March 2014 by San Diego Physician

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official publication of SDCMS March 2014

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“Physicians United for a Healthy San Diego”

NORCAL Mutual is owned and directed by its physician-policyholders, therefore we promise to treat your individual needs as our own. You can expect caring and personal service, as you are our first priority. Visit norcalmutual.com, call 877-453-4486, or contact your broker.

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

S A Nâ&#x20AC;&#x2C6; D I E G Oâ&#x20AC;&#x2C6; P HY S I CI A N .or g O c tob e r 2011

Brad Pruitt, M.D., MBA ‘11 Founder of nPruv “My inspiration for nPruv evolved from my Lab to Market experience. There is no other MBA program around that combines a health sciences focus with a rigorous business curriculum and access to industry leaders. Through Rady, I was prepared to launch and fund a new enterprise. “

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DCMS Bioethics Commission: S Building Bridges of Understanding

PAULA GOODMAN-CREWS, LCSW, AND MITSUO TOMITA, MD

RT BENE E 18 NON B I L What Makes Life Worth Living?

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24 Advance Care Planning: It Should Be for Everyone

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KARL STEINBERG, MD, CMD

dvance Care Planning in A the Community: Taking the Journey Together

SONYA K. CHRISTIANSON, MD

LONDON CARRASCA, MPH, RN

The Ideal of Imperfect Autonomy

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DANIEL J. BRESSLER, MD, FACP

ocial Media: Establishing S Guidelines for Its Ethical Use TIMOTHY BAROUNIS, MD

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Calendar • Get in Touch • Commercial Real Estate Tips & Trends • And More …

Congratulations and Thank You to These SDCMS Members!

An Interview With Dr. David Bazzo VIMAL I. NANAVATI, MD, FACC, FSCAI

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 ES EDITOR: Adam Elder

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Choosing Wisely: Five Things Physicians and Patients Should Question the American Gastroenterological Association

N COM OUT 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), Holly B. Yang, MD AT-LARGE ALTERNATE DIRECTORS Karl E. Steinberg, MD, Phil Kumar, MD, Samuel H. Wood, MD, Elaine J. Watkins, DO, Carl A. Powell, DO 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

Avoid Being Put on the RAC THE DOCTORS COMPANY

Physician Marketplace Classifieds

14 2 March 2014

Ask More, Judge Less HELANE FRONEK, MD, FACP, FACPH

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.]

Advances in the Diagnosis and Treatment of Atrial Fibrillation Atrial fibrillation affects more than 2.4 million Americans. As the incidence of this condition continues to rise, so does the need for primary care specialists and cardiologists to understand overall management and the role of emerging therapeutic agents and techniques. Sharp HealthCare is hosting a conference featuring leaders in the field of cardiac electrophysiology. They will address topics related to medical management and interventional therapies for atrial fibrillation.

7:30 a.m. to 2:30 p.m., Saturday, April 26, 2014 DoubleTree by Hilton Hotel San Diego â&#x20AC;&#x201C; Mission Valley 7450 Hazard Center Drive San Diego, CA 92108 5.0 Continuing Medical Education (CME) credits will be provided. Registration Free for physicians, hospitalists, nurse practitioners and physician assistants

To learn more or to register, visit www.sharp.com/afibconference or call 1-800-82-SHARP (1-800-827-4277).

CORP586A ÂŠ2014 SHC

/////////briefly ///////////////////noted ////////////////////////////////////////////////////////////////////// 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

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.

ICD-10 Implementation: Chapters 7, 8, 17 (webinar) MAR 19: 12:15pm–1:15pm Certified Medical Compliance Officer (course) MAR 24, 31, APR 7, 14, 28, MAY 5, 12, 19, JUN 2, 9, 16, 23: 10:00am–11:30am Get in the Know: How Your Uninsured Patients Can Get Insured (seminar) MAR 27: 5:30pm–7:30pm, Dinner Provided, Email Victor. Bloomberg@SDCMS.org

Cma Webinars CMAnet.org/events Should I Join an ACO? MAR 19: 12:15pm–1:15pm Physician Practice Options: Self-employed vs. Group Affiliation? MAR 26: 12:15pm–1:15pm Surviving Covered California: What Physicians Need to Know APR 23: 12:15pm–1:15pm

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Stage 2 Meaningful Use, the 2014 Edition: What You Need to Know! APR 30: 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. 22nd Annual Butters-Kaplan West Coast Neuropsychology Conference MAR 20–23 (https://cme.ucsd. edu/neuro/) 19th Annual Primary Care in Paradise MAR 24, 25, 26, 27 (www.scripps.org/events/ primary-care-in-paradisemarch-24-2014)

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

29th Annual New Treatments in Chronic Liver Disease MAR 28, 29, 30, 31 (www. scripps.org/events/newtreatments-in-chronic-liverdisease-march-28-2014) Brain Injury Rehabilitation Conference MAY 16, 17 (www.scripps. org/events/brain-injuryrehabilitation-conferencemay-16-2014) RCMA’s 10th Annual “Cruisin’ Thru CME” JUL 9–22 (www.rcmanet. org/Portals/17/04Events/ Flyer/2014Cruise.pdf)

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 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

Beware the Ides of March.

4 march 2014

W SDCMS.org • SanDiegoPhysician.org CEO • EXECUTIVE DIRECTOR Tom Gehring at (858) 565-8597 or Gehring@SDCMS.org

— The Soothsayer to Julius Caesar, Warning of His Death

”

IT PROJECT MANAGER Victor Bloomberg at (619) 252-6716 or Victor.Bloomberg@SDCMS.org

/////////////////////////////////////////////////////////////////////////////////////////////////// All san diego county

Physicians

Join the San Diego County Medical Society for a networking opportunity and mixer

Thursday, April 3

5:00pm to 8:00pm Handlery Hotel, 950 Hotel Circle North San Diego, CA 92108

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Come mingle, socialize, and network with your fellow San Diego County physicians! Complimentary hors d’oeuvres and drinks will be served, and all attendees will be entered to win several raffle prizes, including a two night package with golf, spa, breakfast and dinner at the Temecula Creek Inn.

Medical Reimbursement Specialists

RSVP: Emailthe your namemedical and malpractice insurance. Now, the Doctors Company has provided highest-quality telephone number to Jen Ohmstede The Doctors Company Insurance Services offer the expertise to protect your practice from risks at JOhmstede@SDCMS.org ce. From slips and falls to emerging threats in cyber security—and everything in between. We st coverage at the most competitive prices. So talk to us today and see how helpful our experts ng your practice for the risks it faces right now—and those that may be right around the corner.

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

Special Report: Buying Commercial Property It is easy to get excited about the idea of buying commercial real estate, be it as an investment property or for your practice. If you buy a well-located property in good structural condition, its value will inevitably appreciate over a long enough period of time. Your mortgage payments will likely be fixed for many years while rents continue to climb. You will build equity by paying down principal and through appreciation, and the idea of passive income or — for owner-user purchases — “paying yourself” certainly sounds attractive. If and when you get that call from your broker, friend, or colleague with an opportunity to acquire commercial real estate, make sure you consider the pros and cons.

Owner-User Property An owner-user property is a commercial building or condominium that a business or practice buys for its own use. With medical property, typically a group of practice owners or a health system forms a limited liability company, acquires the property, and leases the space back to the practice or medical group. The obvious exercise is to compare the costs, benefits, and challenges of the purchase opportunity to those of leasing or renewing. Flexibility Many say buying commercial property comes with less flexibility than leasing, but that is not necessarily the case with medical buildings. Most medical office leases have at least five-year terms and are more commonly seven to 10 years or more in length, particularly when a relocation or a significant amount of tenant improvements is involved. In such instances, a future desire or need to relocate, expand, or consolidate prior to the lease expiration is likely going to come with significant cost and challenges. If you own your building, on the other hand, you can sell at any time, with your biggest risk being market conditions at the time you want or need to sell. The single biggest risk of ownership is the potential for circumstances to arise that result in your needing to sell in a down market. Use your resources and advisers, understand the fundamentals of the 6 march 2014

subject property and where you are in the real estate cycle, and spend some time thinking about the likelihood of being forced into selling at some point in the future. Cost Here is a great rule of thumb I like to use as a back-of-the-napkin way to look at the effective cost of buying vs. leasing. Assume 5% interest and a 25-year amortization, a 40% tax bracket and tenant improvement costs of $100 per square foot (i.e., the property is being acquired in shell condition or the T.I.’s will be gutted and rebuilt), and consider the scenario where you are weighing a building or medical condo acquisition vs. the renewal of your existing lease. Naturally, most medical tenants want to avoid relocation given the cost of tenant improvements, but try not to be too quick to conclude that moving does not make sense economically. Using the assumptions mentioned above, after taxes, principal pay-down, and 2% annual appreciation, the buyer is saving money if the property being acquired is less than 200 times the gross monthly rental rate. As an example, buying a property at $500 per square foot is generally more cost-effective than leasing space at $2.50 per square foot ($2.50 on the lease x 200 = $500 per square foot on the purchase). So ask yourself: If I am/will be paying $2.50 per square foot in rent, can I find a property in the area for $500 per square foot or less? You can apply that same math based on your anticipated monthly rent upon renewal ($3.00 in rent vs. $600 per square foot to buy, $3.25 vs. $650, etc.). Of course, you need to be able to afford the mortgage payments and operating expenses before you give too much credit to the long-term benefits of ownership.

Piggybacking on our example, if the purchase price per square foot is 200 times the monthly rental rate, the top-line cost of ownership (before taxes and equity benefits) will exceed your leasing costs by approximately 40%. With the 200X rule, the single most influential variable is the rate of appreciation. If you drop the rate from 2% to 1%, it essentially becomes the “150X” rule. So if you are comparing renewing at $2.50 per square foot, you will want to search for an owner-user property priced at no higher than $375 per square foot. Location There are a number of other factors to consider, such as the growth and stability of your practice, the quality of building, possible varying ages among core physicians or shareholders, and the opportunity cost of investing elsewhere both the money you put down on a purchase and the ongoing premium in monthly top-line cost. But seek caution when being attracted to the lure of property ownership, and be careful with inferior locations. It is a mistake that is too commonly made. Well-located commercial property is less susceptible to swings in market conditions, which means you will enjoy added flexibility and a higher likelihood of surpassing appreciation benchmarks. Poorly located property, on the other hand, will multiply your problems by “200X.” 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.

/////////////////////////////////////////////////////////////////////////////////////////////////// leadership academy

2014 Leadership Academy in San Diego! The 17th annual Western Health Care Leadership Academy is thrilled to welcome keynote speaker Hillary Rodham Clinton, former secretary of state and former U.S. senator from New York. This year’s Academy — formerly the California Health Care Leadership Academy — is scheduled for April 11–13, 2014, at the San Diego Convention Center. Top thinkers and doers will share strategies and resources for accelerating the shift to a more integrated, high performing, and sustainable healthcare system. The conference will examine the most significant challenges facing healthcare today and present proven models and innovative approaches to transform your organization’s care delivery and business practices. Topics will include leadership development, ACA implementation, and practice management. Visit www.westernleadershipacademy.com for more details.

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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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.

Endorsed by

SAN DI EGO PHYSICIAN.org 7

SDCMS-CMA Membership

Congratulations and Thank You to the Following Physicians Who Have Been SDCMS Members for a Third of a Century and Longer! Note: Current SDCMS-CMA Members as of March 3, 2014 SDCMS Member Physician’s Name • Years of Membership Joseph De Luca, MD • 66 Margaret E. Branscom, MD • 64 Alanson A. Mason, MD • 59 Robert M. Barone, MD • 56 Lino P. Trombetta, MD • 54 Raymond Dann, MD • 52 Marjorie A. Crews, MD • 51 Edward J. Sheldon, MD • 51 Garry E. Goldfarb, MD • 48 Robert Penner, MD • 47 Raymond M. Peterson, MD • 47 Myron Schonbrun, MD • 47 Richard N. Learn, MD • 46 Allan H. Rabin, MD • 46 Richard O. Butcher, MD • 45 George W. Kaplan, MD • 45 Donald J. Ritt, MD • 45 John A. Berger, MD • 44 Leonard S. Bernstein, MD • 44 Robert A. Bullock, MD • 44 Allan H. Goodman, MD • 44 Miguel A. Losada, MD • 44 William L. Nyhan, MD • 44 Leonard M. Okun, MD • 44 Leonard David Rutberg, MD • 44 Steven A. Balch, MD • 43 Elaine H. Cohen, MD • 43 H. Douglas Engelhorn, MD • 43 James C. Esch, MD • 43 Edwin B. Fuller, MD • 43 Sidney H. Levine, MD • 43 Richard D. Perlman, MD • 43 8 march 2014

Robert Matthew Thomas Jr., MD • 43 Fernando A. Zamudio, MD • 43 Lawrence Nathan Cooper, MD • 42 Franklin Crystal, MD • 42 Anthony J. Cuomo, MD • 42 Steven R. Drosman, MD • 42 Thomas A. Flanagan, MD • 42 Ronald J. Goldman, MD • 42 Leon R. Kelley, MD • 42 Victor H. Lipp, MD • 42 William G. Moseley, MD • 42 David R. Schmottlach, MD • 42 Russell Stuart Weeks, MD • 42 O. Douglas Wilson, MD • 42 Dennis F. Coughlin, MD • 41 George David Gibson, MD • 41 Danny L. Keiller, MD • 41 Thomas G. Neglia, MD • 41 William A. Pitt, MD • 41 David J. Shaw, MD • 41 Dee Edward Silver, MD • 41 Lawrence P. Bogle, MD • 40 Frank E. Corona, MD • 40 Edward M. Goldstein, MD • 40 William S. Halsey, MD • 40 Yaroslav Kushnir, MD • 40 John J. Lilley, MD • 40 Jerome S. Litvinoff, MD • 40 John B. Marino III, MD • 40 Lawrence S. Pohl, MD • 40 Carlos J. Sanchez, MD • 40 Joseph Shurman, MD • 40

James P. Tasto, MD • 40 Donald C. Balfour, MD • 39 John Michael Casey, MD • 39 Ronald E. Feldman, MD • 39 Henry E. Golembesky, MD • 39 Richard Greenfield, MD • 39 Vincent J. Guzzetta, MD • 39 San C. Hsieh, MD • 39 Steven M. Leshaw, MD • 39 Stuart C. Marshall, MD • 39 Martin Joseph McGreevy, MD • 39 G. Douglas Moir, MD • 39 Gerald W. Ondash, MD • 39 Kenneth Ott, MD • 39 David F. Polster, MD • 39 Bruce M. Prenner, MD • 39 Stephen L. Reitman, MD • 39 William F. Resh, MD • 39 Hyman Arthur Silverman, MD • 39 Robert Singer, MD • 39 Thomas R. Vecchione, MD • 39 Richard L. Buccigross, MD • 38 Paul B. Dean, MD • 38 Nicholas R. Frost, MD • 38 Theodore G. Ganiats, MD • 38 Harry C. Henderson, MD • 38 P. Lance Hendricks, MD • 38 Sandra L. Jassmann, MD • 38 Leonard M. Kornreich, MD • 38 L. Dale Lapp, MD • 38 Marc J. Lebovits, MD • 38 Marshall J. Littman, MD • 38 Peter H.B. McCreight, MD • 38 Daniel A. Nachtsheim, MD • 38 Julie A. Prazich, MD • 38 Robert S. Scheinberg, MD • 38 Jeffrey W. Selzer, MD • 38 Paul F. Speckart, MD • 38 Robert M. Stein, MD • 38 Michael J. Thoene, MD • 38 Patricia C. Venn-Watson, MD • 38 Arthur B. Warshawsky, MD • 38 Robert E. Brucker, MD • 37 James E. Bush, MD • 37 Douglas H. Clements, MD • 37 Stewart L. Frank, MD • 37 Daniel Gardner, MD • 37 Mitchel P. Goldman, MD • 37 Gary L. Isley, MD • 37 Adrian M. Jaffer, MD • 37 Michael K. Kan, MD • 37 Richard A. Katz, MD • 37 Donald C. Lipkis, MD • 37 Jon H. Lischke, MD • 37 Merritt S. Matthews, MD • 37 Howard G. Milstein, MD • 37 Rodrigo A. Munoz, MD • 37 Robert C. Pace, MD • 37 Ruth M. Robles-Goche, MD • 37 Robert J. Santella, MD • 37 Barry M. Scher, MD • 37 Joseph A. Scoma, MD • 37

Richard L. Stennes, MD • 37 Eric C. Yu, MD • 37 Paul J. Zlotnik, MD • 37 Larry N. Ayers, MD • 36 John Randolph Backman, MD • 36 Lawrence D. Eisenhauer, MD • 36 Leon Fajerman, MD • 36 Theodore L. Folkerth, MD • 36 Athanasios J. Foster, MD • 36 Richard G. Friedman, MD • 36 James Thomas Hay, MD • 36 Wayne L. Iverson, MD • 36 Roy Alan Kaplan, MD • 36 Jerry Kolins, MD • 36 Charles R. Kossman, MD • 36 William P. Mann, MD • 36 Leslie Alison Mark, MD • 36 Harrison R. McDonald, MD • 36 Thomas E. Page, MD • 36 Arthur C. Perry, MD • 36 Edward L. Racek, MD • 36 Scott A. Riedler, MD • 36 Jeffrey M. Rosenburg, MD • 36 Edward L. Singer, MD • 36 Steven M. Steinberg, MD • 36 Douglas A. Wemmer, MD • 36 Carol L. Young, MD • 36 Philip Young, MD • 36 Robert S. Yuhas, MD • 36 William T. Chapman, MD • 35 Gregory T. Czer, MD • 35 Victor M. Dalforno, MD • 35 Blaine A. Fowler, MD • 35 Edward B. Friedman, MD • 35 Paul M. Goldfarb, MD • 35 James Santiago Grisolía, MD • 35 James A. Helgager, MD • 35 Charles Jablecki, MD • 35 R. Bruce Johnson, MD • 35 Joseph F. Leonard, MD • 35 Louis J. Levy Jr., MD • 35 Dom Antonio Lopez-Velez, MD • 35 Jose E. Otero, MD • 35 David Michael Priver, MD • 35 Michael John Rensink, MD • 35 Steven R. Ruderman, MD • 35 Jeffrey A. Sandler, MD • 35 Maurice P. Sherman, MD • 35 William I. Stanton, MD • 35 Paul L. Treger, MD • 35 Raymond M. Vance, MD • 35 Benito Villanueva, MD • 35 Marvin J. Zaguli, MD • 35 Robert W. Ziering, MD • 35 Nicholas A. Zubyk, MD • 35 Lance L. Altenau, MD • 34 Hans J. Anderson, MD • 34 C. Dennis Bucko, MD • 34 David C. Campbell, MD • 34 Irene L. Chennell, MD • 34 Jorge M. Del Aguila, MD • 34 Thomas R. Farrell, MD • 34

Doctor’s recommend Robert A. Ginsberg, MD • 34 Michael Gordon, MD • 34 Robert N. Hamburger, MD • 34 David P. Hansen, MD • 34 Joel M. Heiser, MD • 34 William P. Hitchcock, MD • 34 Andrew G. Israel, MD • 34 Marilyn C. Jones, MD • 34 Rokay G.A. Kamyar, MD • 34 Murray J. Kornblit, MD • 34 Eva P.-S. Leonard, MD • 34 Albert L. Martinez, MD • 34 Jeffrey B. Mazin, MD • 34 Ben Medina, MD • 34 S. Michael Millbern, MD • 34 James S. Otoshi, MD • 34 Alexander Rodarte, MD • 34 Nathaniel G. Rose, MD • 34 Eugene W. Rumsey Jr., MD • 34 Pritam Singh, MD • 34 Laurence K. Tanaka, MD • 34 John H. Taylor, MD • 34 Donald P. Tecca, MD • 34 Gary VandenBerg Jr., MD • 34 John E. Welton, MD • 34 Michael C. Wong, MD • 34 John A. Wright Jr., MD • 34 George G. Zorn III, MD • 34 Thomas C. Adamson III, MD • 33 Jorge T. Arce, MD • 33 Gonzalo R. Ballon-Landa, MD • 33 Frank D. Bender, MD • 33 Michael T. Bennett, MD • 33 Duane M. Buringrud, MD • 33 Kenneth W. Carr, MD • 33 Marcus Contardo, MD • 33 Harold Copans, MD • 33 Dennis L. Costello, MD • 33 John H. Detwiler, MD • 33 Bessie B. Floyd, MD • 33 Carla G. Fox, MD • 33 Roger A. Freeman, MD • 33 Peter Sayre Friend, MD • 33 Robert Louis Gagnon, MD • 33 Steven R. Garfin, MD • 33 Jeffrey I. Gorwit, MD • 33 Said M. Hashemi, MD • 33 Robert E. Hertzka, MD • 33 Paul VB Hyde, MD • 33 Hart Isaacs, MD • 33 Gary M. Jacobs, MD • 33 Nancy R. Kollisch, MD • 33 John A. La Fata, MD • 33 Gary P. McFeeters, MD • 33 Ronald H. Miller, MD • 33 David Ross Ostrander, MD • 33 Richard E. Payne, MD • 33 Glenn O. Plummer, MD • 33 Gary Prodanovich, MD • 33 Robin Carol Wedberg, MD • 33 Paul R. Woody, MD • 33

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Voices in Medicine

An Interview With Dr. David Bazzo One in an Occasional Series of Interviews of SDCMS Physician Leaders by Vimal I. Nanavati, MD, FACC, FSCAI Dr. David Bazzo, SDCMS-CMA member since 1994, is board-certified in family medicine and sports medicine and professor at the UC San Diego School of Medicine.

Dr. Nanavati: What would you change in medicine to improve the situation for all patients and physicians, irrespective of their mode of practice? Dr. Bazzo: I would say protecting MICRA is at the top of my list. If MICRA is defeated, it will have wide-ranging impacts on many levels affecting patient care and patient access, and unnecessarily increase the cost to deliver healthcare. MICRA affects all prac10 march 2014

Dr. Nanavati: I understand you’re involved with many educational programs as a UCSD faculty member, including undergraduate education, resident and fellow education, and practicing physician education. Why the interest? Dr. Bazzo: I view medical education as a continuum, not just the silos of medical school, residency, and CME. Doctors are lifelong learners, and I gain personal satis-

In the exam room we impact one patient; through advocacy — and membership — we impact populations.

Dr. Nanavati: Why should every San Diego County physician belong to SDCMS? Dr. Bazzo: Having been an SDCMS member for 20 years now, I can attest to the unique opportunities SDCMS provides physicians. Not only the opportunity to interact with our colleagues across specialties, modes of practice, and localities, but also the ability to advocate collectively for our patients. In the exam room we impact one patient; through advocacy — and membership — we impact populations. Many physicians too often take for granted all that’s being done on their behalf, and on their patients’ behalf, in Sacramento and Washington — for example, defending MICRA, working to change the sustainable growth rate formula, and protecting quality access to care. Simply complaining about the present state of affairs doesn’t amount to anything; we have to be a part of the solution. Paying your SDCMS-CMA membership dues sends a strong message that you support patients’ rights and your rights as a physician to continue taking the best care of your patients without outside interference.

medical issues early and seek preventive care will lead to a healthier society. In the long run, we may realize cost savings as well.

tices and organizations you work under, and is the major issue at hand. Second, we need to fix the sustainable growth rate formula. The SGR does not take into account inflation or cost-of-living indexes used to determine Medicare Part A. According to the SGR, every year physicians are faced with an ever-increasing cut to their Medicare Part B funding. If allowed to go unaddressed by Congress, physicians will be faced with a 26% cut in their reimbursements, forcing most practices to curtail critical services and perhaps forcing some to close. Third, access to physicians is critical. The Affordable Care Act is merely a first step in this direction. Many patients don’t have access to basic medical care and wait until the disease progresses too far before they have no choice but to seek emergency attention. Treating disease in late stages is bad for patients and increases medical costs unnecessarily. Giving people options to address

faction by helping them at all levels. Even through the UCSD Physician Assessment and Clinical Education (PACE) Program, we have the ability to help doctors and patients by enhancing practice when a deficiency has been noted. Additionally, to increase access to primary care, I’ve helped to create the curriculum for the Physician Reentry and Retraining (PRR) Program to strengthen the knowledge and skills of physicians who wish to renter the workforce in primary care. As a physician in practice, I can help one patient at a time. As an educator, I can help many physicians who can then help thousands of patients. The analogy is similar to joining SDCMS-CMA, in other words, the sphere of impact on improved patient health is increased exponentially. Dr. Nanavati: What advice would you give today’s medical students? Dr. Bazzo: There is no better profession than medicine. The reasons are many: you have the singular privilege of serving your fellow man; you have the ability to relieve your patients’ pain and suffering; there will always be a need for medicine and medical care anywhere you may go; the exciting frontier of genetics and genomic medicine lies in our midst, awaiting new hopes to cure diseases long considered chronic and incurable.

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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 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 march 2014

How The List on Page 13 Was Created

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

The American Gastroenterological Association (AGA) convened a work group that included members from the Clinical Practice and Quality Management Committee (CPQMC), chair of the Practice Management and Economics Committee (PMEC), the chief medical officer for the AGA Digestive Health Outcomes Registry®, and members of the AGA Institute governing board. Ideas for the “five things” were solicited from the workgroup for review by the CPQMC, which developed additional topics, resulting in six draft items. The workgroup continued to pare down and refine the list before submitting a final draft to both the CPQMC and the PMEC for approval. After final refinements were made to simplify language and avoid complex clinical terminology, the final list was submitted to and approved by the AGA Institute governing board. AGA’s disclosure and conflict of interest policy can be found at www.gastro.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 Gastroenterological Association (AGA) 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.

For pharmacological treatment of patients with gastroesophageal reflux disease (GERD), long-term acid suppression therapy (proton pump inhibitors or histamine2 receptor antagonists) should be titrated to the lowest effective dose needed to achieve therapeutic goals. The main identifiable risk associated with reducing or discontinuing acid suppression therapy is an increased symptom burden. It follows that the decision regarding the need for (and dosage of) maintenance therapy is driven by the impact of those residual symptoms on the patient’s quality of life rather than as a disease control measure.

Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals. A screening colonoscopy every 10 years is the recommended interval for adults without increased risk for colorectal cancer, beginning at age 50. Published studies indicate the risk of cancer is low for 10 years after a high-quality colonoscopy fails to detect neoplasia in this population. Therefore, following a high-quality colonoscopy with normal results the next interval for any colorectal screening should be 10 years following that normal colonoscopy.

Do not repeat colonoscopy for at least five years for patients who have one or two small (<1 cm) adenomatous polyps, without high-grade dysplasia, completely removed via a high-quality colonoscopy. The timing of a follow-up surveillance colonoscopy should be determined based on the results of a previous high-quality colonoscopy. Evidence-based (published) guidelines provide recommendations that patients with one or two small tubular adenomas with lowgrade dysplasia have surveillance colonoscopy five to 10 years after initial polypectomy. “The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings, family history, and the preferences of the patient and judgment of the physician).”

For a patient who is diagnosed with Barrett’s esophagus, who has undergone a second endoscopy that confirms the absence of dysplasia on biopsy, a follow-up surveillance examination should not be performed in less than three years as per published guidelines. In patients with Barrett’s esophagus without dysplasia (cellular changes) the risk of cancer is very low. In these patients, it is appropriate and safe to exam the esophagus and check for dysplasia no more often than every three years because if these cellular changes occur, they do so very slowly.

For a patient with functional abdominal pain syndrome (as per ROME III criteria), computed tomography (CT) scans should not be repeated unless there is a major change in clinical findings or symptoms. There is a small but measurable increase in one’s cancer risk from X-ray exposure. An abdominal CT scan is one of the higher radiationexposure X-rays — equivalent to three years of natural background radiation. Due to this risk and the high costs of this procedure, CT scans should be performed only when they are likely to provide useful information that changes patient management.

SAN DI EGO PHYSICIAN.org 13

Risk Management

Avoid Being Put on the RAC Be Prepared for a Recovery Audit Contractor Audit By Kathleen Stillwell, MPA/HSA, RN, CPHRM, Patient Safety Risk Manager II, SDCMS-endorsed The Doctors Company — For more patient safety articles and practice tips, visit www. thedoctors.com/patientsafety.

What Is a RAC Audit? Any medical practice submitting claims to a government program, such as Medicare, may contend with a Recovery Audit Contractor (RAC). RAC audits are not one-time or intermittent reviews; they are a systematic and concurrent operating process for ensuring compliance with Medicare’s clinical payment criteria, documentation, and billing requirements. The RAC program was signed into law by the Medicare Prescription Drug Improvement and Modernization Act of 2003 and made permanent by the Tax Relief and Health Care Act of 2006. Its purpose is to identify improper Medicare payments — both overpayments and underpayments. RACs use proprietary software programs to identify potential payment errors in such areas as duplicate payments, fiscal intermediaries’ mistakes, medical necessity, and coding. RACs also conduct medical record reviews. In fiscal years 2010 and 2011, RACs identified half of all claims they reviewed as having resulted in improper payments (1). The program’s mission is to detect and correct past improper payments so that the Center for Medicare and Medicaid Services (CMS) can implement actions that will prevent future improper payments (2): • Providers can avoid submitting claims that do not comply with Medicare rules. • CMS can lower its error rate. • Taxpayers and future Medicare beneficiaries are protected. 14 march 2014

Who Is Subject to a RAC Audit? • Hospitals • Physician practices • Nursing homes • Home health agencies • Durable medical equipment suppliers • Any provider or supplier that submits claims to Medicare Who Is the RAC Auditor? CMS has contracted with RAC auditors for each region in the United States. It is important to know who the RAC auditor is in your region. Never ignore a letter from one of these organizations. The United States is divided into four regions. Each region has a designated recovery audit contractor — California is in Region D: • Region A RAC Auditors: Performant Recovery Inc., and subcontractor PRGSchultz USA Inc. • Region B RAC Auditors: CGI Technologies and Solutions Inc., and subcontractor PRG-Schultz USA Inc. • Region C RAC Auditors: Connolly Consulting Associates Inc., and subcontractor Viant Payment Systems Inc. • Region D RAC Auditors: HealthDataInsights Inc. Las Vegas, Nevada, and subcontractor PRG-Schultz USA Inc.

What Does the RAC Review? The recovery audit looks back three years from the date the clam was paid. RACs are required to employ a staff consisting of nurses, therapists, certified coders, and a physician. The RAC reviews claims on a post-payment basis. There are three types of review: 1. Automated: No medical record needed 2. Semi-automated: Claims review using data and potential human review of a medical record or other documentation 3. Complex: Medical record required What Can You Do to Prepare for a RAC Audit? Assess your risk for billing issues by performing a risk analysis of your billing practices. Assign a knowledgeable member of your staff to review your billing processes and develop a billing compliance plan. Consider hiring a contractor for this task. Identify billing issues, keep track of denied claims, and look for patterns and determine what corrective actions you need to take to avoid improper payments. Common billing errors include: • Inadequately trained staff • Lack of time • Did not follow recommendations in

RAC audits are not one-time or intermittent reviews; they are a systematic and concurrent operating process for ensuring compliance with Medicare’s clinical payment criteria, documentation, and billing requirements. patient histories, cloning (when you cut and paste the same examination findings), and templates filled in to reflect a more thorough or complex examination/visit. Review these issues with your EMR company and determine if your EMR program has the potential to automatically upcode billing based on EMR documentation.

Federal Register bulletins • Did not consult Health and Human Service bulletins • Misinterpretation of rules • New staff/new billing company The person responsible for implementing the billing compliance plan should regularly monitor RAC progress in your region. Each RAC must maintain a website with information on new audit focus areas and the status of a provider’s audits. Areas to include in your assessment and monitoring plan include: • Review denied claims categories by RAC audit • Keep abreast of notifications on CMS website • Review annual Office of Inspector General (OIG) work plan to identify audit areas • Monitor RAC progress at regional RAC (its web postings) • Perform audit of your billing practices Potential Issues With Electronic Medical Records The OIG is studying the link between electronic medical record (EMR) systems and coding for billing. There is a concern that some EMR systems may upcode billing through automatically generated detailed

Fundamentals for Compliance Establish compliance and practice standards and conduct internal monitoring and auditing to evaluate compliance. Conduct appropriate training and education for staff and respond to deficiencies identified during internal audits. Establish corrective action plans and enforce disciplinary standards when necessary. Medical billing is complex. Billers and coders must be knowledgeable about many areas pertaining to billing/reimbursement. Be sure your billing staff understands local medical review policies and is knowledgeable of practice jurisdictions. Billing personnel staff must stay current on coding requirements and keep up with industry changes, understand denial and appeal processes, and be able to identify resources for support. What to Do if You Are Audited Do not ignore a letter from the RAC auditor. It is recommended you have an attorney assist you with your response to a RAC audit. Check with your insurance company to determine if you can get help with the audit. The Doctors Company, for example, provides RAC audit legal assistance for all members as part of its MediGuard® coverage. Before you send records to the auditor, be sure to review them in a “self-review.” Are there common themes? Are you coding with the correct documentation? Make copies of everything you send to the RAC auditor and be sure to keep a copy of all documentation. Send medical records via certified mail. Staying on top of the RAC audit process is important as there are multiple policies and procedures governing RAC audits. The RAC can request a maximum of 10 medical records from a provider in a 45-day period. The time period that may be reviewed has changed from four years to three years. Responses are time-sensitive, and significant penalties may result if they are not handled properly. RACs are paid on a contingency basis for overpayments and underpayments. If you agree with the RAC demand

letter, you have the choice of paying by check or recoupment from future payments, or you may request an extended payment plan. If a recoupment demand is issued, you may pay by check within 30 days with no appeal, allow recoupment from future payments, or request or apply for an extended payment plan. There is an appeal process if you do not agree with the audit findings. Do not confuse the RAC Discussion Period with the appeals process. If you disagree with the RAC determination, do not stop with sending the discussion letter detailing why you disagree with the findings. File an appeal before the 120th day after the demand letter. Send correspondence to RAC via certified mail. It is recommended you have legal representation to advise you in the response to a recoupment demand, to determine if you should appeal, and to ensure you meet the required regulatory requirements of the appeal process. Where to Get More Information on Government Audits More information on the growing risk of government investigations and audits can be obtained through five short videos featuring tips from Kevin R. Warren, Esq., of Michelman & Robinson LLP’s Healthcare Practice at http://ow.ly/rP02n. The videos address how to create an effective compliance program, why it’s important to train staff to avoid improper and exaggerated coding, what steps to take if your practice receives a subpoena, and how to properly protect electronically stored information. References: 1. Medicare Recovery Audit Contractors and CMS’s Actions to Address Improper Payments, Referrals of Potential Fraud, and Performance. Office of Inspector General. U.S. Department of Health and Human Service. August 2013. https://oig.hhs. gov/oei/reports/oei-04-11-00680.asp. Accessed Dec. 16, 2013. 1. The Recovery Audit Program and Medicare: The Who, What, When, Where, How and Why? Centers for Medicare & Medicaid Services. May 13, 2013. www. cms.gov/Research-Statistics-Dataand-Systems/Monitoring-Programs/ Recovery-Audit-Program/Downloads/ The-Recovery-Audit-Program-andMedicare-Slides-051313.pdf. Accessed Dec. 16, 2013. SAN DI EGO PHYSICIAN.org 15

Bioethics

SDCMS Bioethics Commission Building Bridges of Understanding

By Paula Goodman-Crews, LCSW, and Mitsuo Tomita, MD

At 5:45 p.m., the San Diego County Medical Society (SDCMS) meeting room was beginning to fill. Some rushed in, availing themselves of the hosted buffet dinner before the meeting officially began. Some sauntered in, making their way slowly, stopping to greet colleagues they had not seen in a few months. A retired physician and a UC San Diego professor emeritus, happy to see each other, took seats side by side. A bevy of nursing students was already seated, their names on tent cards and their computers poised for note taking. At the stroke of 6 p.m., everyone was seated. The subject matter that night — “Ethical Issues in Clinical Genetics and Genomics” — presented by Kaiser Permanente physician Mark Nunes, MD, and UC San Diego genetic counselor Lisa Madlensky, PhD, provoked a diversity of reactions and dialogue. Do patients have a right to their genetic information? Which conditions meet criteria for prenatal/pre-implantation diagnosis? Who decides what criteria and on what basis? Who should have access to banking of genetic material? Should newborn genetic screening be mandatory? A diversity of ethics topics is addressed on a regular basis by the members of the SDCMS Bioethics Commission. The Commission’s open membership boasts representatives interested in bioethics from all of the major San Diego County hospitals, including Children’s, Balboa Naval, VA, UC San Diego, Kaiser Permanente, Palomar, Sharp, Grossmont, Scripps Mercy, Scripps Green, Scripps La Jolla, and Edgemoor. Representatives from San Diego County hospices and other long-term care facilities, bioethics schol16 march 2014

ars, and nursing and medical students from surrounding schools attend. The group is multidisciplinary, and — in addition to physicians — nurses, social workers, psychologists, lawyers, and chaplains attend. In short, any professional interested in the practice of bioethics is invited to attend the meetings. One thing is clear: People look forward to attending the SDCMS Bioethics Commission quarterly meetings. Back in 2007, our intent was to form a “moral medical community,” and that goal has been realized. As defined by the Markkula Center for Applied Ethics, “Moral community refers to the network of those to whom we recognize an ethical connection through the demands of justice, the bonds of compassion, or a sense of obligation.” The late physician and ethicist Edmund Pellgrino wrote, “Medicine is at heart a moral enterprise, and those who practice it are de facto members of a moral community. We share a collective moral identity, commitment, and obligation.” In 2007, after surveying and learning there was a collective interest by San Diego hospital bioethics committee chairs in forming a professional community interested in ethics and the practice of medicine, Lynette Cederquist, MD, SDCMS-CMA member since 2005, and Paula Goodman-Crews, LCSW, co-founded the SDCMS Bioethics Commission. Formed under the gracious auspices of SDCMS, the Bioethics Commission has met on a quarterly basis since its inception. It is attended by healthcare professionals who are interested in exploring the ethical dimensions of the clinical and organizational practice of healthcare.

The SDCMS Bioethics Commission’s goals, as written in our bylaws, are straightforward. We endeavor to create a forum for San Diego County physicians and allied health professionals for: • the discussion of bioethics issues • the sharing of bioethics best practices • the development of nonbinding bioethics standards for San Diego County • communications to, for, and from physicians and allied health professionals in matters of bioethics • education on bioethics matters Since its inception, the SDCMS Bioethics Commission, in addition to sponsoring quarterly meetings, created a model draft nonbeneficial treatment policy, a reflection of a San Diego County community standard of practice. This model policy has been shared in most local hospitals and was used as one of several model policies by the California Medical Association in the creation of their model policy, “Responding to Requests for Nonbeneficial Treatment.” In addition, the SDCMS Bioethics Commission was awarded two two-year POLST Community Coalition grants by the California Health Care Foundation under the auspices of the Coalition for Compassionate Care of California. SDCMS Bioethics Commission members have given tremendous time and energy, offering advance care planning/POLST outreach, and engagement, training, and educational seminars to hospitals, skilled nursing facilities, hospices, long-term care custodial facilities, and assisted-living and retirement homes. Our latest endeavor, a partnership with the California State San Marcos Institute for Palliative Care, has resulted in the offering of trainings with community faith leaders to promote dialogue in order to build bridges of understanding. After serving three years as physician co-chair, Dr. Cederquist passed the leadership helm to Mitsuo Tomita, MD, retired SDCMS-CMA member physician, who remains passionate about clinical and public bioethics. Under Dr. Tomita’s leadership, we continue to seek increased engagement with the community-at-large about ethical issues like organ donation, pandemic planning, and advance-care planning. Any physician interested in attending an SDCMS Bioethics Commission meeting is welcome — please email your requests to Kyle Lewis at SDCMS at KLewis@SDCMS.org. Ms. Goodman-Crews is bioethics director, Kaiser Permanente, co-director, SCAL Kaiser Bioethics Program, and co-chair of the SDCMS Bioethics Commission. Dr. Tomita, retired SDCMS-CMA member, is board-certified in family medicine and co-chair of the SDCMS Bioethics Commission.

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Bioethics

What Makes Life Worth Living? By Sonya K. Christianson, MD

Note: All patient names and identifying information have been changed for privacy protection. As a palliative care physician, I find myself regularly posing two questions to my patients: “What makes your life worth living?” or the antithetical question, “What makes life too terrible to live?” Some people have spent months or years in careful thought and deliberation, and have created detailed advance directives through extensive discussions with their primary physicians. Some people know exactly what 18 march 2014

“Do Not Resuscitate” means. More often, however, I find that people have never given these questions a single thought. Commonly, I spend hours with patients and families exploring their values, culture, and beliefs. I ask them probing questions, painting pictures for them of common potential life scenarios — potential outcomes to difficult and critical decisions in medical care. Too often I discover that I am the first doctor to discuss the end of their lives in detail. It’s heartbreaking to think of the number of times I’ve encountered patients who feel angry or frustrated. “If I had known, I

wouldn’t have had this surgery,” “No one has ever talked to me about dying,” or “I would have rather had two months at home than six months in the hospital. Now it’s too late.” In medicine, when treating critical, lifethreatening illness, the question, “What makes life worth living?” should be at the forefront of every treatment decision, made by both patient and doctor. If this question is forgotten, medical care can be given with grave consequences: in discordance with a patient’s values and wishes. As a palliative care physician, I believe in helping patients live the life they want to live. Case #1: “Nancy” Nancy was a 75-year-old woman who had been living independently, cooking her own meals, paying her own bills, and playing chess regularly with her neighbor. She had a sharp sense of humor, and made me laugh with every interaction I had with her. She had no living family — never married, no siblings, and no children. She had fallen and broken her hip, and was admitted for evaluation. The hospitalist called me to see her, saying this patient was “crazy” for refusing surgery. “Nancy, tell me what makes your life worth living? Why would surgery be so terrible?” I asked. After some probing and humor-filled conversation, I found the answer to my question.

“I’m not afraid of surgery. I just can’t stand the idea of living in a rehab facility for weeks.” Living dependently on anyone, even for a limited amount of time, would be too terrible to live through. I learned that Nancy’s parents had died when she was young, and she had fought for her existence throughout her entire life. She had never been dependent on another human being, and to begin now would be absolutely unacceptable. Living in a facility would not be a life worth living. Case #2: “Mary” Mary was a 94-year-old woman with a diagnosis of melanoma localized to her lower left leg. The cancerous lesions were large, oozing copious amounts of fluid and requiring twice-daily dressing changes. Because the cancer was localized, a potentially curative treatment would be amputation of the leg. However, surgery on this frail, elderly woman would mean general anesthesia, weeks of rehabilitation, and potential complex neuropathic pain. There was much discussion among the doctors over the risks and benefits of the surgery. As expected, our answer became clear after long discussions with Mary. “These dressings changes are terrible. I hate having some stranger come to my room every day and spending hours changing them. I hate how smelly my leg is, and how disgusting it looks. I’d rather risk death than live with this disgusting leg.” I learned that Mary had always taken great care in her physical appearance. She took pride in saying, “My husband never saw me without my teeth to the day he died.” Her hair was always perfectly coiffed, and she insisted on putting on lipstick every morning before seeing anyone. To Mary, her physical dignity was of utmost importance. She didn’t mind losing potential function, or even physical independence. Physical dignity was what made life worth living for Mary, and she did not want to live without it. Case #3: “Carlos” Carlos is a 58-year-old man who has been living at a long-term acute care (LTAC) facility for the past 16 months. I’ve often thought that “long-term” and “acute care” were dissonant terms. The antagonism of these two concepts aptly represents the struggle of these patients. These patients live acutely at the brink of death, vulnerable to any simple infection, and yet remain in this precarious state for months at the mercy of machines and carefully monitored

laboratory values. Carlos has a tracheostomy and gets his nutrition through a PEG tube. He has been living dependently on a ventilator for the entirety of these 16 months. He has been hospitalized 10 times in the last year, usually for pneumonia or a UTI, treated with appropriate IV antibiotics, and transferred back to the LTAC afterward. The admitting hospitalist often asks for my consultation when he is admitted to the hospital. The first time I met him, I assembled a family meeting to include his wife, daughter, and Carlos. “Carlos, what brings you joy every day?” Carlos can only move his mouth in a faint whisper due to his tracheostomy. His primary language is Spanish, and we have an interpreter at his bedside. After a loving gaze at his wife, and a few mouth-whispers, we get his answer. “I live to see my wife’s beautiful face.” Carlos has decided that he can live attached to a machine, be dependent on artificial nutrition, and have strangers turning him and poking him with needles on a regular basis. All this is a reasonable price to pay as long as he is able to lift his head slightly, hold his wife’s hand, and experience their mutual love. This was a life worth living. This message made his wife tearful, as she later confessed to me, “He’s so strong. If it were me, I would never be able to live that way.” For his wife, this situation would not be a life worth living.

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I personally believe in one thing: I believe in helping patients live the life they want to live. This is not an easy thing to do. It involves hours of in-depth conversation, learning the patients’ backgrounds, personalities, family structures, cultural values, and identities. All three of these patients were facing life-ordeath decisions. In our medical culture where doctors are given 15 minutes of face-to-face time per day, it’s not surprising that these decisions are difficult. When it comes to critical decisions near the end of life, it is imperative that we have adequate time to listen to our patients’ stories. When my patients’ personalities come alive, and I see how they so vibrantly live, the answers become clear. I simply help them be who they are.

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Dr. Christianson, SDCMS-CMA member since 2011, is currently chief of palliative medicine for Scripps Mercy Hospital in San Diego. She was a former Dr. Seuss Foundation Fellow at San Diego Hospice and the Institute for Palliative Medicine, and chief resident of the Scripps Family Medicine Residency Program. SAN DI EGO PHYSICIAN.org 19 CAP_1402.indd 1

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Bioethics

The Ideal of Imperfect Autonomy By Daniel J. Bressler, MD, FACP

20 march february 2014 2014

Autonomy Defined The term autonomy derives from the Greek words for “self” and “law.” It can be understood as the principle of self-direction, self-determination, and self-management. The modern conception assumes that a person who possesses autonomy is rational, satisfies a certain level of intelligence called “capacity,” and is not being coerced by outside forces. It is associated in philosophical and political theory with the concepts of free will, choice, and democracy. Autonomy’s Place in Modern Bioethics Autonomy is one of the four basic pillars of the modern bioethical paradigm, the other three being beneficence (the obligation to help), non-maleficence (the duty not to harm), and justice (the goal of distributing limited resources fairly). Each of these principles has its own justification, constituency, and advocates. The relative importance of each of these principles varies between societies based on their cultural, legal, and religious traditions. In the United States, with its rich libertarian-inflected history going back to the Jeffersonian ideal

of fiercely independent small farmers, as well as the Protestantism of the original colonies, autonomy has a unique potency vis-à-vis the other bioethical principles. That is why, for example, the concept of justice-based rationing of ICU beds or dialysis units (which can be seen as a restriction on autonomy) is more controversial in America than in Britain or Sweden. Autonomy Is Problematic and May Even Be Reasonably Called “Illusory” But who is, in fact, rational? Many of us are full of assumptions about the world that conflict with rationalism. A significant portion of the population believes in ghosts and UFOs. Without passing judgment on these beliefs, it’s fair to say that they conflict with

a rationalist view of the world. Furthermore, there is a large portion of the population that distrusts the “cold” rationality of scientific medicine or suspects a type of conspiracy on the part of doctors, hospitals, AMA, or the pharmaceutical industry. Even among the portion of the population without obviously irrational or conspiratorial beliefs, there is a deep, irreducible irrationality demonstrated through thoughtful studies in the field of behavioral psychology and behavioral economics. In classic experiments with names such as The Prisoner’s Dilemma, The Ultimatum Game, and The Dictator’s Game, researchers have shown that people repeatedly act in ways contrary to their own rationally calculable best interest, driven by emotional instincts, unacknowledged biases, and misvaluing of information. And who among us acts unaffected by the coercion of internal or external forces? Who doesn’t (at least sometimes) go against their own better judgment to please a loved one? Who is unencumbered by guilt, obligation, or shame so that their decisions, however couched in self-justification, are really the result of hidden coercive factors? Moreover, whose unconscious fears and drives are even known to them? So who then is truly free? This unanswerable question has troubled philosophers from Greece’s Plato to UCSD’s Patricia Churchland. Clearly, our actions and thoughts are immensely influenced by genes, in-utero events, early-childhood experience, and chance encounters both good and bad. This leaves very little room — some claim no room — for free will. And yet we feel free. We feel we choose one diagnostic approach over another. Our patients feel they choose the active surveillance over the operative treatment (or vice versa). It’s a choice that may feel free, uncoerced, and rational (and thus satisfy the criteria for autonomous choice), but there remain legitimate challenges to the reliability of that feeling. Like Autonomy, All the Bioethical Concepts Are Flawed So where does that leave our cherished bioethical principle? Acknowledging these deficiencies in the ideal concept of autonomy does not render it any less important in its interplay with the other primary principles. The problems with autonomy can also be applied to beneficence, non-maleficence, and justice. All of them are riddled by biases, tacit cultural or institutional assumptions, and by frank irrationality. Estimations of beneficence and non-maleficence are beset by the kind of errors in judgment and thinking discussed in detail

by Harvard’s Jerome Groopman in his book How Doctors Think. He posits that the most common mistakes come from the application of readily available but false analogies, a dependency on how things are “supposed” to work, and a denial of uncertainty. Justice — that magnificent concept — is itself hopelessly mired in circular thinking. To say that limited resources are to be fairly distributed in no way helps define “fairly.” Definitions of fairness often refer back to “justice.” And so the wheel spins, stopped semi-arbitrarily by what a culture has come to define as fair or just. So we can no more dismiss autonomy than we can any of the other analytic principles of the modern bioethical process. All are flawed and yet each is useful. Autonomy plays its part in the ecology of decision-making by providing a bulwark against excessive domination by the medical care system. Choices that may seem perfectly obvious and ethical to a doctor (that is, satisfying the criteria of beneficence, non-maleficence, and justice) may violate the goals and beliefs of a patient. One common and obvious example is the refusal, on religious grounds, of transfusions by Jehovah’s Witnesses. But there are countless others. From my practice, in particular, patients frequently exercise their autonomy by declining “rationally indicated” flu vaccines, colonoscopies, mammograms, and statin medications based on their own worldviews as well as their own “reading of the data.” Two Cheers for Autonomy Autonomy is an imperfect and imperfectable ideal that deserved two cheers — not the full three of “hip-hip-hooray.” Without its protective counterbalance, each of us would be vulnerable to the intrusion and domination by entrenched powers. Our patients would be force-fed our closest approximation to evidence-based medicine whether or not that violated their own beliefs or calculations. Autonomy provides the basis for processes of informed consent, advanced directives, and even of leaving the hospital against medical advice. It is an indispensable feature of medicine as practiced in a democratic society, a bullhorn for voices that can too easily get lost amid the roar of the medical enterprise, a flawed but necessary protector of liberty. Dr. Bressler, SDCMS-CMA member since 1988, is chair of the Biomedical Ethics Committee at Scripps Mercy Hospital, sits on SDCMS’s Bioethics Commission, and is a longtime contributing writer to San Diego Physician. SAN DI EGO PHYSICIAN.org 21

Bioethics

Some commentators and guidelines suggest that physicians pursue a sort of online “dual citizenship,” keeping their professional identity separate from the social identity they use to communicate with friends and family.

Social Media Establishing Guidelines for Its Ethical Use By Timothy Barounis, MD

In May of 2004, a second-year medical student at the time, I received a harsh introduction to the concept of online medical professionalism. It was the beginning of Web 2.0. Facebook had just launched the previous February; Twitter would appear on the social media landscape a couple of years later. I was enamored with the idea of creating content that would immediately be visible to anyone in the world, and the ease with which this could now be accomplished. My first blog post, describing my combination of fear and excitement at the prospect of doing my first history and physical on a real patient the following day, would be published on Feb. 12, 2004. Before its eventual demise three months later, the content of this blog would set events in motion that would very nearly get me kicked out of medical school. In the years since 2004, various organizations, including AMA, the Massachusetts 22 march 2014

Medical Society, The British Medical Association, and, more recently, The American College of Physicians and the Federation of State Medical Boards, have put forth guidelines for online conduct. The guidelines give common-sense recommendations (e.g., maintain patient privacy, maintain professional boundaries with patients, disclose potential conflicts of interest), but they tend to be short on specifics. Can I describe a patient with a rare condition? How rare does it have to be before I am concerned that the patient could be identified? The recommendations cited above are a good start, but more guidance is needed. If one is to peruse the content of blogs written by medical professionals, one will find that a large portion of this content is devoted to discussing patients. Patients are described both positively and negatively, and posts give varying degrees of clinical information. None of this is unethical or

unprofessional in and of itself. We have a long and proud tradition of improving medical practice via the sharing of our clinical experiences with others in the profession. We also have a long, and perhaps less proud, tradition of walking a very fine line with regard to protecting patient confidentiality when it comes to this practice. A 2008 survey of the content of medical blogs found that around 17% contained sufficient information for patients to be able to identify themselves. Such ethical lapses are rarely blatant. They almost never contain names or other identifiers that are listed as protected under HIPAA. And the authors of this content are almost always well meaning. But the fact that it happens with regularity is not surprising, given the infinitesimal period of time that now exists between inception and publication. While violations of patient privacy are uncontroversial breeches of ethics, what about more subjective lapses in professional conduct? A 2009 survey of U.S. medical schools found that 60% reported incidents of students posting unprofessional content online. Violations of patient privacy were among those cited, but other infractions included use of profanity, discriminatory language, and sexually suggestive material. Who is to be the final arbiter of what is offensive or inappropriate? If a medical student has a penchant for writing and publishing erotic fiction, should she be reported? Disciplined? What if they feature herself as the protagonist? Margaret Sanger was famously jailed in 1916 for distributing information about birth control on the grounds that it violated the anti-obscenity laws of the time. As of 2010, about 10% of medical schools had adopted formal policies regarding what is acceptable to post online. Sadly, like those guidelines put forth by AMA, ACP/ FSMB, and others, they tend to be vague and unhelpful. They provide no “safe harbor” for what is considered ethical content. Rather,

they err on the side of caution: “If it could get you in trouble, don’t post it.” Of course, there is some utility in this. Doctors and other health professionals have many practical reasons to want to avoid offending people. But there is a big difference between refraining from being rude or offensive for practical reasons (e.g., loss of friendships, damage to relationships with patients, disruption of a harmonious workplace) and refraining from posting material because one has a professional obligation to do so. Health professionals bear many ethical obligations, including the duty to protect patient privacy; however, we also have the duty to protect health professionals’ freedom of expression when it comes to publishing content that does not violate ethical standards. Some commentators and guidelines suggest that physicians pursue a sort of online “dual citizenship,” keeping their professional identity separate from the social identity they use to communicate with friends and family. While this may be helpful when it comes to maintaining appropriate professional boundaries (e.g., you should not “friend” your patients), it, unfortunately,

does not protect you against the repercussions of posting what some might consider to be unprofessional content. Case in point: A Missouri ob-gyn posts the following rant on her Facebook page, “So, I have a patient who has chosen to either no-show or be late (sometimes hours) for all of her prenatal visits, ultrasounds, and NSTs. She is now three hours late for her induction. May I show up late to her delivery?” The doctor who posted this, using her nonprofessional identity, was disciplined, though apparently did not lose her job. The lesson here is that everything that is said or expressed through social media is said publicly. Whether it’s a patient who tweets himself out of a liver transplant by posting pictures of himself consuming alcohol (real case), a doctor ranting about a perpetually late patient, or a medical student discussing a first clinical encounter, anything expressed online will be scrutinized and judged. And, in the absence of any universal set of standard criteria to determine which speech is acceptable, a doctor takes her professional license into her hands whenever she creates online content for public viewing. This, in my view,

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is a problem. It is perfectly reasonable that doctors’ reputations and/or relationships be affected by what they say, online or otherwise. But it is unacceptable that a doctor or medical trainee’s ability to practice be adversely affected for expressing thoughts or opinions that are outside the mainstream. Indeed, it is this very speech that we must take particular care to protect. What is needed are generally accepted “safe harbor” criteria that protect freedom of expression, while also protecting patient privacy and the integrity of the medical profession. This is a daunting task, one that may ultimately be settled by nine men and women in black robes. But the current guiding philosophies of “actively manage your online presence” and “if in doubt, don’t post it” are not true ethical guidelines and are insufficient to meet the challenges of the digital age. For a list of references accompanying this article, email Editor@SDCMS.org. Dr. Barounis, SDCMS-CMA member since 2013, is a family medicine physician at UC San Diego. He tweets using an undisclosed alias.

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Bioethics

Please encourage your patients to take these important issues up with their families before they are faced with a crisis.

Advance Care Planning

It Should Be for Everyone By Karl Steinberg, MD, CMD

24 March 2014

At SDCMS’s Bioethics Commission meetings, as at bioethics consults in hospitals and other medical settings, discussion often centers around what constitutes the best course of action in the current — usually pretty grim — clinical scenario. Our task as bioethics consultants, while not always possible, is to achieve consensus among all parties, and this is best done when the patient has decisional capacity and is able to guide the process. However, in real life, the patient is usually incapacitated, and there is conflict among family members or healthcare providers. In these cases, it is useful when the patient has completed an advance healthcare directive (AHCD), but only a small minority of Californians have done this — even though it is recommended that everyone over 18 complete one. (How many of you readers have not done this yourselves? It’s easy, and you really have no excuse!) Along with designating an agent they can really trust to make decisions on their behalf (not necessarily always a spouse or adult child), patients should be educated as to what an AHCD does and doesn’t do. Many people believe that when they check the “choice not to prolong life” box on the form, that makes their wishes crystal clear. But, in fact, the language is very vague (“I do not want my life to be prolonged if the likely risks and burdens of treatment would outweigh the expected benefits”), so it is wise for people to discuss in more detail with their agent and other loved ones, even though these discussions can be difficult. There are resources available to help physicians help their patients initiate these discussions, including the Conversation Project (www.theconversationproject.org) and PREPARE (www.prepareforyourcare. org). Please encourage your patients to take these important issues up with their families before they are faced with a crisis. One limitation of an advance directive is that it cannot direct emergency responders on what care to provide. Since 2009, California has had an official POLST (Physician Orders for Life Sustaining Treatment) form available that is an actionable doctor’s order, and that paramedics and other healthcare providers must follow. These bright pink forms can direct a variety of specific inter-

ventions — CPR in the event of a full cardiac and respiratory arrest, tube feeding, etc. — and are generally recommended for people nearing the end of life, although people of any age and health status may complete it. It requires a doctor’s signature and the original should go wherever the patient goes. At home, it is customary to post it on the refrigerator or bedpost where first responders will look for it. The California POLST form has been revised, and the new version will be available in October, but older versions are still valid. As part of our education process, it’s our responsibility to let patients know what their prognosis is, and how likely they are to survive certain interventions, unless they really do not want to know. Our honesty about these issues tends to help people have realistic expectations, and also to plan accordingly and take care of unfinished business. Prognosticating can be difficult, and we tend to overestimate our own patients’ life expectancies, but there are tools available, including ePrognosis (www.ePrognosis. org) that can be very helpful. Palliative care consultation can also help when physicians do not have the time, inclination, or skill set

to have these discussions. Our patients often believe that CPR is a fairly routine, benign procedure that almost always works. In reality, nothing could be further from the truth. Out-of-hospital CPR in the case of a full arrest, especially in a frail or chronically ill patient, carries a dismal survival rate … probably less than 1%. What’s more, a lot of our patients tell us, “I would not want to be kept alive on tubes and machines, ever.” If such a patient has an arrest and is in the tiny minority who survives CPR, there is about a 100% chance that, if they ever regain consciousness, they will do so in an ICU, on a ventilator, and probably with some rib fractures to boot. These facts should help inform our discussions with our patients and their (often unrealistic) family members, and we owe it to them to prevent the unwanted, painful, and sometimes protracted interventions that are our default when people’s wishes are not known. And while some people do want their lives prolonged even by extraordinary means and at all costs, even when their functional level or cognition may be dismal, these people are in a distinct minority. But if we don’t ask, we will never know, leaving those of us who serve as

bioethics consultants to try to patch together what constitutes a person’s substituted judgment or best interests. For clinicians who care for patients nearing the end of life, please keep AHCD and POLST forms in outpatient offices, and bring up these topics with your patients. The forms are readily available (www.caPOLST.org), and it is really worthwhile to take the time to have these discussions — encourage patients and their families to discuss these important matters as well. Perhaps a bit counterintuitively, people really appreciate it. Using time-based counseling codes, advance care planning discussions during office and facility visits are already compensable under Medicare and other insurance coverage. There’s really no excuse to subject people to invasive, intrusive, and sometimes violent care when they do not want it. Dr. Steinberg, SDCMS-CMA member since 1995, is an Oceanside-based nursing home and hospice physician who takes his dogs to work every day. Dr. Steinberg is as well vice chair of the Compassionate Care Coalition of California and sits on the SDCMS Bioethics Commission.

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SAN DI EGO PHYSICIAN.org 25

Bioethics

“Insanity: doing the same thing over and over again and expecting different results.” — Albert Einstein (attributed)

Advance Care Planning in the Community Taking the Journey Together By London Carrasca, MPH, RN

26 March 2014

“I am not afraid of death; I just don’t want to be there when it happens.” — Woody Allen In this article, I wish to explore the underlying concepts that the above epigraphs address and how they are (or aren’t) incorporated into our current healthcare paradigm. I hope to provide ideas for improvements that we as healthcare providers can implement to foster change in our healthcare culture and community. As noted previously, we seem to have become a society of technologists and at times have lost sight of the goals of medicine and the lost art of healing. The role of the humanistic healthcare professional — with all the responsibilities that include difficult and time-consuming conversations such as endof-life (EOL) discussions — has been replaced by the role of the technologist, i.e., expensive utilization of high technology and aggressive treatments, but not always better quality of life and functional capacity outcomes, and with harm attached to them. The bioethical duty of the healthcare

professional is to cure sometimes, to relieve often, and to comfort always (attributed to Ambroise Paré, 1510–1590), while addressing the goals of medical treatment, benefit vs. harm (burden), and benefit vs. effect of potential medical treatment options. Factors to be considered are the relief of suffering, the preservation or restoration of functioning, and the quality as well as the extent of life sustained. The obligation to alleviate pain, suffering, and disability is as serious as an obligation to save an endangered life. All of us who wish to do that must continue to be activists … and must be prepared to remain focused on our goals for the best care, whatever challenges present themselves. The path of change is slow, but such worthy goals must be kept in focus at the end of the journey. The goals of medicine — curative vs. palliative or concurrent focus — should be addressed in a thoughtful manner, including considerations regarding realistic and attainable goals; time-limited trials; shared decision-making with the patient and/or surrogate decision-maker(s), and exploration of influencing worldviews; prognostication; framing conversations; and collaborative approach of the treating healthcare team. This overarching perspective should be kept in focus during every patient encounter. The physician also has a “systems bioethics” responsibility to the healthcare team (not lone decision-maker in the process) and a duty to recognize the impact on other physicians, healthcare providers, and the healthcare system. There should be collaboration and coordination with other stakeholders who are involved in the patient’s medical treatment, and they should be included in the decision-making process. This should include cooperation and coordination of advance-care planning (ACP) for patients among healthcare providers. There are currently many opportunities for education and quality improvement for ACP in our community. All healthcare providers have a duty to the community in which they live and work and belong as societal members. As role models, they should be part of the rational, intellectual communication and community engagement that is much needed in today’s environment of readily available “misinformation” and rhetoric in the media about end-of-life topics. The “elephant in the room” is EOL. As a society, we have attempted to delete this aspect of our existence (living and dying) as if we have the power to make it disappear on our command. A quote from a recent issue of JAMA: “Despite strong feelings about end-of-life care, fewer than half of the adults (37%) surveyed reported having thought much about their wishes regarding such care,

35% said they had thought about it, and 27% said they had devoted little or no thought to the issue.” As a result of this avoidance, many healthcare providers and patients never address the important topic of ACP for end-of-life (death happens at all ages, so it’s not just a topic for the geriatric population). With this avoidance, we create unneeded suffering by not addressing this in a proactive manner. Proactive ACP gives the healthcare provider, patient, and surrogate decision-maker(s) (i.e., family and/or friends) an opportunity to have thoughtful, meaningful dialogue about the patient’s wishes and realistic goals of medical treatment. In addition, it’s an opportunity for education regarding palliative care — clarification: all palliative care is not limited to care at the EOL — and/or hospice medical treatment, grieving/bereavement services, and community resources available (i.e., disposition of the body) prior to a situation where all of the decisions need to be made in a crisis mode. From the patient and/or caregiver perspective, this is an opportunity for empowering the patient and/ or surrogate decision-maker(s) to make these difficult decisions in a less stressful manner and making them aware of community supportive systems/resources for the end-of-life process. From a public health/community healthcare perspective, there are definitely areas of improvement, such as community-wide integration of electronic medical records (EMR) for advance care directives; statewide advance-care directive registry; statewide law review (i.e., review surrogate decisionmaker(s) responsibilities and require the surrogate decision-maker(s) to sign a legal document acknowledging his/her consent to become the surrogate decision-maker(s)); assessment of decision-making capacity of surrogate decision-maker(s); and provision of access to ACP education and documents via healthcare providers/systems and their websites. It’s an opportunity for all healthcare providers to repeat the same thing over and over and improve the outcome. In addition, we need not be afraid of death but embrace it as part of the continuum of our finite human presence and not see death as a medical failure.

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For a copy of this article with references and resources, please email Editor@SDCMS.org. Ms. Carrasca is co-chair of Rady Children’s Hospital-San Diego (RCHSD) Bioethics Committee; RCHSD & Sharp Metropolitan Medical Campus bioethics consultant; community bioethics committee member at three San Diego-area hospitals, and a member of the SDCMS Bioethics Commission.

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Physicians: Download the POLST Form in PDF at www.capolst.org and Make Copies for Your Patients HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY

Physician Orders for Life-Sustaining Treatment (POLST)

EMSA #111 B

(Effective 4/1/2011)

Check One

First follow these orders, then contact physician. This is a Physician Order Sheet based on the person’s current medical condition and wishes. Any section not completed implies full treatment for that section. A copy of the signed POLST form is legal and valid. POLST complements an Advance Directive and is not intended to replace that document. Everyone shall be treated with dignity and respect.

Patient Last Name:

Date Form Prepared:

Patient First Name:

Patient Date of Birth:

Patient Middle Name:

Medical Record #: (optional)

CARDIOPULMONARY RESUSCITATION (CPR):

If person has no pulse and is not breathing. When NOT in cardiopulmonary arrest, follow orders in Sections B and C. Attempt Resuscitation/CPR (Selecting CPR in Section A requires selecting Full Treatment in Section B) Do Not Attempt Resuscitation/DNR (Allow Natural Death)

MEDICAL INTERVENTIONS: If person has pulse and/or is breathing. Comfort Measures Only Relieve pain and suffering through the use of medication by any route,

positioning, wound care and other measures. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Transfer to hospital only if comfort needs cannot be met in current location. Limited Additional Interventions In addition to care described in Comfort Measures Only, use medical treatment, antibiotics, and IV fluids as indicated. Do not intubate. May use non-invasive positive airway pressure. Generally avoid intensive care. Transfer to hospital only if comfort needs cannot be met in current location. Full Treatment In addition to care described in Comfort Measures Only and Limited Additional Interventions, use intubation, advanced airway interventions, mechanical ventilation, and defibrillation/ cardioversion as indicated. Transfer to hospital if indicated. Includes intensive care.

Additional Orders: __________________________________________________________________ __________________________________________________________________________________

ARTIFICIALLY ADMINISTERED NUTRITION:

INFORMATION AND SIGNATURES:

Check One

Offer food by mouth if feasible and desired.

No artificial means of nutrition, including feeding tubes. Additional Orders:_________________________ Trial period of artificial nutrition, including feeding tubes. _________________________________________ Long-term artificial nutrition, including feeding tubes. _________________________________________

Discussed with:

Patient (Patient Has Capacity)

Advance Directive dated ________ available and reviewed Æ Advance Directive not available No Advance Directive

Legally Recognized Decisionmaker Health Care Agent if named in Advance Directive: Name: _________________________________________ Phone: _________________________________________

Signature of Physician

My signature below indicates to the best of my knowledge that these orders are consistent with the person’s medical condition and preferences.

Print Physician Name:

Physician Phone Number:

Physician License Number: Date:

Physician Signature: (required)

Signature of Patient or Legally Recognized Decisionmaker

By signing this form, the legally recognized decisionmaker acknowledges that this request regarding resuscitative measures is consistent with the known desires of, and with the best interest of, the individual who is the subject of the form. Print Name: Relationship: (write self if patient)

Signature: (required) Address:

Date: Daytime Phone Number:

Evening Phone Number:

SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED

Physicians: Download the POLST Form in PDF at www.capolst.org and Make Copies for Your Patients HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY Patient Information Name (last, first, middle):

Date of Birth:

Health Care Provider Assisting with Form Preparation Name:

Additional Contact Name:

Completing POLST

Title:

Phone Number:

Relationship to Patient:

Phone Number:

Gender:

Directions for Health Care Provider

• Completing a POLST form is voluntary. California law requires that a POLST form be followed by health care providers, and provides immunity to those who comply in good faith. In the hospital setting, a patient will be assessed by a physician who will issue appropriate orders. • POLST does not replace the Advance Directive. When available, review the Advance Directive and POLST form to ensure consistency, and update forms appropriately to resolve any conflicts. • POLST must be completed by a health care provider based on patient preferences and medical indications. • A legally recognized decisionmaker may include a court-appointed conservator or guardian, agent designated in an Advance Directive, orally designated surrogate, spouse, registered domestic partner, parent of a minor, closest available relative, or person whom the patient’s physician believes best knows what is in the patient’s best interest and will make decisions in accordance with the patient’s expressed wishes and values to the extent known. • POLST must be signed by a physician and the patient or decisionmaker to be valid. Verbal orders are acceptable with follow-up signature by physician in accordance with facility/community policy. • Certain medical conditions or treatments may prohibit a person from residing in a residential care facility for the elderly. • If a translated form is used with patient or decisionmaker, attach it to the signed English POLST form. • Use of original form is strongly encouraged. Photocopies and FAXes of signed POLST forms are legal and valid. A copy should be retained in patient’s medical record, on Ultra Pink paper when possible. Using POLST • Any incomplete section of POLST implies full treatment for that section. Section A: • If found pulseless and not breathing, no defibrillator (including automated external defibrillators) or chest compressions should be used on a person who has chosen “Do Not Attempt Resuscitation.” Section B: • When comfort cannot be achieved in the current setting, the person, including someone with “Comfort Measures Only,” should be transferred to a setting able to provide comfort (e.g., treatment of a hip fracture). • Non-invasive positive airway pressure includes continuous positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP), and bag valve mask (BVM) assisted respirations. • IV antibiotics and hydration generally are not “Comfort Measures.” • Treatment of dehydration prolongs life. If person desires IV fluids, indicate “Limited Interventions” or “Full Treatment.” • Depending on local EMS protocol, “Additional Orders” written in Section B may not be implemented by EMS personnel. Reviewing POLST It is recommended that POLST be reviewed periodically. Review is recommended when: • The person is transferred from one care setting or care level to another, or • There is a substantial change in the person’s health status, or • The person’s treatment preferences change. Modifying and Voiding POLST • A patient with capacity can, at any time, request alternative treatment. • A patient with capacity can, at any time, revoke a POLST by any means that indicates intent to revoke. It is recommended that revocation be documented by drawing a line through Sections A through D, writing “VOID” in large letters, and signing and dating this line. • A legally recognized decisionmaker may request to modify the orders, in collaboration with the physician, based on the known desires of the individual or, if unknown, the individual’s best interests. This form is approved by the California Emergency Medical Services Authority in cooperation with the statewide POLST Task Force. For more information or a copy of the form, visit www.caPOLST.org.

SEND FORM WITH PERSON WHENEVER TRANSFERRED OR DISCHARGED

Second Annual

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Commercial Real Estate

Jones Lang LaSalle (858) 410-6377 chris.ross@am.jll.com us.joneslanglasalle.com/ healthcare

EHR

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Higher Education

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Hospitals

Sharp Hospital sharp.com

Imaging

Imaging Healthcare Specialists (866) 558-4320 imaginghealthcare.com

Insurance

The Doctors Company (800) 852-8872 thedoctors.com/SDCMS Cooperative of American Physicians (800) 356-5672 MD@CAPphysicians.com capphysicians.com MIEC (800) 227-4527 underwriting@miec.com miec.com Norcal Mutual Insurance Company (877) 453-4486 info@norcalmutual.com norcalmutual.com/start

Investments

Sequoian Investments LLC (855) 390-5626 alex@sequ.com sequ.com

Mortgage Banking

BBVA — Daniel Schroeder (858) 356-2601 daniel.schroeder@bbvacompass.com bbvacompass.com

Personal Training

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Technology

Soundoff Computing (858) 569-0300 ofer@soundoffcomputing.com soundoffcomputing.com



Additional information can be found at the Practice Management Resources page at www.SDCMS.org.

32 march 2014

SAN DI EGO PHYSICIAN.org 32

Special mortgage financing for physicians Our special home financing program is designed specifically to meet your needs as a busy physician for the purchase of your primary residence. s 'JOBODJOH BWBJMBCMF XJUI MPX EPXO QBZNFOU VQ UP SFลขJOBODFT XJUI IJHI MPBO UP WBMVFT BMTP BWBJMBCMF s 1SJWBUF NPSUHBHF JOTVSBODF JT OPU SFRVJSFE s 4JOHMF GBNJMZ IPNFT BSF FMJHJCMF 'PS EFUBJMT DPOUBDU

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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 PHYSICIANS: RETIRED WITH LICENSE? Alternative care office in San Diego area looking for California licensed MD for consultative work. One or two days a month. Part-time, excellent compensation. Contact James at (760) 703-3767. [208] PART-TIME OPHTHALMOLOGY POSITION AVAILABLE: Scripps La Jolla campus. Half day per week to start. General ophthalmology but should be proficient in anterior segment surgery. Guaranteed minimum plus negotiable production. Contact ljeyedoc92037@gmail.com. [206] SEEKING A PART-TIME BC/BE INTERNAL MEDICINE PHYSICIAN: SHARP Rees-Stealy Medical Group, a 450+ physician multi-specialty group in San Diego, is seeking a part-time BC/ BE internal medicine physician to join our staff at our Genesee location. We offer a first-year competitive-compensation guarantee and an excellent benefits package. Please email CV to lori. miller@sharp.com. [204] SEEKING A PART-TIME BC/BE INTERNAL MEDICINE / PEDIATRICS OR FAMILY MEDICINE PHYSICIAN: SHARP Rees-Stealy Medical Group, a 450+ physician multi-specialty group in San Diego, is seeking a part-time BC/BE internal medicine / pediatrics or family medicine physician to join our staff at our Carmel Valley location. We offer a first-year competitive-compensation guarantee and an excellent benefits package. Please email CV to lori.miller@sharp.com. [205] PHYSICIAN NEEDED: Full-time or part-time pediatrician needed. Busy, well-established pediatric practice in Chula Vista. No rounding on newborns, nor hospital admissions. Minimal night calls and weekends. Benefits include liability insurance, paid vacations, sick time, and health insurance. Bilingual English / Spanish preferred. Please email CV to rios_araico@sbcglobal.net. [202] 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] 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) 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 La Jolla family medicine practice for sale: Excellent potential to optimize you own personal lifestyle. Highly valued locale and excellent reputation for caring service. Multi-specialty

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 march 2014

certified physician looking for the perfect candidate to assume care for a special group of patients. Requires board certification with interest in family, sports, and preventive medicine. Services community with low-overhead, micro-practice model via scheduled and same-day appointments. Patients have demonstrated long-term commitment to physician. Easy call coverage given no hospital practice required. Healthy insurance mix. Personalized business consulting optional. Reply: info@caresmart.com. [207] LOW-STRESS, GYNECOLOGY-ONLY PRIVATE PRACTICE FOR SALE: Turnkey operation. One employee and low overhead, month-to-month lease. Minimal HMO. Perfect part-time work or add obstetrics. Various arrangements available. Email drjenma@pacbell.net. [203] 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 OPPORTUNITY IN EAST COUNTY (LA MESA): Jackson Drive at Fletcher Parkway. Beautiful physical and hand therapy clinic (2800 sq. ft.) has furnished office space available to lease. Space currently available is 700–850 sq. ft. on the first floor. Includes utilities, general office and kitchen supplies/expense, and cleaning service. The office is close to Sharp Grossmont Hospital, trolley and bus lines. ADA compliant space and plenty of parking. Contact Jeanette Barrack at jeanette@ rehabst.com or at (619) 251-2417. [201] OFFICE SPACE AND PRACTICE OPPORTUNITY BANKERS HILL / HILLCREST: Surgical office space available to share in newly renovated private medical office building. Beautifully updated building inside and out. Located in Bankers Hill / Hillcrest area just minutes to Scripps Mercy Hospital. Fully accredited ambulatory surgery center onsite that is also available for use. Ideal practice setting for part-time or full-time plastic surgeon, facial plastic surgeon, or ENT surgeon. Shared office staff may be possible. Email KLewis@SDCMS.org for additional information. [200] 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] 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] LUXURIOUS / BEAUTIFULLY DECORATED DOCTOR’S OFFICE NEXT TO SHARP HOSPITAL FOR SUB-LEASE OR FULL LEASE: The office is conveniently located just at the opening of Highway 163 and Genesee Avenue. Lease price if very reasonable and appropriate for ENT, plastic surgeons, OB/GYN, psychologists, research laboratories, etc. Please contact Mia at (858) 279-8111 or at (619) 8238111. Thank you. [836]

BUILD TO SUIT: Up to 1,900ft2 office space on University Avenue in vibrant La Mesa / East San Diego, across from the Joan Kroc Center. Next door to busy pediatrics practice, ideal for medical, dental, optometry, lab, radiology, or ancillary services. Comes with 12 assigned, gated parking spaces, dual restrooms, server room, lighted tower sign. Build-out allowance to $20,000 for 4–5 year lease. $3,700 per month gross (no extras), negotiable. Contact venk@cox.net or (619) 504-5830. [835] SHARE OFFICE SPACE IN LA MESA JUST OFF OF LA MESA BLVD: 2 exam rooms and one minor OR room with potential to share other exam rooms in building. Medicare certified ambulatory surgery center next door. Minutes from Sharp Grossmont Hospital. Very reasonable rent. Please email KLewis@SDCMS.org for more information. [867] NONPHYSICIAN POSITIONS AVAILABLE / WANTED

SCRIPPS 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]

MEDICAL ASSISTANT WANTED FOR SPORTS/ REGENERATIVE MEDICINE PRACTICE (ENCINITAS): BA or BS preferred. Please reply with resume and letter of interest to ssbunyak@hotmail.com. [199]

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]

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] 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

Personal & Professional Development

Ask More, Judge Less by Helane Fronek, MD, FACP, FACPh

36 MArch 2014

Every Valentine’s Day, I recall a funny incident that taught me a lot about communication. One year, my husband and I independently purchased new desk chairs for each other. They were thoughtful gifts, for sure. Unfortunately, I didn’t like the chair he chose for me, and he didn’t like the chair I bought for him. Once we stopped trying to talk each other into liking their new chair, we found the perfect solution: We exchanged chairs and have been happy and comfortable ever since. We each see the world through our own prism, which reflects past experiences, personal preferences, or simply the size and shape of our body. It takes effort to remember that others don’t see, believe, or feel the way we do. This makes it difficult to understand why patients don’t always follow our suggestions. We know how devastating hypertension or diabetes can be, so we label patients who don’t take their medications “noncompliant.” One way of counteracting our rush to judgment when someone does something we find objectionable comes from the people at Vital Smarts, who suggest we ask ourselves, “Why would a reasonable, rational, decent person do this?” Possible responses might include, “because our

patient doesn’t know the consequences of hypertension or diabetes,” or “because our patient doesn’t have the social support to change his behavior.” These realizations equip us to act in a more effective way in order to benefit — and not become frustrated with — our patient. Sometimes our prism affects our interpretation of events and creates grave misunderstandings. In America, we are used to direct, inquisitive interactions. “What do you do for a living? Where is your family from?” are common ways to begin a conversation with a stranger we wish to get to know. But, to people from other cultures, these abrupt questions might feel intrusive and rude. In return, we might interpret their more general comments about history, politics, or the weather as a lack of interest in us. Our reliance on our prism causes us to assume that others see things the way we do. Our kids’ fifth grade history teacher cautioned her students against assuming. “When you assume, “ she said, “you make an ass out of u and me.” Maybe a bit risqué for 5th grade, but definitely true! On too many occasions, I assumed I knew what someone was thinking, only to find out how wrong I was after my actions or words caused hurt, insult, or embarrassment. A wiser approach is to do something radical — to ask people what they believe and why they believe what they do. “I’m curious,” we might begin. “How do you see this situation? What do you like about this? Why did you choose to do this, rather than that?” Coming from a place of curiosity, we can demonstrate our interest, as opposed to our judgment. We can forge a true connection and maybe even learn something we had never considered. If there was ever an antidote to judgment, it is curiosity. 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.

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

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