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May

Contents

Volume 101, Number 5

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

feature Naval Medical Center San Diego: Caring for Our Nation’s Heroes and Their Families

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)

By Rear Adm. Bruce L. Gillingham, MD, FAAOS

14

Introduction

15

8

High Reliability Organization

16

Medical Training and Research for All Environments

16

A Decade of War Advances Navy Medicine

18

ardiac Care in the Clinic and in the C Community

departments

21

4 Briefly Noted: Calendar • Ask Your Physician Advocate • And More …

22 Military Traditions Coupled With Nontraditional Care

8

24

10

ancer Care and Blast Injuries Below C the Belt

“Hey, Doc. Know What Happiness Is?”

BY STEVEN J. DAVIS, MD, DLFAPA

I Drew a Perfect Circle

By DANIEL J. BRESSLER, MD

If the Cost of Medication Is Too Good to Be True, the Drug May Be Counterfeit

By THE DOCTORS COMPANY

28

12

Choosing Wisely: Five Things Physicians and Patients Should Question

By THE AMERICAN ACADEMY OF ALLERGY, ASTHMA AND IMMUNOLOGY

GEOGRAPHIC AND GEOGRAPHIC ALTERNATE DIRECTORS EAST COUNTY: Venu Prabaker, MD, Alexandra E. Page, MD, Jay P. Mongiardo, MD, Alt: Susan Kaweski, MD (CALPAC Treasurer) HILLCREST: Gregory M. Balourdas, MD, Thomas C. Lian, MD, Alt: (open) KEARNY MESA: Jason P. Lujan, MD, John G. Lane, MD, Alt: Anthony E. Magit, MD, Alt: Sergio R. Flores, MD LA JOLLA: Geva E. Mannor, MD, Wayne Sun, MD, Alt: Lawrence D. Goldberg, MD NORTH COUNTY: James H. Schultz, MD, Eileen S. Natuzzi, MD, Michael A. Lobatz, MD, Alt: Anthony H. Sacks, MD SOUTH BAY: Reno D. Tiangco, MD, Michael H. Verdolin, MD, Alt: 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 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: Albert Ray, MD (CMA Trustee, AMA Alternate Delegate) CMA PAST PRESIDENTS: James T. Hay, MD (AMA Delegate), Robert E. Hertzka, MD (Legislative Committee Chair, AMA Delegate), Ralph R. Ocampo, MD CMA TRUSTEE: Robert E. Wailes, MD CMA SSGPF Delegates: James W. Ochi, MD, Marc M. Sedwitz, MD CMA SSGPF ALTERNATE DELEGATES: Dan I. Giurgiu, MD, Ritvik Mehta, MD AMA ALTERNATE DELEGATE: Lisa S. Miller, MD

26

Physician Marketplace Classifieds

28

Rx: Nature / Sig: Enjoy QD / Refill: Unlimited

By HELANE FRONEK, MD, FACP, FACPH 2 May 2014

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.]

90%

90%

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

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

Financial and Legal Life Skills (for Financially and Legally Clueless Docs) (workshop) MAY 31: 8:00am–12:00pm OSHA Update (seminar/ webinar) JUL 10: 11:30am–1:00pm Consent and Abuse Reporting: Your Duties and Responsibilities (seminar/ webinar) JUL 17: 11:30am–1:00pm Advocacy Training (workshop) JUL 19: 8:00am–12:00pm

Cma Webinars CMAnet.org/events The Power of the Pen: The Physician’s Responsibility in Prescribing and Referring for Medi-Cal Patients JUN 18: 12:15pm–1:15pm Recipe for Financial Success: Key Steps to Increasing Your Net Income JUL 16: 12:15pm–1:15pm

What to Expect From a Medi-Cal Audit JUL 30: 12:15pm–1:15pm HIPAA Breach Notification and California Requirements JUL 31: 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.

Trauma Across the Lifespan JUN 7–8 (www. traumaacrossthelifespan. com — jointly sponsored by the APA and the San Diego Psychiatric Society) RCMA’s 10th Annual “Cruisin’ Thru CME” JUL 9–22 (www.rcmanet. org/Portals/17/04Events/ Flyer/2014Cruise.pdf) Summer Medical Academy JUL 14–25 (facesforthefuture. org/san-diego/san-diego.html) 31st Annual Primary Care Summer Conference AUG 1–3 (www.scripps.org/ sparkle-assets/documents/ primary_care_summer_2014. pdf)

Ask Your Physician Advocate SDCMS Member Question: Can you provide me with the average salary for an office manager, receptionist, and medical assistant in San Diego County?

Answer: Yes. SDCMS has completed compiling the data for our 2013 Medical Office Salary Survey. This survey provides salary information for all nonphysician staff in a practice. SDCMS members who are interested in the results of this survey can contact your SDCMS physician advocate, Marisol Gonzalez, to obtain a copy. She can be reached at (858) 300-2783 or at MGonzalez@SDCMS.org.

4 may 2014

get in touch

Your SDCMS and SDCMSF Support Teams Are Here to Help!

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

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

“

The ultimate aim of all our service is to graduate from freedom to compulsion.

— Rav Eliyahu Eliezer Dessler (1892–1953)

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Presently, PAVE’s efforts focus on men and women who are returning from Afghanistan and Iraq to San Diego County. Our local region is already home to more veterans than any other and expects to add 15,000 this year. Most of these veterans are young and unfamiliar with the serious and complex physical and mental illnesses they suffer. A high percentage of them suffer from posttraumatic stress disorder, traumatic brain injury, and other mental problems. These conditions add to the burden of their effective understanding and utilization of their healthcare benefits.

Started in 2013 under the leadership of retired anesthesiologists Harvey Shapiro and Rosemarie Marshall Johnson, and designed by a dedicated committee of physicians (PAVE Steering Committee: Drs. Johnson and Shapiro, co-chairs, Dr. Albert Breland, Dr. Steven Davis, Dr. Arnold Gass, Dr. Eric Marcus, and Dr. Robin Rowland), PAVE matches each retired physician volunteer with a veteran, meeting one on one to answer their questions and guide the young veterans to take control of their healthcare.

PAVE physicians do not provide medical care but rather encourage and support these veterans as they learn to access and understand their health needs and advocate for their resolution.

Physicians interested in volunteering are encouraged to call the SDCMS Foundation at (858) 300-2789.

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/////////briefly ///////////////////noted ////////////////////////////////////////////////////////////////////// veteran health

Operation Family Caregiver Supports Family and Friends of Disabled Veterans and Service Members.

There is a bountiful array of social services for post-9/11 veterans and active military personnel. Just as important to the wellbeing of the military family is attention to the needs of the caregivers of service members. Operation Family Caregiver (OFC) delivers a problem-solving intervention, which has proven effective at reducing caregiver depression and improving their health, along with reducing the anxiety of children in the home. A grant from the Rosalynn Carter Institute for Caregiving (RCI) was given to Southern Caregiver Resource Center (SCRC) to implement OFC because of the agency’s successful track record supporting caregivers in San Diego County since 1987.

An OFC coach meets four times with each caregiver; each time begins with the caregiver’s identifying key problems.

By utilizing an evidence-based, problem-solving model with a coach, the caregiver becomes adept at positively resolving problems independently.

Coaches meet with caregivers where it’s most convenient for the caregiver: the caregiver’s home, a community location, SCRC’s Kearny Mesa office, or via Skype. In between visits, an OFC coach calls the caregiver to check their progress toward achieving goals. SCRC’s coaches are skilled at recognizing client needs and assisting them to obtain additional support.

Given that 65% of family members caring for veterans face high levels of caregiver stress, levels much higher than those of other caregivers, SCRC is dedicated to providing this service to caregivers of those injured post-9/11. The grant from RCI — along with additional donations from corporations and individuals — has made it possible to provide this service at no cost.

Some of the caregivers who are most challenged are adjusting to invisible wounds of their loved ones. Traumatic brain injuries or post-traumatic stress disorder may not have been diagnosed, but family members see that their loved one is not the same person who joined the military. Helping caregivers identify possible effects of these wounds allows the family to cope better with their challenges. Resources provided to all caregivers focus on stress management (for themselves and children), safety and well-being, asking for help, identifying helpful webpages and organizations, and coping with the emotional aspects of being a caregiver.

OFC collaborates with a multitude of military, veteran, and community service organizations locally and nationally.

For more information or support, visit www.caregivercenter.org or www.operationfamilycaregiver.org, or call (858) 268-4432.

6 May 2014

Covered California

First Open Enrollment Period for Covered California Exceeds Expectations More than 3 million consumers statewide enrolled in health insurance plans or Medi-Cal before April 15, according to Covered California and the California Department of Health Care Services. Covered California saw a total of 1,395,929, exceeding projected numbers by more than 815,000. Nearly 90% of those enrolled are eligible for financial subsidies to help cover their health insurance cost.

Medi-Cal accounted for more than 60% of enrollees, with nearly 2 million consumers enrolled, including 1.1 million through the Covered California portal and county offices. Nearly 60% of those enrolled are former Low Income Health Program (LIHP) members who were transitioned to Medi-Cal. Additionally, more than 1,150 small businesses — representing about 4,900 employees and their dependents — enrolled in Covered California’s Small Business Health Options Program (SHOP) through March 31. SHOP enrollment is also open year-round.

Californians aged 18–34, Latino and Asian Americans all had strong enrollment, with Asian enrollment more than doubling projected numbers. Nearly 30% of individuals enrolled were aged 18–34 despite only making up 25% of the state’s population.

“When we began this journey last October, our goal was to help Californians get quality, affordable healthcare coverage,” says DHCS director Toby Douglas. “With the help of our county partners, Covered California, and thousands of concerned citizens and organizations who contributed, we’ve made incredible progress toward our goal in just six months.”

residency

2014 UC San Diego School of Medicine Match Data Highlights Where are they going?

• Staying in San Diego: 19% • Staying in California (not San Diego): 46% • Moving to another state: 35% What specialties are they going into?

• Primary Care: 42% * Family Medicine: 11 * Internal Medicine: 20 * Pediatrics: 19 • Nonsurgical Specialties: 18% * Specialties with at least three residents: »» Pathology: 3 »» Psychiatry: 6 »» Radiology: 10

• Surgical Specialties: 41% * Specialties with at least three residents: »» Anesthesiology: 6 »» Dermatology: 3 »» Emergency Medicine: 4 »» General Surgery: 14 »» Obstetrics and Gynecology: 8 »» Urology: 3

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POETRY AND MEDICINE

I Drew a Perfect Circle

by Daniel J. Bressler, MD I Drew a Perfect Circle

In medicine, as in all endeavors, we can pursue but never achieve perfection. It is an ideal that is forever out of reach. Nevertheless, it can inspire us — as it did Cervantes’ Don Quixote — “to fight the unbeatable foe.” One such foe is chronic disease. There is no perfect treatment for congestive heart failure, rheumatoid arthritis, diabetes, or a myriad of others, and yet the seeking of perfection in research and clinical medicine keeps us improving our therapies and refining our perspectives.

Beauty and truth often serve as stand-ins for perfection. Surgeons talk about beautiful operations and scientists about beautiful experiments. In the final stanza of his most famous poem, “Ode on a Grecian 8 may 2014

Urn,” the 19 -century doctor-poet John Keats tells us that “Beauty is truth, truth beauty.” Even in the messy realm of biomedical ethics, one can propose perfectionistic ideals of ethical truth and ethical beauty.

In this little poem, “I Drew a Perfect Circle,” the story of an attempt to create this ideal shape becomes the object lesson. Its message is one of humility rather than futility. As physicians, we can imagine and pursue perfection but must be content with its never being fully ours.

I drew a perfect circle On the canvas of the sky With the paintbrush of my finger And the compass of my eye

th

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

“Beauty is truth, truth beauty.”

I couldn’t take it with me It was lost within a cloud The outline became indistinct Like a face amongst a crowd I sought a form’s perfection Against the infinite blue To find that famed connection Between the beautiful and true I drew a perfect circle And this I’ve come to know That only in imagining Do perfect circles grow.

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Residents can simply reference “California Rx Card” to have their prescription processed through the program. California Rx Card is accepted at over 56,000 participating regional and national pharmacies.

California Rx Card has been working closely with clinics and hospitals around the state to distribute free discount prescription cards to all Californians so that all residents will have access to this free program. California Rx Card was launched to help the uninsured and underinsured residents afford their prescription medications. The program can also be used by people that have health insurance coverage with no prescription benefits, which is common in many health savings accounts (HSA) and high deductible health plans.

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Risk Management

If the Cost of a Medication Is Too Good to Be True, the Drug May Be Counterfeit Contributed by SDCMS-endorsed The Doctors Company and Partnership for Safe Medicines. For more patient safety articles and practice tips, visit www.thedoctors. com/patientsafety. For more information on counterfeit medicines, visit www. safemedicines.org.

In the past few years, a number of developments have occurred — including drug shortages and patients having trouble affording their prescriptions — that might seem to justify importing medications from overseas. The world outside U.S. borders appears to offer a ready sup10 May 2014

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ply of cheaper medications easily obtained through unlicensed distributors, trips across the border, or online pharmacies.

The laws that prohibit importing nonFDA-approved medicines are designed to ensure that patients receive medications that meet the FDA’s requirements for safety, purity, and potency. It is illegal to import unapproved, misbranded, adulterated, or foreign versions of U.S.-approved medications into the country. The law also applies to medical devices.

Regardless of the supplier, purchasing or using non-FDA-approved drug products exposes the physician to criminal and civil liability. Medical malpractice insurance may not cover any errors in this area, making physicians personally liable for claims that they provided counterfeit drugs.

The medication doesn’t even have to be counterfeit for the physician to suffer legal consequences: Medications that have the correct ingredients but haven’t been FDAapproved are still illegal to use.

Physicians and their office staff may inadvertently order counterfeit drugs or devices. Follow these tips to protect yourself and your patients from the risks of illegal medications and devices: • Require training for everyone involved in purchasing medications.

• Be wary of fax or email blast offers from an unauthorized distributor selling “discounted” foreign medications or devices.

• Have clear policies that dictate how to verify the license of a wholesaler providing medications. For example, require that your staff verify all vendors by checking wholesaler accreditation and licensing at http://safedr.ug/ VAWDaccredited and http://safedr.ug/ fdalicense.

• Obtain medications only from secure sources.

• Know the warning signs that a product may be counterfeit: °° Are prices or deals too good to be true? °° Was the fax/email offer unsolicited and from an unknown seller? °° Is the labeling in a foreign language when it’s normally in English? °° Is the package damaged or soiled? °° Are all tamper seals present and intact?

• If in doubt, call the manufacturer to check if the lot number is still valid and matches the expiration date.

• Educate patients about avoiding counterfeit drugs with free resources like the S.A.F.E.D.R.U.G. checklist at www. safemedicines.org/safedrugs.html.

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

SAN DI EGO PHYSICIAN.org 11

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 opposite page — 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 May 2014

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.

How The List on Page 13 Was Created The American Academy of Allergy, Asthma & Immunology (AAAAI) Executive Committee created a task force to lead work on Choosing Wisely consisting of board members, the AAAAI

president and secretary/treasurer, and AAAAI participants in the Joint Task Force on Practice Parameters. Through multiple society publications and notifications, AAAAI members were invited to offer feedback and recommend elements to be included in the list.

A targeted email was also sent to an extended group of AAAAI leadership inviting them to participate.

The work group reviewed the submissions to ensure the best science in the specialty was included. Based on this, additional members were recruited for their expertise.

Suggested elements were considered for appropriateness, relevance to the core of the specialty, potential overuse of resources, and opportunities to improve patient care. They were further refined to maximize impact and eliminate overlap, and then ranked in order of potential importance both for the specialty and for the public. Finally, the work group chose its top five recommendations, which were then approved by the Executive Committee. AAAAI’s disclosure and conflict of interest policy can be found at www. aaaai.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 Academy of Allergy, Asthma & Immunology Note: These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional.

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

1

2

Don’t perform unproven diagnostic tests, such as immunoglobulin G (IgG) testing or an indiscriminate battery of immunoglobulin E (IgE) tests, in the evaluation of allergy.

Appropriate diagnosis and treatment of allergies requires specific IgE testing (either skin or blood tests) based on the patient’s clinical history. The use of other tests or methods to diagnose allergies is unproven and can lead to inappropriate diagnosis and treatment.

Appropriate diagnosis and treatment is both cost-effective and essential for optimal patient care.

Don’t order sinus computed tomography (CT) or indiscriminately prescribe antibiotics for uncomplicated acute rhinosinusitis.

Viral infections cause the majority of acute rhinosinusitis and only 0.5% to 2% progress to bacterial infections. Most acute rhinosinusitis resolves without treatment in two weeks. Uncomplicated acute rhinosinusitis is generally diagnosed clinically and does not require a sinus CT scan or other imaging. Antibiotics are not recommended for patients with uncomplicated acute rhinosinusitis who have mild illness and assurance of follow-up. If a decision is made to treat, amoxicillin should be first-line antibiotic treatment for most acute rhinosinsutis.

Don’t routinely do diagnostic testing in patients with chronic urticaria.

3

In the overwhelming majority of patients with chronic urticaria, a definite etiology is not identified. Limited laboratory testing may be warranted to exclude underlying causes. Targeted laboratory testing based on clinical suspicion is appropriate. Routine extensive testing is neither cost-effective nor associated with improved clinical outcomes. Skin or serum-specific IgE testing for inhalants or foods is not indicated, unless there is a clear history implicating an allergen as a provoking or perpetuating factor for urticaria.

Don’t recommend replacement immunoglobulin therapy for recurrent infections unless impaired antibody responses to vaccines are demonstrated.

4

Immunoglobulin (gammaglobulin) replacement is expensive and does not improve outcomes unless there is impairment of antigenspecific IgG antibody responses to vaccine immunizations or natural infections. Low levels of immunoglobulins (isotypes or subclasses), without impaired antigen-specific IgG antibody responses, do not indicate a need for immunoglobulin replacement therapy. Exceptions include IgG levels <150mg/dl and genetically defined/suspected disorders. Measurement of IgG subclasses is not routinely useful in determining the need for immunoglobulin therapy. Selective IgA deficiency is not an indication for administration of immunoglobulin.

Don’t diagnose or manage asthma without spirometry.

5

Clinicians often rely solely upon symptoms when diagnosing and managing asthma, but these symptoms may be misleading and be from alternate causes. Therefore spirometry is essential to confirm the diagnosis in those patients who can perform this procedure.

Recent guidelines highlight spirometry’s value in stratifying disease severity and monitoring control. History and physical exam alone may over- or underestimate asthma control. Beyond the increased costs of care, repercussions of misdiagnosing asthma include delaying a correct diagnosis and treatment.

SAN DI EGO PHYSICIAN.org 13

Navy

Medicine

Naval Medical Center San Diego

By Rear Adm. Bruce L. Gillingham, MD, FAAOS Dr. Gillingham, SDCMS-CMA member since 2014, is Commander of Naval Medical Center San Diego and Navy Medicine West.

14 May 2014

Caring for Our Nation’s Heroes and Their Families

The Naval Medical Center San Diego (NMCSD) is a Joint Commission-accredited tertiary academic medical facility dedicated to providing care to our nation’s military heroes and their families; educating and training the Navy’s future doctors, nurses, hospital corpsmen and medical technicians, and deploying medical forces to support our nation’s warfighters literally around the world. NMCSD’s tradition of military medical care excellence is woven into the fabric of San Diego and dates back to a tent hospital established in Balboa Park in World War I. The pink Spanish Colonial Revival-style buildings long known by locals as “Balboa Naval Hospital” opened in 1925. The iconic administration building, transferred to the city in 1988 following the construction of our newest facility, is still visible from Park Boulevard.

As the commander of NMCSD, I have three primary responsibilities: (1) to provide safe, high-quality care to active duty and retired service members and their families who live in the San Diego area; (2) to educate and train new military physicians, nurses, hospital corpsmen, and allied health providers, and to ensure our staff members who accompany our Navy and Marine Corps warfighters on deployment are at the top of their game and prepared to provide a high standard of care even in austere environments; and (3) to ensure the military forces who deploy from the San Diego area are medically ready. Balancing these three missions requires the dedication and commitment of more than 6,500 uniformed and civilian staff members, many of whom work in our primary care clinics located throughout San Diego County. We also appreciate our partnerships with the many local healthcare organizations that help us care for our patients — partnerships that were particularly important during our recent conflicts. It was not uncommon to have more than 10% of our active duty staff deployed, which, despite the admirable efforts of all who remained behind, decreased our overall treatment capacity. At present, only about 2% of our staff is deployed, and we have returned to full operating capacity. Although we are the primary caregiver for our beneficiaries, we look forward to continued collaboration with you, our civilian colleagues, as we seek to provide only the highest standard of care to our patients.

In the following paragraphs, I will provide an overview of our facility, describe some of the initiatives we have undertaken to ensure we are meeting and exceeding national quality benchmarks, and highlight some of our outstanding capabilities.

High Reliability Organization Like our colleagues in Naval Aviation and Navy Nuclear Power, we in Navy Medicine are focused on creating and maintaining a culture of high reliability. High-reliability organizations focus on decreasing variability and on producing consistent, high-quality results over time. The same quality-driven principles are integrated into daily practice at NMCSD by more than 1,100 providers who comprise our medical staff. Many of our clinicians can draw from their experiences serving aboard nuclear-powered ships, aircraft carriers, or in operational theaters such as Iraq and Afghanistan, and apply those skills to the care we provide our beneficiaries in specialties ranging from neonatology and pediatric neurosurgery to cardiothoracic surgery and hematology/oncology. Led by Cmdr.

(Dr.) Chris Cornelissen, our director of quality management and a fellowship-trained cardiothoracic anesthesiologist, we have dedicated ourselves to sustaining a culture of patient safety and clinical quality based on a foundation of teamwork and multidisciplinary collaboration not unlike that practiced by our Naval Special Warfare colleagues. The team huddle practiced in the operating room before a surgical procedure is replicated many times each day by clinical teams seeking to adopt best practices, exceed national quality benchmarks, and enhance procedural skills. These painstaking preparations are the foundation of achieving a highreliability mindset.

A cornerstone of our patient safety culture is the adoption of TeamSTEPPS® principles applied throughout all areas of NMCSD. TeamSTEPPS® — a patient safety program created through a collaborative effort of the Department of Defense and the Agency for Healthcare Research and Quality — traces its roots at NMCSD to the creation of Med Teams in 2005, a multidisciplinary teamtraining effort focused on quality, safety, and efficacy of healthcare delivery. Team events such as a planning brief, huddle, debrief, and two-challenge rule are some of the concepts introduced to enhance team communication, highlight safety concerns, and

streamline transitions of care for patients. Under the direction of a program manager, multidisciplinary clinician and non-clinician leaders were assigned to develop unit-based TeamSTEPPS® training strategies throughout the entire medical center and will train all NMCSD staff this calendar year.

At NMCSD, many important patient safety and quality measures have taken root and become sustainable through the efforts of several innovative, physician-led multidisciplinary teams.

Obstetrical care, cancer care, and surgical quality improvement are three examples of NMCSD’s keen focus on clinical high reliability. In obstetrical care, clinicians from the Department of Obstetrics and Gynecology reviewed their rates of third- and fourthdegree lacerations that occur as a part of childbirth, compared them to national benchmarks, and developed a proactive training and monitoring program allowing physicians to review individual practice patterns. As a result, the NMCSD obstetrical team was recognized with a Department of Defense Quality and Patient Safety Award for 2013.

NMCSD’s Cancer Clinical Quality Team fully aligns with best clinical practice to deliver cutting-edge therapy while ensuring patient- and family-centered care for our cancer patients. As a result of the team’s efforts, NMCSD has received three consecutive outstanding achievement awards from the American College of Surgeons Commission on Cancer. During the most recent survey, NMCSD garnered the highest number of commendations achievable and received a full three-year certification.

Since 2003, NMCSD has been a participant in the Department of Defense collaborative for the American College of Surgeons/ National Surgical Quality Improvement Program (ACS/NSQIP).

Multidisciplinary teams and front-line clinicians utilize NSQIP data to identify opportunities to enhance surgical clinical quality. Surgical quality data is regularly reviewed by our Quality Care Council and medical center Executive Steering Council. This comprehensive review espouses a culture of transparency as we look for ways to enhance surgical quality at every opportunity. Our most recent semiannual report highlighted exemplary outcomes for gynecology and otolaryngology returns to the operating room, and exemplary results for plastic surgery surgical-site infections in comparison to participating ACS NSQIP. Since 2008, the Bioskills and Simulation Training Center (BSTC) has provided team-based training to enhance the clinical skills of all healthcare providers at NMCSD. A NMCSD’s tradition world-class facility staffed of military medical care by a team with combat caexcellence is woven into sualty experience, the BSTC the fabric of San Diego supports cadaveric and simulator-based training and dates back to a exercises to enhance profestent hospital established sional practice, unit-based in Balboa Park in TeamSTEPPS® training, World War I. and Mock Code Blue training enhancing critical crisis-management decisionmaking capabilities, and team communication during high-stakes simulation scenarios.

Recently certified as a Fundamentals of Laparoscopic Surgery™ Regional Testing Center, the BSTC supports minimally invasive surgical training for trainees and practicing surgeons from multiple specialties. Additionally, the BSTC has developed collaborative educational relationships with deploying expeditionary medical teams and healthcare institutions around San Diego and across the nation.

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Medicine our residency and fellowship programs include a military-unique curriculum that encompasses humanitarian clinical rotations as well as combat casualty care training.

Many of our residents have advanced clinical experience following operational service as U.S. Navy flight surgeons and undersea medical officers.

Upon graduation, residents and fellows serve in U.S. military academic medical centers and community hospitals in the United States and overseas. All graduates and faculty have the opportunity to serve as part of joint operational military medical teams.

NMCSD has a vibrant research program with an Institutional Review Board responsible for more than 300 active protocols. Our Clinical Investigations Department (CID) supports research efforts throughout the Navy Medicine West region ranging north to Seattle and east across the Pacific to Guam and Japan. CID supports operational readiness, patient care, and medical education by facilitating scientifically sound research and publications with a focus on “academic excellence with operational relevance.” We are fortunate to collaborate through research agreements with local San Diego organizations, including Sanford-Burnham Medical Research Institute, Veteran’s Village of San Diego, University of California San Diego, and San Diego State University. The major focus of our research efforts involves the intersection of quality healthcare, GME, and operational support to warfighters. Our research portfolio includes publications and current investigations regarding laser scar revision; amputee gait analysis and phantom limb pain; urologic robotics; advancements in orthopedic traumatic injury care; traumatic brain injury and post-traumatic stress. State-of-the-art National Institutes of Health-sponsored cancer treatment protocols have been active for decades, contributing to advances in cancer treatment. We are proud of our 65-year heritage of medical education, training, and research that supports physicians who are entrusted to care for America’s heroes.

Figure 1: The annual C.A.R.E. Summit at NMCSD has rapidly become a leader in focused multidisciplinary innovation and training, featuring top military and civilian experts from a variety of disciplines

Medical Training and Research for All Environments NMCSD’s medical teams embody a tradition of operational excellence aboard ships, submarines, aviation squadrons, or embedded with the Marines. Navy Medicine is integrating cutting-edge technology, innovative training, and team collaboration to drive enhanced patient safety and clinical excellence into the future while providing top-notch care to all beneficiaries.

NMCSD has been formally training physicians since 1946 when it was certified by the Council on Education of the American Medical Association to conduct training for 29 doctors in 10 special branches of medicine. Currently, we are certified by the Accreditation Council for Graduate Medical Education as a tertiary-care academic medical center sponsoring 20 Graduate Medical Education (GME) programs. Under the guidance of Capt. (Dr.) Richard Green, a board-certified anesthesiologist, more than 300 physicians are trained annually in 15 residency and five fellowship programs. Our GME mission includes preparing U.S. Navy faculty and resident physicians to lead and serve in operational military environments worldwide. Our programs are led by a diverse faculty from toptier institutions around the country who have served for the past 10 years with distinction in Afghanistan, Iraq, and other areas of global conflict. In Although we are the addition, our faculty primary caregiver routinely collaborates for our beneficiaries, with U.S. government we look forward agencies and civilian nonprofit orgato continued nizations to provide collaboration with first-rate humanitaryou, our civilian ian civic assistance in colleagues, as we response to disasters and global humaniseek to provide tarian relief efforts. only the highest Along with meeting standard of care to all training requireour patients. ments for civilian program accreditation, 16 May 2014

A Decade of War Advances Navy Medicine Advancements in medical care, transport, and coordination through more than a decade of recent military conflict have produced the greatest global system of trauma care ever seen, responsible for unprecedented survival rates despite catastrophic injuries including multiple amputations (1). This has mandated equally innovative rehabilitative solutions to enhance reintegration and improve the quality of life for our injured service members. Combat-injured men and women are eligible for lifelong care and support through military treatment facilities and the U.S. Department of Veterans’ Affairs (VA) Veterans’ Health Administration (VHA) System. To better coordinate care and foster innovation, military centers of excellence in rehabilitation began to take form at the nation’s premier military medical facilities beginning in approximately 2007. The Comprehensive Combat and Complex Casualty Care (C5) program at NMCSD is one such entity. C5 provides a comprehensive program of care that guides patients from inpatient status through the transition back to active duty or into

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Medicine civilian life and beyond. Key elements include personalized case management, mental health support, traumatic brain injury care, prosthetic fitting and fabrication, physical, occupational, and recreational therapy, multispecialty surgical and nonsurgical medical care, and family support and transition services.

While many patients treated in C5 are U.S. Marines based at nearby Camp Pendleton, the center cares for patients from all branches of service. The center was originally designed for the rehabilitation of men and women injured on the battlefield, but the model of care applies equally well to rehabilitation from any type of trauma. Indeed, one of the durable legacies of the center is the advancement of a highly coordinated approach to trauma care and rehabilitation regardless of the nature of the injury. Consistent with Dr. William Mayo’s maxim “rehabilitation is to be a master word in medicine,” the common sense of mission, consolidated location, and lack of financial disincentives facilitate a degree of multispecialty collaboration that is a model for how to create an integrated practice unit. This effort is manifest in the creation of a novel initiative called the Comprehensive Advanced Restorative Effort (C.A.R.E), a component of C5 and NMCSD promoting aesthetic and functional rehabilitation for injured service members. Founded by Capt. (Dr.) Craig Salt, a plastic surgeon, and Cmdr. (Dr.) Peter Shumaker, a dermatologist, this patient-centered program combines case management with rapid and integrated consultation, including a wide variety of disciplines such as plastic and facial plastic surgery, dermatology, orthopedic surgery, oro-maxillofacial surgery, physical medicine, physical and occupational therapy, and mental health. Internal tracking has demonstrated significantly faster appointing, broader multispecialty exposure, and excellent patient satisfaction. The annual C.A.R.E. Summit at NMCSD has rapidly become a leader in focused multidisciplinary innovation and training, featuring top military and civilian experts from a variety of disciplines (see Figure 1).

One example of the unanticipated benefits of this broad-based approach to trauma rehabilitation in the military is the routine integration of dermatologists into the treatment team. The NMCSD Dermatology Department has been among the pioneers in the early integration of ablative fractional laser resurfacing for the management of debilitating traumatic scars and contractures, arguably

18 May 2014

one of the most important developments in scar treatment in decades (2, 3). Laser hair reduction for amputation stumps has also proven to be a particularly valuable tool in improving the comfort and fit of prosthetic devices and enhancing overall rehabilitation (see Figure 2).

Another example is the overall elevation rehabilitation goals, as illustrated by amputee care. While the vast majority of amputations within VHA are a result of diabetes and peripheral vascular disease, enhanced survival from catastrophic injury has resulted in the entry of thousands of younger amputees without extensive medical comorbidities into the system and challenged established paradigms (4). Simply walking is no longer sufficient, and this group of patients often wants to participate in normal activities at levels as high or even higher than their counterparts (see Figure 3). As a result, wear and tear on prosthetics is increased and needs for repair and replacement are greater. Furthermore, different prosthetics required for different activities such as running and biking are all provided at no cost to the patient. The military and VA medical systems have responded by creating the most comprehensive system of prosthetic care in the world, bolstered by continuing research.

Though combat operations are purported to end in Afghanistan at the end of 2014, this clearly will not be the end to the need or the responsibility to provide excellence in lifelong care for our wounded veterans who may spend the next 50 or 60 years coping with the residual effects of amputations and other related injuries.

Cardiac Care in the Clinic and in the Community The Cardiac Catheterization Laboratories (CCL) at NMCSD has a long tradition of providing the most technically advanced, ethically conscientious, high-quality interventional cardiac care for our active duty and retired beneficiaries as well as their families.

Annually, ~1,000 advanced cardiac procedures are performed in the NMCSD CCL, including diagnostic cardiac catheterizations, percutaneous coronary interventions, peripheral angioplasties, pacemaker implantations, and electrophysiology studies. The CCL also participates in San Diego’s 24/7 STEMI Receiving Consortium, caring not only for our DOD beneficiaries, but any patient requiring life-saving procedures for heart attacks. The CCL now also offers mitral and aortic valvuloplasty, paravalvular leak repair, and complex shunt closures such as patent foramen ovale, atrial septal defect, ventricular septal defect, coronary artery fistulas, and patent ductus arteriosus leFigure 2: Laser sions. Cmdr. (Dr.) Keshav R. hair reduction for amputation stumps Nayak, director of the CCL has also proven to be along with Cmdr. (Dr.) Wila particularly valuable liam Bennett, are NMCSD’s tool in improving the cardiac interventionists and comfort and fit of were trained in high-risk prosthetic devices heart procedures here in San and enhancing overall rehabilitation Diego. They are superbly assisted by a group of highly trained and capable cardiovascular technicians.

Together as a team, the CCL performs high-risk coronary interventions, including use of rotational atherectomy, intravascular ultrasound, intraaortic balloon pumping, impella percutaneous left ventricular assist device, and opening chronic total occlusions using the most advanced techniques for safe reopening of 100% blockages.

The CCL also incorporates the cardiac electrophysiology team providing state-of-the-art therapies in the management of cardiac rhythm disorders. This includes catheter ablation for supraventricular tachycardias, atrial flutter, atrial fibrillation, and ventricular tachycardias, as well as cardiac devices such as pacemakers, implantable defibrillators (ICD), and cardiac resynchronization therapy (CRT) devices. Cmdr. (Dr.) Gregory Francisco, director of the CCL EP lab, explains, “We pride ourselves in the rapid diagnosis and treatment of our patients, especially our active-duty patients, so they can return to full duty as soon as possible.”

The CCL relies heavily on state-of-the-art imaging services offered by both the Radiology Department and Echocardiography Laboratory at NMCSD. Dr. Gil Boswell, director of Cardiac Imaging, uses the most advanced cardiac imaging equipment unparalleled in the community to include four separate wide bore 3 tesla MRI machines and 3 CT machines, capable of the finest image resolution.

The dual-source paired 128-row CT scanners are able to image the entire heart in a fraction of a second, resulting in the use of less intravenous contrast, at a much lower radiation dose. With certain scan techniques, imaging of the heart, aorta, and brain can be completed in one quick scan. The Echocardiography Laboratory is led by Cmdr.

(Dr.) Steven Romero, board-certified in echocardiography, and offers a wide range of services, including trans-thoracic and trans-esophageal, both with 3D capabilities, as well as echo stress testing. Intraoperative live 3D echocardiography is crucial for success of many structural heart cases performed in the CCL.

Figure 3: Simply walking is no longer sufficient, and this group of patients often wants to participate in normal activities at levels as high or even higher than their counterparts

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TrusT A Common sense ApproACh To InformATIon TeChnology Cancer Care and Blast Injuries Below the Belt Urology at NMCSD has a long and distinguished history. NMCSD first started to train urology residents in the early 1950s and was the first program in San Diego.

Since that time the urology residency program has continuously trained urological surgeons for practice at military medical centers overseas, across the country, and in direct support of humanitarian and combat operations. Throughout its history the program has continued to focus on innovation, research, and patient-centered care.

For many men, diagnosis of testicular cancer is a life-altering and challenging experience. According to the most recent data from the National Cancer Institute, the incidence of testicular cancer continues to rise, affecting more than 8,000 men annually at an average age of 33 years — a patient population that is highly represented in the military. As the major military referral center on the West Coast, NMCSD has the opportunity to care for many of these young men. Urologists at NMCSD treat 20–30 new testicular cancer patients each year, and have developed a unique expertise in managing these sailors, soldiers, airmen, and Marines. In 2008, Cooper et al. reported on the demographic trends and excellent treatment outcomes of the 338 patients treated at NMCSD over a 20-year period.

After orchiectomy, testicular cancer is associated with a 10–50% risk of relapse depending on risk factors, so thoughtful discussions at multidisciplinary Tumor Boards with careful evaluation of risks and benefits have become a standard practice.

According to Cmdr. (Dr.) Sean Stroup, head of urologic oncology, “Treatment decisions about testicular cancer care are very individualized. These discussions include coordinated radiology and pathologic review, recommendations for clinical trials, assistance with sperm cryopreservation, and discussions about surveillance or treatment between medical oncology, radiation oncology, and urology.” This format has become a model at the institution.

Treatment decisions also impact the rigor of follow up and the ability of these men to be declared “cancer-free” and capable of worldwide deployment. Cmdr.

(Dr.) James O. L’Esperance, director of robotic surgery, has pioneered an innovative, robotic-assisted, minimally invasive surgical approach to remove retroperitoneal lymph nodes, the preferred landing spot for metastatic testicular cancer cells. This approach, performed at NMCSD since 2008, has significantly reduced blood loss, reduced pain, length of stay, and return of bowel function when compared to the open surgical alternative. This approach maintains oncologic principles of a complete dissection and sympathetic nerve preser-

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Medicine vation for normal ejaculatory function. L’Esperance The team huddle feels this approach “represents the perfect anpracticed in the swer for testicular cancer operating room management, with quick before a surgical return to full duty and efprocedure is fective outcomes.”

Testicular cancer rereplicated many quires lifelong follow-up times each day because of the risk of late by clinical teams relapse, but this innovative seeking to adopt and comprehensive program is achieving results. best practices, Blast injuries from imexceed provised explosive devices national quality (IEDs) have extracted a benchmarks, terrible toll on many young and enhance men and women during Operation Enduring procedural skills.

Freedom. In particular, external genitalia injuries have become increasingly common in recent conflicts, and account for up to 13% of injuries.

This represents an increase of nearly 350% compared to the baseline for such injuries in 20th century conflicts. The majority of these injuries involve the external genitalia. According to Cmdr.

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22 May 2014

(Dr.) Donald Crain, Department Head Urology, and a specialist in infertility, these patients suffer “life-changing loss of proper sexual, bowel, and urinary function and fertility.”

At NMCSD we have developed, in coordination with C5, an integrated pathway for assessment of genitourinary injuries. According to Lt. (Dr.) Eric Biewenga, a resident and lead researcher in this area, this “holistic approach focuses on psychological and physical therapy support, hormonal assessment, fertility services, and restoring normal urinary and sexual function.”

Military Traditions Coupled With Nontraditional Care One of the most important things we have learned over the past decade of treating war wounded is the value of promoting health and wellness through a wide variety of approaches, including several types of recreational therapy and educational strategies.

Although our initial focus was on injured service members, our Health and Wellness staff, led by Helen Metzger, has expanded these services to all of our patients. For example, a woman comes in contorted with chronic pain, and leaves the adaptive yoga class with more ease and grace as she learns to release with her breath.

A soldier who lost his pride of his physical excellence with the loss of his legs displays pride and leadership once again as a NMCSD Wolfpack wheelchair basketball national champion and mentor to his newer teammates. A father learns to accept his new war-al-

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tered face while going to the zoo with his child and other combatinjured military and their families in a community reintegration activity. Being tumbled in the ocean waves echoes her feelings of powerlessness, but the sailor learns to relax with it, rise to the surface, and ride the wave on her surfboard in the Surf Clinic. I see a man arrive who refuses to make eye contact as he struggles to control his suppressed rage. After he puts his anger to song during the Music Therapy Clinic, he learns to safely release and find new perspective from sharing with others.

No matter what health challenge a patient faces, the Health and Wellness Department staff dedicates their full time and resources toward bringing back the joy in their life. The Wounded, Ill, and Injured (WII) Wellness Division of Health and Wellness treats patients with a wide array of conditions, from amputations, depression, PTSD, cancer, and chronic pain. We don’t treat the condition that brought them to the hospital, but we teach them how to be well while living with or resolving from the condition. The patient will receive a comprehensive wellness assessment, and then be internally consulted to one or a variety of additional providers in Health and Wellness, to include mental health, exercise physiology, recreation therapy, nutrition, and health education. From there the patient is entered into a variety of programs that include Community Reintegration, Adaptive Sports, Creative Expression, Leisure Education, Exercise Therapy, Healthy Eating, and Mind and Body Medicine. The resiliency demonstrated every day by our patients is an inspiration to all of us who have the privilege to serve them.

It is an honor to lead the selfless men and women of Naval Medical Center San Diego as we care for our nation’s defenders and their families. We are committed to the same principles of high reliability and teamwork as our operational colleagues and we will not fail in our primary mission of providing safe, high-quality healthcare in an environment of compassion and caring. Our patients deserve nothing less.

Notes: 1. Eastridge BJ, Mabry RL, Seguin P, Cantrell J, Tops T, Uribe P, Mallett O, Zubko T, Oetjen-Gerdes L, Rasmussen TE, Butler FK, Kotwal RS, Holcomb JB, Wade C, Champion H, Lawnick M, Moores L, Blackbourne LH. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S431-7.

2. Shumaker PR, Kwan J, Landers JT, Uebelhoer NS. Functional improvements in traumatic scars and scar contractures using an ablative fractional laser protocol. J Trauma Acute Care Surg.

2012;73:S116-21.

3. Anderson RR, Donelan MB, Greeson E, Hivnor C, Ross EV, Shumaker PR, Uebelhoer NS, Waibel JS. Consensus Report: Laser treatment of traumatic scars with an emphasis on ablative fractional resurfacing. JAMA Dermatol 2014;150:187-93.

4. Amputation system of care. VHA handbook 1172.03. http:// www1.va.gov/vhapublications/ViewPublication.asp?pub_ ID=2774. Last accessed March 18, 2014.

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“Hey, Doc. Know What Happiness Is?” Integration of a Psychiatrist on a Military Physical Rehabilitation Unit

By Steven J. Davis, MD, DLFAPA Dr. Davis is a longtime SDCMS member, currently retired.

24 May 2014

A therapy session at Walter Reed Army Medical Center (WRAMC) in Washington, DC, began with: “Hey, Doc. Know what happiness is? Happiness is good health and a bad memory.” He entered on crutches with a left transtibial amputation and combat memories as a sniper. He had neither good health nor good memories.

He had very little happiness.

In response to the attacks of 9/11, the United “Every morning States embarked upon two wars, in Afghanistan when I get up, I look at myself and (Operation Enduring Freedom, or OEF) and Iraq I have no legs.”

(Operation Iraqi Freedom, or OIF). I had the unexpected privilege of working as a locum contract psychiatrist at Walter Reed from 2010 to 2012 at the height of aggressive combat when village foot patrols were at their highest. By then we had been sending young men and women on multiple deployments for more than nine years.

Whereas, in professional and popular writing, TBI and PTSD were the signature, invisible OEF/OIF war injuries, at Walter Reed the signature injury was traumatic amputation. 90–95% of amputee patients were admitted and treated at WRAMC. By the end of 2012, they had received and treated more than 1,700 amputee patients, generally carrying 150 active patients at any given time.

During the year 2011–12, for the first time in military history, more than half exhibited multiple limb loss, including some triple and quadruple casualties. All required sophisticated tertiary-level multidisciplinary team management. No one had been prepared for this carnage, and military medical staffs at WRAMC and sister institutions were under continuous duress. Because of medical staff deployments, contractors filled the gaps.

The Psychiatric Consultation and Liaison Service (PCLS), under its chair, Hal Wain, PhD, evolved from a traditional C&L serTheir stories of combat and trauma were molded to fit their psyvice into a bifurcated model. One arm served traditional complex chological strengths, forgive their guilt for leaving their friends and medical/surgical patients, while the second arm functioned as a the fight behind, and, in their constructions, preserve their self-esproactive early interventionist service committed to the support teem. It was never important that their story be fully accurate nor, and behavioral healthcare for every wounded warrior and family given the presumed concussive neuronal effects of blast injuries, within the first 24–48 hours of WRAMC arrival. It approximated that it even have been possible. Over time, their “story” changed, battlefield medicine as it was not uncommon for the wounded to be but it always commemorated survival (their “alive day”) and beonly 36–72 hours removed from the originating trauma. came internalized and reorganized by its repeated retelling.

Hal creatively renamed the service Preventive Medical PsyA young Marine with a high L transfemoral amputation and teschiatry, and, with the support of the Physical Rehabilitation and ticular and penile injury initially avoided talking about his injuries Orthopedic Departments, I became physically embedded on the or the combat that led to them. Instead he constructed his “storehab floor itself (known as MATC, or Military Advanced Training ryline” around a framework of competence and potency. He deCenter), consistent with the military field combat model of moving scribed in detail his very first combat encounter, not his last. critical services forward. I was a constant presence and introduced “Get away from me. You creep me out when you stand over me my role as our name implied, Prevention is first and Psychiatry is like that.” He had a shrapnel-peppered face, had high bilateral last. Slowly, the Marines got it. I saw everyone. transfemoral amputations, and loss of all digits except his thumb on PCLS interventions began on the hospital wards where grief and one hand and loss of thumb and preservation of digits on the other. the miracle of survival were the earliest psychological and spiritual By any standard, he was grievously mangled. He projected how he responses. The MATC embraced an aggressive sports medicine believed he must appear to others. (Get away from me, I must creep model and featured an array of high tech weight, cardio machines, you out. No one would want to talk to me. I’m so disfigured.) and stretching mats, all of which were already familiar to these The work could be arduous but was continuously rewarding and young athlete warriors. That I was physically embedded, fully inspiring. I had always understood honor and integrity, but these integrated into the treatment team, and that I saw everyone (and wounded taught me the fullness of sacrifice and brotherhood. It their family) as they arrived on rehab demythologized psychiatry, was their shared commonality that made the unbearable bearable. automated access, and mitigated stigma. I served three populaMore than any staff intervention, it was love for each other — their tions simultaneously, patient and family and staff, all staggered by brothers, a wounded mirror of themselves — that enabled recovery. challenging traumatic physical and psychological disorganization.

Many not only survived but thrived — perhaps 20% of the recent “Every morning when I get up, I look at myself and I have no legs.

U.S. Paralympics team were “graduates” of Walter Reed.

I do it again when I go to bed at night. One of these days, I’ll find a I kept personal notes, case vignettes, and periodically still reway to accept it … and I do, mostly.” He caressed his residual limbs flect on two remarkably unique years, unknown except to those through parts of the session. who have served during these and past periods of combat. To work On his first deployment to Afghanistan, R.S. stepped on a presalongside that dedicated and talented staff has been a career pinsure plate IED and “woke up” in WRAMC with severe polytrauma. nacle. One physical therapist remarked that “it was like working in He suffered both L and R transfemoral amputations, an open pelthe NFL” — nothing else in her career (or mine) would ever match vic fracture with elaborate external fixation, buttock and rectal the stakes, intensity, or professionalism. I was more often a quiet lacerations, L orchiectomy, and multiple shrapnel pepper wounds. observer than an active therapist. I listened, bore witness, offered Extended intubation left him uncommunicative for weeks. “I want validation, and countered with respect. They gave more to me than to be the first double AK to go back through Ranger training.” His I gave to them. was a common refrain, a longing to recover the competence he had I was an accident of place and moment in our nation’s history. A briefly known, a wish to restore his career identity, and a wish to reunique and unforgettable witness. I encourage you to read any acconnect to his Army family. If only he could go back and start over. count of wartime medicine.

SAN DI EGO PHYSICIAN.org 25

classifieds PRACTICE ANNOUNCEMENTS DR. TANIA RIVERA, RHEUMATOLOGIST, RECENTLY RELOCATED TO SAN DIEGO: Dr. Rivera has opened two practices in La Jolla and Bankers Hill. She also provides consultation services at Scripps Memorial La Jolla and Scripps Mercy Hospital. Dr. Rivera has been practicing medicine for about 12 years. She performed rheumatology fellowship at New York University Medical Center, and thereafter practiced rheumatology in Princeton, New Jersey. While she treats the full range of rheumatologic diseases, her special interests include lupus nephritis, lupus and pregnancy, fibromyalgia, osteoporosis, and osteoarthritis. Dr. Rivera provides intra-articular injections and biologic treatments in the office, including denosumab. Telephone (858)336-2810 or visit http://www.rheumsd.com. [232] PHYSICIAN POSITIONS AVAILABLE seeking family practice / internal medicine physician: Join an exciting group with tremendous growth potential in a collegial atmosphere! Artemis Medical Group is currently seeking a part-time possible full-time family practice / internal medicine physician to join our new medical group in Hillcrest. The right candidate will be at the forefront of launching this clinic. Candidate must be able to work independently, must have strong leadership skills and excellent communication skills. Able to provide supervision to mid-level providers. Knowledge of EMR/EHR and bilingual (English/Spanish) helpful. We offer a full benefit package. Competitive salary. Board certified a plus. Please email CV to artemismedicalgroup@gmail.com. [237] PEDIATRICIAN POSITION AVAILABLE: Parttime primary care pediatric position available in beautiful San Diego, California, to provide coverage for newborn care in Maternal Child Health Unit and community outpatient pediatric clinic.

Job duty includes supervision and teaching of residents and medical students. Average 20–24 patients daily. No evening or weekend calls or attendance of deliveries. Centrally located in San Diego with easy access to gorgeous beaches, parks, hiking trails, San Diego Zoo, and fine dining. Opening available now. Must be certified for PALS and NRP. BC or BE. Please submit inquiry and CV to nrupley@yahoo.com. [233] BOARD-CERTIFIED PHYSICIANS, PHYSICIAN ASSISTANTS, AND NURSE PRACTITIONERS NEEDED FOR URGENT CARE: Part-time positions available but a full-time opportunity may be offered to the right candidate. Must possess a current California medical license and ACLS certification. Please email or fax CV to (619) 5692590. Visit www.DoctorsExpressSanDiego.com for more information. [229a] PART-TIME PRIMARY CARE PHYSICIAN (URGENT CARE, PACIFIC BEACH): We are seeking a part-time primary care physician for a well-established busy primary care family practice / urgent care located in Pacific Beach. The candidate must be able to provide compassionate care in a fast-paced environment. Knowledge of musculoskeletal medicine and X-Ray is required. Must be able to suture and have experience with wound care. We have a state-of-the art medical facility.

Please email your CV in confidence for consideration to pbyrnes@andersonmedicalcenter.com.

Compensation: Depends on Experience [224]

SEEKING PER-DIEM PHYSICIAN: San Diego North County group looking for per-diem physician for busy urgent care. Family medicine physician preferred. Need coverage evening and weekends. Malpractice is covered. Please email CV to judy@cassidymg.com or fax to (760) 6302558, Attn.: Judy. [222] SEEKING IM PCP: Growing multispecialty North County practice seeks internal medicine PCP. Please send CV and request for information to anon625@cox.net. [220] PHYSICIANS: Well-established, busy pain management practice in San Diego Mission Valley is seeking a staff physician, preferably experienced in pain management and/or family practice. Convenient location in a new and modern office setting. We offer a competitive salary, flexible work schedules, and a benefits package that provides malpractice coverage, CME allowance, as well as excellent professional growth potential. Please email your curriculum vitae/résumé in confidence to painclinicsandiego@gmail.com. [216] PEDIATRICIAN: To take over existing practice for Arch Health Partners, an award-winning medical foundation affiliated with the Palomar Health System in North San Diego County. M–F, 8:00am – 5:00pm. Send CV to catherine.jones@ archhealth.org or fax to (858) 618.5820. [213] URGENT CARE PHYSICIAN — PER DIEM: Arch Health Partners is an award-winning medical foundation affiliated with the Palomar Health System in North San Diego County. Hours: 9:00am to 9:00pm. Send CV to catherine.jones@ archhealth.org or fax to (858) 618.5820. [212] 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] 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]

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.

26 may 2014

PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com) is a fastgrowing group of house-call doctors. Great pay ($140–$220+K), flexible hours, choose your own days (full or part time). No ER call or inpatient duties required. Transportation and personal assistant provided. Call Chris Hunt, MD, at (619) 992-5330 or email CV to drhunt@thehousecalldocs.com. Visit www.thehousecalldocs.com. [037] PHYSICIANS NEEDED: Family medicine, pediatrics, and OB/GYN. Vista Community Clinic, a private nonprofit outpatient clinic serving the communities of North San Diego County, has opening for part-time, per-diem positions. Must 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. EEO Employer/ Vet/Disabled/AA [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 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] OFFICE SPACE WANTED 3998 VISTA WAY, IN OCEANSIDE: Four medical office spaces approximately 1,300–2,800 square feet available for lease. Close proximity to Tri-City Hospital with pedestrian walkway connected to parking lot of hospital, and groundfloor access. Lease price: $1.75+NNN. Tenant improvement allowance to customize the suites is available. For further information, please contact Lucia Shamshoian at (760) 931-1134, ext. 13, or at shamshoian@coveycommercial.com. [234] HAND SURGEON LOOKING FOR PART-TIME OFFICE LOCATION: Looking for space to share in La Jolla to Del Mar areas. Limited space and time needs. One-half to one day per week. We have flexibility to accommodate your schedule and staffing. Please contact me at greg@thehanddoctor.com. [231] LOOKING FOR SUBLEASE: Subspecialist looking for space to sublease in the following locations: Encinitas / Carlsbad or Carmel Valley / Sorrento Valley / La Jolla / UTC. Would be able to move in May or later. Please contact sandiegodoctor23@yahoo.com with space location, availability, and type of arrangement (full or partial sublease, rooms / days available, etc.). [230]

OFFICE SPACE AVAILABLE 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] NEW MEDICAL OFFICE SPACE AVAILABLE FOR SUBLEASE IN KEARNY MESA: Brand new office suite located at 3750 Convoy Street with nine exam rooms and digital X-ray, hi-speed wireless, free parking for patients and staff, conference room in building. Several minutes from Sharp Memorial and Children’s Hospitals. Convenient freeway access to 163 and 805. Multiple half-day clinics available. Please contact Lisa Vaughn at (858) 278-8300, ext. 210, for more information. [235] LA JOLLA OFFICE SPACE: Share reception, waiting area, and exam/consultation rooms with neurosurgeon and orthopedic surgeon in new office. Five exam rooms. On-site X-rays with radiograph tech available. Office is close to Scripps Memorial Hospital. In Golden Triangle between 805 and 5 freeways. Terms negotiable. Please contact Kathy Koppinger at (858) 678-0455. [223] BANKERS HILL PRIMARY CARE AND RESEARCH OFFICE SPACE TO SUBLEASE: 50year established primary care practice and clinical research office with currently two internists has space to sublease to another primary care MD (internal medicine or subspecialties / family practice) to help curb overhead and see acute overflow patients. Also can provide opportunity to get involved with clinical research.

Flexible terms / space. Free parking, close to hospital, easy access to freeways. Contact Cindy at allmedgrp@hotmail.com. [146] POWAY OFFICE SPACE FOR SUBLEASE: Private exam room or rooms available for one day a week or more. Ideal for physician, chiropractor, massage therapist. Low rates. Email inquiries to kathysutton41@yahoo.com. [173] WOMEN’S HEALTH / WELLNESS OFFICE HAS SPACE AVAILABLE FOR SUBLEASE: Exam room, office, and/or shared staff optional. Fully furnished exam rooms available and ready for use. Location features onsite billing, reception, medical assistants, potential use of in-office procedure room, and a rooftop lounge. If you are interested, please reply with the heading “Space for Sublease” outlining the details of space and/ or staff use desired, with your contact information, and we will contact you to set up a showing.

Reply to Mrs. Kim at cvwh858@gmail.com. [217] MEDICAL OFFICE SPACE AVAILABLE FOR SUBLEASE IN LA JOLLA: 9834 Genesee Avenue, Suite 400 (Poole Building). Steps away from Scripps Memorial Hospital, La Jolla. Please contact Seth D. Bulow, MD, at (858) 622-9076 if you are interested. [215] SCRIPPS ENCINITAS CONSULTATION ROOM/ EXAM ROOMS: Available consultation room with two examination rooms on the campus of Scripps Encinitas. Will be available a total of 10 half days per week. Located next to the Surgery Center.

Receptionist help provided if needed. Contact Stephanie at (760) 753-8413. [703] POWAY / RANCHO BERNARDO — OFFICE FOR SUBLEASE: Spacious, beautiful, newly reno-

vated, 1,467 sq-ft furnished suite, on the ground floor, next to main entrance, in a busy class A medical building (Gateway), next to Pomerado Hospital, with three exam rooms, fourth large doctor’s office. Ample parking. Lab and radiology onsite. Ideal sublease / satellite location, flexible days of the week. Contact Nerin at the office at (858) 521-0806 or at mzarei@cox.net. [873] BUILD TO SUIT: Up to 1,900ft2 office space on University Avenue in vibrant La Mesa / East San Diego, across from the Joan Kroc Center. Next door to busy pediatrics practice, ideal for medical, dental, optometry, lab, radiology, or ancillary services. Comes with 12 assigned, gated parking spaces, dual restrooms, server room, lighted tower sign. Build-out allowance to $20,000 for 4–5 year lease. $3,700 per month gross (no extras), negotiable. Contact venk@cox.net or (619) 504-5830. [835] SHARE OFFICE SPACE IN LA MESA JUST OFF OF LA MESA BLVD: 2 exam rooms and one minor OR room with potential to share other exam rooms in building. Medicare certified ambulatory surgery center next door. Minutes from Sharp Grossmont Hospital. Very reasonable rent. Please email KLewis@SDCMS.org for more information. [867] NONPHYSICIAN POSITIONS AVAILABLE / WANTED BOARD-CERTIFIED PHYSICIANS, PHYSICIAN ASSISTANTS, AND NURSE PRACTITIONERS NEEDED FOR URGENT CARE: Part-time positions available but a full-time opportunity may be offered to the right candidate. Must possess a current California medical license and ACLS certification. Please email or fax CV to (619) 5692590. Visit www.DoctorsExpressSanDiego.com for more information. [229b] PHYSICIAN ASSISTANT OPENING: Well-established orthopaedic practice in San Diego County has an opening for an experienced, licensed orthopaedic physician assistant. Responsibilities include patient evaluation, diagnosis and treatment, in-office injections. This is a clinic-based position. We are considering both part-time and full-time candidates. Interested parties, email your CV with a cover letter including part-/fulltime preference and salary range / requirements to lisas@sdsm.net (Word or PDF format only please). Thank you for your interest. [226] SEEKING PHYSICIAN ASSISTANT: Physician assistant needed on per-diem basis for busy urgent care in the San Diego North County area.

Hours are evening and/or weekends. Please email CV to judy@cassidymg.com or fax to (760) 630-2558. [221] SEEKING PA / NP AND RN: Medical spa in the Del Mar / Solana Beach area is seeking PA / NP and RN. Should have experience with laser hair removal, IPL, CO2 laser, Botox and fillers, and sales. Positive attitude, ability to multitask, perform patient treatment, sales, consultations, effective communicator, work in a team environment, focused on client care, knowledge of lasers and laser theory, quick learner, self motivated.

PA/NP will perform consultations and good faith examinations. Minimum requirements: PA, NP, RN California license. This is a part-time position, 1–2 days a week. Please email résumé / cover letter to synergyamasb@gmail.com or fax to (858) 259-0864. [219] PART-TIME OB-GYN NURSE PRACTITIONER: Busy established OB-GYN office in La Jolla seeking a part-time OB-GYN nurse practitioner. Please email resume to ljpp36@sbcglobal.net. [214]

SEEKING NURSE PRACTITIONER: Independent pediatrics private practices in Poway and La Mesa seeking nurse practitioner (preferably pediatrics experienced) for maternity coverage in April and July for 10–12 weeks or more. Poway is for 2–3 days per week; La Mesa is for 1–2 days per week. Appointment may be extended depending upon each situation, i.e., if original provider returning to full-time, part-time care or not at all. Please contact Venk Adigopula at (619) 5045830 with queries about the two positions or email resume and interest letter to venk@gpeds. sdcoxmail.com (La Mesa) or venk@vvpeds.com (Poway). [211] NURSE PRACTITIONERS AND PHYSICIAN’S ASSISTANTS: Established, busy pain management practice in San Diego Mission Valley is looking for a nurse practitioner and physician’s assistant, preferably experienced in pain management or family practice. Knowledge of controlled substance prescriptions and regulations is required. Interpretation of diagnostic tests and the ability to apply skills involved in interdisciplinary pain management is necessary. We offer a competitive salary and benefits package that provides malpractice coverage, CME allowance, as well as excellent professional growth potential. Please email your curriculum vitae/résumé to painclinicsandiego@gmail.com. [210] PHYSICIAN ASSISTANT WANTED FOR SPORTS, SPINE, AND ARTHRITIS REGENERATIVE MEDICINE PRACTICE (ENCINITAS): Please reply with resume, letter of interest, and salary requirements to ssbunyak@hotmail.com. [199] NURSE PRACTITIONER: Needed for house-call physician in San Diego. Full-time, competitive benefits package and salary. Call (619) 992-5330 or email drhunt@thehousecalldocs.com. Visit www.thehousecalldocs.com. [152] PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Needed for house-call physician San Diego. Part-time, flexible days / hours. Competitive compensation. Call (619) 992-5330 or email drhunt@thehousecalldocs.com. Visit www.thehousecalldocs.com. [038] MEDICAL EQUIPMENT WANTED PHYSICIAN SEEkING ANTIQUE / VINTAGE DOCTOR’S OFFICE SCALE: Would like the traditional standing upright variety with the balance beam on top for adult patients. The scale needs to be in functional order, in at least good condition, without missing parts, and without significant rust, but nonrestored is fine. Would prefer a white cast iron scale with chrome or nickel beam and weights, not an electronic scale. Any vintage OK, but would prefer from the 1920s to the 1950s.

Email mjohnson1947@sbcglobal.net, preferably with picture(s). 25 years local MD. [218] SERVICES OFFERED HEALTHY DIET CLASSES: Looking to improve your patients’ lives through a healthy diet but can’t find the time to educate during office visits?

Jennifer Nemeth, a registered nurse, nutritionist, and certified Food for Life instructor, is passionate about teaching the benefits of a plant-based diet to lose weight and prevent / reverse heart disease, cancer, and diabetes. In her classes, patients learn how to make the best food choices and how to cook — and taste test! — delicious plant-based meals to promote wellness. Send patients to reinventingnutrition.com for upcoming classes or contact Jennifer Nemeth, RN, at (619) 940-7648 or at jenn@reinventingnutrition.com. [236]

SAN DI EGO PHYSICIAN.org 27

Personal & Professional Development

Rx: NATURE Sig: Enjoy QD Refill: Unlimited

by Helane Fronek, MD, FACP, FACPh

The room was filled with excited female medical students from across the country and a cadre of busy, dedicated women physicians.

The annual meeting of the American Medical Women’s Association (AMWA) is a special gathering, partly because of the unique networking and mentoring that occurs but also because the talks cover a range of topics and the speakers have time to delve deeply into their subjects.

Anthony Fauci, MD, the director of the National Institute of Allergy and Infectious Diseases, reviewed the history of the AIDS epidemic and the phenomenal progress that has been made. When patients first began to present with this puzzling disease, their life expectancy was six to eight months. Now, most people diagnosed with AIDS can look forward 28 May 2014

Imagine if we each “prescribed nature” — for our patients and ourselves.

to a near-normal lifespan. Arianna Huffington, CEO and founder of The Huffington Post, emphasized the need to define success not just as money and power, but with a third metric that focuses on our wellbeing, wisdom, wonder, and giving.

As Arianna likes to say, our current, narrow-minded view of success “isn’t working for men, it’s not working for women, and it’s not working for polar bears.” Danielle Ofri, MD, PhD, a busy internist at Bellevue and author of several excellent books on the relationship between doctors and patients, shared her insightful reflections on the ways we influence our patients by the things we say and how we say them, and the ways that each patient influences us.

AMWA was formed in 1915 when AMA refused to allow women physi-

cians to join its ranks. Although times have changed and the current president of AMA is a woman, AMWA continues to serve many important functions, including offering this excellent program. I hope that San Diego’s women in medicine will join me in forming a local branch of AMWA in the coming months.

But among all the speakers, Mark Tercek, CEO of The Nature Conservancy, shared an idea — both simple and audacious — that was most inspirational, practical, and potentially far-reaching. He challenged the physicians in the room to “prescribe nature.” After all, we ask our patients to take medications, exercise, and stop smoking. Medications are often accompanied by unwanted side effects. The benefits of exercise take time to be realized.

Smoking is one of the most difficult habits to give up. But nature … that’s a prescription that has immediate, positive benefits with no harmful side effects.

Spending time in nature can lower our blood pressure, reduce our stress, provide a sense of awe and gratitude that puts other problems in perspective, and help us cope better. It also has the added benefit of encouraging us to protect these precious spaces in our world. Imagine if we each “prescribed nature” — for our patients and ourselves. Not only would we be doing something good for our patients’ medical conditions, we would be impacting their quality of life and protecting our beautiful, natural environment for future generations to enjoy. It sounds like a prescription that is indicated for everyone.

Dr. Fronek, SDCMS-CMA member since 2010, is assistant clinical professor of medicine at UC San Diego School of Medicine and a certified physician development coach who works with physicians to gain more power in their lives and create lives of greater joy. Read her blog at helanefronekmd.wordpress.com.

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