sharp Fallbrook Coronado

980

1,020

UCSD La Jolla

Palomar Alvarado Downtown Pomerado (old)

2,000

2,130

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5,669

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2011

2013

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2008

2009

2008

2013

2010

2009

2011

2010

2011

2012

2012

2013

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2009

2010

2011

2012

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1,138

1,177

1,195

1,530

1,579

1,598

2011

1,600

1,624

2,242

2,060

2,000

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1,722

1,809

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Naval

13

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13

6

6 2

0 Over the Past Year 2 No

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No

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Selected Patients (21-89%)

12

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0

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12

17

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2

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3

3

3

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2

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Yes

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1

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30 jan uary 2014

1

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1

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1

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Yes

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1

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1

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1

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3

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1

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3

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1

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1919

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060

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No

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17

17

4

Yes

Yes

BOB DESIMONE, MBA, CPA

THE DOCTORS INSURANCE AGENCY CA AGENT #0722131

No

4

»The average length of stay in a San Diego ED for a patient who is treated and discharged home is less than 3 hours and 15 minutes. The average length of stay if the patient is admitted to the hospital is over 5½ hours. Both times have improved over the years.

No

Save the date for

SDCMS’s Membership Mixer 215 S. Highway 101, Ste. 117 Solana Beach, CA 92075 bdesimone@tdia.com (800) 464-2986 (858) 345-1370 Fax (858) 345-1376

Thursday evening, April 3rd Handlery Hotel, Mission Valley

SAN DI EGO PHYSICIAN.org 31

10

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19

— same answer for 7 years

5 2013

1

1

1

1

1

No

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Yes

16

No

Electronic Prescription Writing?

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16

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1

5

10

10

10

2010

2011

2012

6 4

3

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No No

B

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2008

2009

2013

tie

nt

8 2007

pa

C

In

in ay el D

A

N

nc

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ill

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12

Major Decrease in On-call Deficiencies

No

nt

ts

ic

or

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ta

R

Yes Yes Yes

Pediatrics

Yes

Electronic Prescription Discharge Both Writing?

Ophthalmology

1

OB

5 1

Frequent Flyers / Care Plan Frequent Flyers / Care Plan / /Pain Program PainManagement Management Program Increasing IncreasingTrend Trend

Yes

»It has become the standard for larger Electronic Prescription Writing? hospitals to have a pharmacist working 16 in the ED.

No

1313

ggest Obstacle for Length of Stay Discharged Patients

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12

8

8

9 7

1

2

1

Yes

2

No

A

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Se rv

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32 jan uary 2014

No

su e

g af fin

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on

st

su

itu

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n

Yes

5

Yes

No

No Problems

2012

Neurology

2011

ENT

2010

Orthopedics

2009

Oral Surgery

2008

Plastics

2007

Cardiology

3

Urology

2013

Neurosurgery

2012

Hand

2011

Plastics

2009

GI

2008 4

16 2010

Surgery

2007

»Computer Systems Used: • Cerner: 8 • EPIC: 4 • Centricity: 4 3 3 3 3 • Siemens: 1 2 2 2 2 • Essentris: 1 1 • 1Meditech: 1 • ProMed: 1

16

6

0

12

Second Annual

classifieds PHYSICIAN POSITIONS WANTED LOOKING FOR SURGICALLY RELATED OPPORTUNITIES: I am a semi-retired general surgeon seeking part-time or per diem surgically related opportunities in the San Diego area. I have taken mandatory retirement from our multispecialty group partnership at Kaiser Permanente, San Diego, am in excellent health, and plan to continue active practice for at least the next few years. Surgical assisting and office or clinic duties would be very acceptable. I am board certified in general surgery and an active member of the American College of Surgeons. I have over 30 years of general surgical and laparoscopic experience in a busy practice. Email me at mravden@ earthlink.net. [197] PHYSICIAN POSITIONS AVAILABLE JOINT VENTURE OPPORTUNITY FOR LICENSED MD FOR PRP THERAPY TREATMENTS: Retired or Semi-retired MD OK. San Diego area. Please call Alvars for details at (619) 905-1090. [196] INTERNAL MEDICINE PHYSICIAN, NORTH SAN DIEGO COUNTY: Private practice internal medicine group in North San Diego County seeks BC/BE internist for full-time outpatient internal medicine practice. This is an excellent opportunity to practice with a well-established group of internists. Email CV to dgosejohan@ncim.net. [190] INTERNAL MEDICINE — PRIVATE PRACTICE, PART-TIME OPPORTUNITY **LIFE / WORK BALANCE**: Unusual and exceptionally attractive private practice IM opportunity in beautiful North San Diego County. Stable, long-term, parttime, outpatient position in a highly regarded group practice with >30 years in the community.

Collegial, single-specialty group, exceptional office staff, and very high quality patient care set this far apart from many other situations. Office location is easily accessible from anywhere in the county. Multiple scheduling options available, making this a very attractive option for any physician who wishes to work exclusively part-time or who wishes to combine this with other job opportunities. Outstanding way to experience the best of private practice! Please email CV to portofino3@aol.com or call (619) 248-2324. [186] LOOKING FOR ENERGETIC OPHTHALMOLOGISTS: The UCSD Student-Run Free Clinic Project is looking for energetic ophthalmologists who love teaching to volunteer their time to act as attending physicians at the Ophthalmology Free Clinic. Attendings would have the choice to volunteer at two different clinic sites: the First Lutheran Church in Downtown San Diego and/ or Baker Elementary School. Both clinics are four hours long, are held monthly, and provide services to the uninsured patient population of San Diego. Monthly commitment is not required.

Malpractice is covered by UC Regents via a voluntary faculty appointment. For more information, please email SunnyDSmith@gmail.com. [185] SEEKING BC/BE INTERNIST FOR FULL-TIME POSITION: Private group practice in Escondido with excellent reputation for quality of care. EHR implemented. Complete benefit package and competitive salary. Partnership tract. Email CV to EIM2011SDP@gmail.com. [184]

INTERNAL MEDICINE AND PSYCHIATRY PHYSICIANS: South Bay private practice seeking both internists and psychiatrists licensed to practice medicine in the state of California.

Current DEA license and malpractice insurance required. BC/BE preferred. Independent contractor opportunity for providing services to area hospitals, nursing homes, and B&C. Please fax CV to (619) 327-0164 or send to sishaquemd@ yahoo.com. [181] PHYSICIAN WANTED — LA MESA / EL CAJON: Busy internal medicine practice with strong focus in geriatric patients is currently hiring a physician.

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. A national leader among community health centers, Family Health Centers of San Diego is a private, nonprofit community clinic organization that is an integral part of San Diego’s healthcare safety net. Since 1970, our mission has been to provide caring, affordable, high-quality healthcare and supportive services to everyone, with a special commitment to uninsured, low-income, and medically underserved persons. Every member of our team plays an important role in improving the health of our patients and community. We offer an excellent, comprehensive benefits package that includes malpractice coverage, NHSC loan repay eligibility, and much, much more! For more information, please call Anna Jameson at (619) 906-4591 or email ajameson@fhcsd.org. If you would like to fax your CV, fax it to (619) 876-4426. For more information and to apply, visit our website and apply online at www.fhcsd.org [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) 992-5330 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

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 jan uary 2014

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 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

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

LA JOLLA (NEAR UTC) OFFICE FOR SUBLEASE OR TO SHARE: Scripps Memorial medical office building, 9834 Genesee Ave. — great location by the front of the main entrance of the hospital between I-5 and I-805. Multidisciplinary group. Excellent referral base in the office and on the hospital campus. Please call (858) 455-7535 or (858) 320-0525 and ask for the secretary, Sandy. [127]

OFFICE SPACE POWAY/RANCHO BERNARDO: Medical office space for lease, all or part. Up to 1,100SF. Great location in medical/dental complex in Poway, next to Pomerado Hospital (borders Rancho Bernardo). Open treatment areas and private treatment rooms, two bathrooms, waiting room/lobby, front office. Second floor.

Elevator/stair access. Beautiful view of the hills.

Ideal for medical, complementary / alternative medicine, physical therapy, chiropractic, acupuncture, massage / body work, etc. Patients / clients from Poway, Rancho Bernardo, Carmel Mountain, 4-S Ranch, Scripps Ranch, Escondido, Ramona, and surrounding areas. Contact Debbie Summers at (858) 382-8127 or at debjsummers1@yahoo.com. [195] SPACIOUS, NEWLY REMODELED 2ND FLOOR MEDICAL OFFICE SPACE FOR RENT IN THE KEARNY MESA AREA: Good space for patient care or for clinical research use. Easy access, lots of parking. Approximately 1500SF. Private physician office, 2 exam rooms, and nurse desk/work area. Shared reception area, patient waiting rooms, and lab. Contact Trudy Brass, Manager, Allergy and Asthma Medical Group and Research Center, at (858) 292-1144 or at trudybrass@allergyandasthma.com. [193] TORREY HILLS MEDICAL BUILDING: 4765 Carmel Mountain Rd., San Diego 92130: 1 space available; Suite 201; 1,120SF; rental rate: negotiable; max. contiguous: 3,449SF; sublease: yes; sublease expires Jan. 2018; available: now. Fully built-out medical office in new Class “A” building, Ample parking garage exclusive for tenants and patients. Patient drop area. Highly upgraded with upscale finishes/exam rooms. Suites 201 and 202 may be combined for 3,449SF total. Located in growing commercial and residential area. New on/off ramps at Carmel Valley Rd. for immediate access to all of San Diego County. Outstanding exposure to adjoining retail center/community.

Contact Gateway Financial Real Estate, James Pieri, Jr., at (619) 972-2214. [192] 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] 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) 997-9727. 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] 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) 2798111 or at (619) 823-8111. Thank you. [836] SCRIPPS ENCINITAS CONSULTATION ROOM/ EXAM ROOMS: Available consultation room with two examination rooms on the campus of Scripps Encinitas. Will be available a total of 10 half days per week. Located next to the Surgery Center.

Receptionist help provided if needed. Contact Stephanie at (760) 753-8413. [703] POWAY / RANCHO BERNARDO — OFFICE FOR SUBLEASE: Spacious, beautiful, newly renovated, 1,467 sq-ft furnished suite, on the ground floor, next to main entrance, in a busy class A medical building (Gateway), next to Pomerado Hospital, with three exam rooms, fourth large doctor’s office. Ample parking. Lab and radiology onsite. Ideal sublease / satellite location, flexible days of the week. Contact Nerin at the office at (858) 521-0806 or at mzarei@cox.net. [873] BUILD TO SUIT: Up to 1,900ft2 office space on University Avenue in vibrant La Mesa / East San Diego, across from the Joan Kroc Center. Next door to busy pediatrics practice, ideal for medical, dental, optometry, lab, radiology, or ancillary services. Comes with 12 assigned, gated parking spaces, dual restrooms, server room, lighted tower sign. Build-out allowance to $20,000 for 4–5 year lease. $3,700 per month gross (no extras), negotiable. Contact venk@cox.net or (619) 504-5830. [835] SHARE OFFICE SPACE IN LA MESA JUST OFF OF LA MESA BLVD: 2 exam rooms and one minor OR room with potential to share other exam rooms in building. Medicare certified ambulatory surgery center next door. Minutes from Sharp Grossmont Hospital. Very reasonable rent. Please email KLewis@SDCMS.org for more information. [867] NONPHYSICIAN POSITIONS AVAILABLE / WANTED MEDICAL RECEPTIONIST NEEDED: Must be detailed-orientated and organized. Knowledge of all types of insurance (Medicare, Medi-Cal, HMO, PPO), knowledge of Allscripts PM and EHR is a plus! Bilingual English/Spanish. Duties: scheduling and confirmation of patient appointments; checking in and out of patients and processing co-pays, as well as on-the-spot referrals for a specialist/procedures; triage patient messages to physicians, which may include medications or emergencies; prepare and maintain accurate medical record files and notes according to procedures; follow up with insurance companies for insurance eligibility and authorizations. Two years experience as a medical receptionist required! Fax resume to (760) 967-9010. [198]

MEDICAL BILLER AND CODER: The ideal candidate will be a great communicator, with extensive experience in out-of-network billing and neurosurgery field. Will be able to set up in-house billing procedures as we transition from outsourced billing to in-house, and oversee all aspects of the billing cycle. Qualifications Required: 3–5 years experience in surgical and out-of-network billing a must; medical billing and coding certification required; ICD-10 coding certification or experience preferred; high computer literacy and experience with EMR systems required; knowledge of eClinical Works software preferred. Salary: 60K + incentive and benefits. Please send your resume, cover letter, and salary history to olgald@ sdneurosurgery.com. [191] EXPERIENCED, PART-TIME BILLER/CODER FOR SPORTS/SPINE/PAIN PRACTICE (ENCINITAS): Growing medical practice seeks experienced, motivated, consistent biller/coder to work 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]

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

SAN DI EGO PHYSICIAN.org 35

POETRY AND MEDICINE

Rain, Moonlight, and a Secret Password

by Daniel J. Bressler, MD A primary care practice,

such as mine, is full of close encounters with death and dying. In short order, the clinical conversation can transform from “Hello, how are you?” to “I’m afraid the tests show you’re dying.”

Some sobering recent examples [rendered anonymous by altering identifying information] include: a vital and engaging elderly lawyer who presented to me with an extreme kind of arm pain that I suspected (and soon validated

by X-ray) meant a pathologic fracture from newly diagnosed aggressive metastatic cancer; a loving, middleaged nurse whom I cleared for elective gynecologic surgery developed a postop aspiration pneumonia that soon became complicated by adult respiratory distress syndrome; a non-urgent work-up for fatigue in a senior advertising executive and long-distance swimmer led to a diagnosis of advanced congestive heart failure with an ejection fraction of 15%, likely from viral myocarditis. These cases remind me that part of being a physician is the responsibility of shunning wishful thinking. Yes, we can hope for the best, but we must also prepare for, rule out, and treat the worst, including such deadly diseases.

This past March, during a strong early-evening rainstorm, I remember lying on my bed listening to some seeming pattern as the whipped, wet wind pounded the roof. Later that evening, when the storm let up, I took my dog for a moonlit walk in our Mission Hills 36 jan uary 2014

neighborhood. The lunar light seemed to want to give me a message, and yet I couldn’t quite grasp it. The message was subliminal, non-linguistic. It was “merely” an intimation.

“Philosophy is the practice of dying.”

I first heard this phrase in a college philosophy class. Socrates, facing his own death, says it in Plato’s play Phaedo.

Although I never grasped its meaning, it stayed with me over the next four decades. Over the years I would occasionally recall it and try to extract a convincing interpretation, always to no avail. Sometimes it would arise during my reflections on the dying process or death of one of my patients or someone else in my inner circle of concern. It also arose on that moonlit March walk with my perennially philosophic pooch, Izzy.

I came home that night and scribbled some lines that eventually became this poem, “Intimations.” In it, I try to find what the wind on the roof, the moonlight through the clouds, and this old Platonic proverb were telling me.

By way of clarification, the word shibboleth comes to English from the Hebrew Bible (Judges xii:4-6) where it is used by the Gileadites in their battle with the Ephraimites as a linguistic tool to distinguish friend from foe. It means “secret password.”

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

Intimations

This wind is the sighing of angels This moonlight the dazzle of saints This sea that we hear in a seashell Is the ocean regathering rains.

This prayer is a search for that number That clues us to laugh in our tomb A sound we can almost remember A shibboleth learned in the womb.

This chant is the practice of dying This breath is eternity’s friend This kite of infinity’s flying Pulling the string in our hand.

We sense it through loss and through trances We feel it through grief and through song We see it in glimpses and glances It’s that taste on the tip our tongue It’s a hunch, a hope, and a vision A hint, a scent, and a theme It’s the golden key out of this prison It’s the voice rising out of a dream.

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