official publication of SDCMS October 2014
Tuesday November 4
2014
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Remarkable new options for your patients with advanced heart failure As San Diego’s only provider to offer a full spectrum of treatment for advanced heart failure, Sharp HealthCare gives you unprecedented choices to help improve your patients’ quality of life. New techniques, such as MitraClip and TAVR, provide solutions for Level 3 and 4 heart failure patients with few options before. You’ll work in partnership with board-certified physicians specializing in our complete range of treatments — from medical management and transplantation to destination mechanical assist devices. And your patients will be cared for with the leading-edge technology, skill and compassion that are hallmarks of The Sharp Experience. At Sharp, it’s easy to find the specialist who matches your patient’s individual needs. Heart Failure/Valve Coordinator Annette Contasti, RN, MSN, CHFN, will work with you on a referral recommendation. Call (858) 939-5656 or email annette.contasti@sharp.com.
CORP616A ©2014 SHC
Oct.
Contents
Volume 101, Number 10
MANAGING EDITOR: Kyle Lewis EDITORIAL BOARD: Theodore M. Mazer, MD, James Santiago Grisolía, MD, Robert E. Peters, PhD, MD, David M. Priver, MD, Van C. Johnson, MD, Roderick C. Rapier, MD MARKETING & PRODUCTION MANAGER: Jennifer Rohr SALES DIRECTOR: Dari Pebdani ART DIRECTOR: Lisa Williams COPY EDITOR: Adam Elder SDCMS BOARD OF DIRECTORS OFFICERS PRESIDENT: J. Steven Poceta, MD PRESIDENT-ELECT: William T-C Tseng, MD, MPH (CMA Trustee) TREASURER: Mihir Y. Parikh, MD SECRETARY: Mark W. Sornson, MD IMMEDIATE PAST PRESIDENT: Robert E. Peters, PhD, MD 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: Thomas J. Savides, MD KEARNY MESA: Sergio R. Flores, MD, John G. Lane, MD, Alt: Anthony E. Magit, MD, Alt: Eileen R. Quintela, MD LA JOLLA: Geva E. Mannor, MD, Marc M. Sedwitz, 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
Tuesday November 4
2014
feature 8
Proposition 46 Isn’t the CURE(S)
AT-LARGE DIRECTORS Lawrence S. Friedman, MD, Karrar H. Ali, MD, Kosala Samarasinghe, MD, David E.J. Bazzo, MD, Stephen R. Hayden, MD, Peter O. Raudaskoski, MD, Vimal Nanavati, MD (Board Representative), Holly B. Yang, MD
BY J. STEVEN POCETA, MD, PRESIDENT, SDCMS
departments
12
4
22
Briefly Noted: Calendar • Earlybird Special • New and Returning Members • Volunteer Opportunities • And More … 10 Photographs, Stopwatches, and Countdown Timers: The Magic Picture Frame
BY KARL STEINBERG, MD, CMD
24
12
26
Physician Marketplace: Classifieds
Listening to Your Dying Patient: How Do We Best Serve a Patient Who Says He Wants to Die?
28 “Facebook Friend”: New Definition or Misnomer?
BY JAMES SANTIAGO GRISOLÍA, MD
14
18
e Cyber-secure: Protect Patient B Records, Avoid Fines, and Safeguard Your Reputation
BY HELANE FRONEK, MD, FACP, FACPH
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BY THE DOCTORS COMPANY 2 Oc tober 2014
OTHER NONVOTING MEMBERS YOUNG PHYSICIAN ALTERNATE DIRECTOR: Daniel D. Klaristenfeld, MD RESIDENT PHYSICIAN ALTERNATE DIRECTOR: Diana C. Gomez, MD RETIRED PHYSICIAN ALTERNATE DIRECTOR: Mitsuo Tomita, MD SDCMS FOUNDATION PRESIDENT: Albert Ray, MD (CMA Trustee, AMA Delegate) CMA SPEAKER: Theodore M. Mazer, MD CMA PAST PRESIDENTS: James T. Hay, MD (AMA Delegate), Robert E. Hertzka, MD (Legislative Committee Chair, AMA Delegate), Ralph R. Ocampo, MD CMA TRUSTEES: Robert E. Wailes, MD, Erin L. Whitaker, MD CMA SSGPF Delegate: James W. Ochi, MD CMA SSGPF ALTERNATE DELEGATES: Dan I. Giurgiu, MD, Ritvik Mehta, MD AMA ALTERNATE DELEGATE: Lisa S. Miller, MD
hysicians Given ‘Safer’ Way P to Implement and Use EHRs BY THE DOCTORS COMPANY
BY MATTHEW SOSKINS, PHD, ESQ.
OTHER VOTING MEMBERS COMMUNICATIONS CHAIR: Sherry L. Franklin, MD (CMA Trustee) YOUNG PHYSICIAN DIRECTOR: Edwin S. Chen, MD RESIDENT PHYSICIAN DIRECTOR: Jane Bugea, MD RETIRED PHYSICIAN DIRECTOR: Rosemarie M. Johnson, MD MEDICAL STUDENT DIRECTOR: Spencer D. Fuller
014 POLST Form: Revision 2 Effective October 1, 2014
BY DANIEL J. BRESSLER, MD, FACP
Suspect a Data Breach? Do This Immediately
AT-LARGE ALTERNATE DIRECTORS Karl E. Steinberg, MD, Jeffrey O. Leach, MD, Toluwalase A. Ajayi, MD, Phil Kumar, MD, Wayne C. Sun, MD, Kyle P. Edmonds, MD, Carl A. Powell, DO, Marcella M. Wilson, MD
n
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 $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]
NORTH COUNTY’S NEWEST AND MOST
COVETED MEDICAL CAMPUS
PHYSICIANS
OPEN HOUSE
THURSDAY OCT 23 RD 4-7 PM @ NORTH COAST MEDICAL PLAZA
ENJOY DELICIOUS HORS D’OEUVRES AND DRINKS
RSVP: BRITTNEY WILLIAMSON brittney.williamson@cushwake.com
1-858-334-4039 VISIBLE
363 FEET linear frontage on Palomar Airport Road (4 3 ,4 9 2 C A RS P E R DAY )
ACCESSIBLE 6 0 1 0 H i d d e n Va l l e y R o a d , C a r l s b a d , C A 9 2 0 1 1
1 MILE from Interstate 5
90,000 SF
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S T R AT E G I C North County’s most affluent demographics ($ 9 8 ,6 1 4 AVG HO U S E H O LD I N C O M E I N A 5 M I L E R A D IU S )
50,000 SF existing medical office building
Staged suite provided by:
39,000 SF
proposed build-to-suit opportunity FOR MORE INFORMATION, PLEASE VISIT TRAVIS IVES Associate Director Lic. # 1889097 858.334.4041 travis.ives@cushwake.com
WWW.NORTHCOASTMEDICALPLAZA.COM CUSHMAN & WAKEFIELD OF SAN DIEGO, INC. CA License No. 1329963 4747 Executive Drive, 9th Floor San Diego, CA 92121
/////////briefly ///////////////////noted ////////////////////////////////////////////////////////////////////// calendar SDCMS Seminars & Webinars SDCMS.org
25th Annual Cardiovascular Interventions OCT 21–24 (www.scripps.org/ sparkle-assets/documents/ cardiovascular_interventions_ brochure_2014.pdf)
Covered California: What Your Healthcare Team Needs to Know (seminar/webinar) NOV 13: 11:30am–1:00pm
Science and Connection: A New Era of Integrative Health and Medicine OCT 26–30 (www.scripps. org/events/science-andconnection-a-new-eraof-integrative-health-andmedicine-october-25-2014)
Pain Management Strategies to Decrease Liability Risk (seminar/webinar) NOV 20: 11:30am–12:30pm
San Diego’s 9th Annual Emergency Care Summit OCT 30 (www.surveymonkey. com/s/SDCMS_Summit_14)
For further information or to register for any of the following SDCMS seminars, webinars, workshops, and courses, email Seminars@SDCMS.org.
Cma Webinars CMAnet.org/events Managing Up! For Managers OCT 29: 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. 61 Annual Meeting of the American Academy of Child & Adolescent Psychiatry OCT 20–25 (Manchester Grand Hyatt & Marriott Marquis & Marina) st
Genome: Unlocking Life’s Code OCT 21 (cme.ucsd.edu/ GENOME)
Physicians of Exceptional Excellence (Top Doctors) Gala NOV 1 (www. sandiegomagazine.com/ San-Diego-Magazine/ February-2014/Top-DoctorsGala) The 2014 San Diego Day of Trauma NOV 7 (www.scripps.org/ events/san-diego-day-oftrauma-november-7-2014) Outpatient Joint Replacement Seminar NOV 8 (www. globaloneventures.com/ events) Essential Tools in Serving Diverse Populations NOV 18 (Scottish Rite Event Center on Camino del Rio South, registration open in September)
* MEMBER
FEATURED
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!
“
The only real voyage of discovery consists not in seeing new landscapes, but in having new eyes, in seeing the universe with the eyes of another, of hundreds of others, in seeing the hundreds of universes that each of them sees.
”
— Marcel Proust, French Novelist, Critic, and Essayist (1871–1922)
4 Oc tober 2014
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Save $5 0 SDCMS-CMA Member Physicians: If you are paying full, non-discounted dues and are with a medical group of 150 or fewer physicians, you will receive a 5% discount on your 2015 SDCMS-CMA dues if you renew and pay in full before October 31, 2014.
Pay Early… Save Money
Renew Online Today at SDCMS.org or Call SDCMS at (858) 565-8888
Practice Management
Contracting
Relocation Management
Credentialing
Technological Advances
Billing Service Business Growth Executive Assistant Financial Management EHR Meaningful Use Support Operational Management Practice Assessment
We can help - absolutely! te
SDCMS-CMA Members
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lutions So Celebrating
Absolu
Early Bird Special!
858.256.0351 • www.abs-sol.com
2004 - 2014
“think SDCMS FIRST!” Start by contacting SDCMS at (858) 565-8888 or at SDCMS@SDCMS.org.
SAN DI EGO PHYSICIAN.org 5
/////////briefly ///////////////////noted ////////////////////////////////////////////////////////////////////// giving back
SDCMS-CMA Membership
Welcome New and Returning SDCMS-CMA Members! New Members Rachel A. Abramson, MD Pediatrics San Diego (619) 583-6133 Jyoti Arya, MD Plastic Surgery San Diego (858) 554-9940 Vijay G. Babu, MD Pain Management (Anesthesiology) San Diego (619) 761-5308 Vishal Bansal, MD Surgical Critical Care San Diego (619) 543-7096 Marcos Borrero, MD General Practice San Diego (619) 423-5616 Richard S. Campbell, MD, MS Occupational Medicine Chula Vista (619) 585-4050 Timothy G. Canty, MD Vascular Surgery San Diego (619) 528-5507 Elizabeth N. Cao, MD Obstetrics and Gynecology Escondido • (760) 4328800 Steven L-W Chen, MD, MBA, FACS Surgical Oncology San Diego • (858) 5710606 Todd W. Costantini, MD Surgical Critical Care San Diego (619) 543-7107 Emily E. Fletcher, MD Pediatrics Chula Vista (619) 656-3040
6 Oc tober 2014
Andrei Fodoreanu, MD Pediatrics La Jolla (619) 426-7910
Rachel E. Perkins, MD Pediatrics San Diego (760) 547-1010
Brooke E. Friedman, MD Reproductive Endocrinology/Infertility La Jolla (858) 552-9177
Krista L. Roybal, MD Psychiatry San Diego (858) 202-1822
Laura N. Godat, MD Surgical Critical Care San Diego (619) 543-7162 Susan D. Heifetz, MD Internal Medicine Vista (760) 941-9844 Sherry C-S Huang, MD Pediatric Gastroenterology San Diego (619) 543-7544 Leslie M. Kobayashi, MD Surgical Critical Care San Diego (619) 543-5805 Jeanne G. Lee, MD Surgical Critical Care San Diego (619) 543-7087
Ashvin B. Shenoy, MD Pediatrics San Diego (619) 262-8624 Brian D. Stone, MD Allergy and Immunology San Diego (619) 286-6687 Amanda R. Terry, MD Pediatrics Encinitas (760) 436-4511 Jon T. Umlauf, MD, MPH Nuclear Medicine San Diego (619) 528-5000 Felisa U. Velesrubio, MD Infectious Disease National City (619) 869-1296 RETURNING MEMBERS
Curtis W. Leong, MD Pediatrics La Jolla (858) 459-4351
Steve H. Koh, MD Geriatric Psychiatry San Diego (619) 665-3816
James D. Lingle, MD General Practice San Diego (404) 264-0800
Patrick G. McCallion, MD Otolaryngology La Mesa (619) 464-3353
Bryant H. Nguyen, MD Interventional Cardiology San Diego (619) 567-4050
James C. Perry, MD Pediatric Cardiology San Diego (858) 576-5855
Richard M. Obler, MD Emergency Medicine La Jolla (858) 922-1073 Spencer S. Olsen, MD Occupational Medicine La Mesa (619) 697-3093
PHYSICIAN VOLUNTEERS NEEDED! Email Your Physician Volunteer Opportunities to Editor@SDCMS.org VOLUNTEER PHYSICIANS WANTED FOR PROJECT ACCESS: Volunteer specialty
physicians needed for the following specialties: pulmonology, urology, neurology, and sleep study. We are seeking these specialists throughout all regions of San Diego. Commitment can vary by practice. The mission of Project Access is to improve community health, access to care for all, and wellness for patients and physicians through engaged volunteerism. Help us help the most vulnerable population seek care. For more information, please call Ana Seda at (858) 565-8161 or email Ana.Seda@SDCMSF.org, or visit our website at www.sdcmsf.org. FAMILY MEDICINE/GENERAL INTERNAL MEDICINE PHYSICIANS NEEDED: Excel-
lent family medicine and general internal medicine community docs to serve as role models and teachers to UCSD first- and second-year medical students in their Ambulatory Care Apprenticeship Program. This is a longitudinal one-afternoon-every-otherweek clinical experience that extends from the beginning of medical school to the end of the second year, approximately 25 sessions in all. The goals are to allow students to practice history-taking and physical examination skills, learn what primary care is all about, and develop a nurturing student-mentor relationship with a positive, enthusiastic practicing primary care physician in the community. Join us! Call Rusty Kallenberg, MD, at (619) 838-8047 or email gkallenberg@ucsd.edu. HUMANITARIAN TEAMS NEED MEDICAL VOLUNTEERS FOR HAITI: The
Seattle-King County Disaster Team is looking for physicians for one week primary care medical clinics in rural Haiti in February and June 2015. This is a rewarding opportunity to work with the people of Haiti and provide care in a very austere environment in a medically underserved area. Seattle-King County Disaster Team — a US-based nonprofit — has been operating these clinics since 1998. They coordinate all in-country travel and logistics. Please contact Bob Downey at (619) 905-7157 or by email at labboy@earthlink.net if you are interested in applying.
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SAN DI EGO PHYSICIAN.org 7
micra
6 4 n o i t i s o p o r P ) S ( URE ’ C e h t t Isn ceta, MD, Pres By J. Steven Po
ident, SD CMS
On Nov. 4, voters will be asked to weigh in on Proposition 46, a costly and deceptive measure funded and sponsored almost exclusively by trial lawyers. In addition to raising healthcare costs and reducing access to quality medical care, Prop. 46 could put patient prescription drug history at risk of being hacked and would force physicians and pharmacists to use an unworkable database.
8 Oc tober 2014
The Controlled Utilization Review and Evaluation System, or CURES, is a statewide, governmentrun database that allows physicians to know which medications patients are taking. In concept, it could be a helpful tool in ensuring that patients don’t “doctor shop,” i.e., visit several doctors to get multiple prescriptions for controlled substances. Though the database already exists, it is underfunded, understaffed, and technologically incapable of handling the massively increased demands this ballot measure will place on it. In its current form, the CURES database is plagued with system errors and major deficiencies. The state staffer in charge of CURES recently testified that the database is “not sufficient enough to carry out the mission that we need.” To see excerpts of his testimony, visit www.NoOn46.com/ terrible-joke.
Prop. 46 includes a provision that would mandate physicians and pharmacists check the CURES database before prescribing Schedule II or III drugs — a list of medications that is far too long for this magazine.
In fact, in evaluating Prop. 46, the independent, nonpartisan Legislative Analyst noted, “Currently, CURES does not have sufficient capacity to handle the higher level of use that is expected to occur when providers are required to register beginning in 2016.” While a potentially useful database, CURES simply isn’t able to handle what’s being asked of it. The healthcare community helped to pass SB 809, which will increase funding for the database and update the technology along with adding funds for more staff; unfortunately, upgrades won’t be ready until the middle of 2015 at the earliest. Despite all of this, Prop. 46 includes a provision that would mandate physicians and pharmacists check the CURES database before prescribing Schedule II or III drugs — a list of medications that is far too long for this magazine. This “CURES mandate flaw” puts physicians in the untenable position of either breaking their professional oath to give patients the best possible care or breaking the law. What’s more, the CURES mandate comes without any increased security to ensure that the database is up and running efficiently, effectively, and safely before legally making healthcare professionals check it. That’s a risky gamble in these days of massive data breaches. Many of you reading this know firsthand the difficulties of the CURES database and have yourselves tried to use it to improve and advance patient safety. You then also know how unlikely it is that the CURES mandate will work. In the few weeks left between now and Election Day, I cannot stress enough how important it is to spread the word about the dangers of Prop. 46.
As you’ve read in previous issues of San Diego Physician, Prop. 46 is really three measures carelessly thrown together by trial attorneys with the hopes that adding “sweetener” provisions — including the CURES piece discussed above — will trick voters. The real intentions are to increase the cap on medical malpractice payouts, which will increase healthcare costs for everyone and decrease access for those who need it most. Prop. 46 will result in money being pulled directly out of the healthcare delivery system and put into the pockets of trial attorneys, at the expense of voters everywhere. How can you get engaged in the final stages of the No on Prop. 46 campaign? • Contribute! Any amount helps us to communicate with voters about the real intentions of Prop. 46. Public polling shows that when voters hear who is behind the measure and what the consequences would be, they vote NO. You can easily donate today by visiting the campaign website at NoOn46.com and clicking “Contribute.” • Order Material! If you haven’t taped No on 46 posters to your office windows, now is the time to do so. In addition to posters, you can order English and Spanish lab coat cards, patient brochures, buttons, and bumper stickers at NoOn46.com. For yard signs, contact SDCMS at (858) 565-8888 or at SDCMS@SDCMS.org. • Sign up to officially oppose Prop. 46 at NoOn46.com. • Commit to tell your friends, family, patients, and colleagues about the impact Prop. 46 will have on your healthcare costs, access, and privacy.
Medical Professional Liability Protection, and more! 800-356-5672 www.caPphysicians.com
San Diego orange LoS angeLeS PaLo aLTo SacramenTo
SAN DI EGO PHYSICIAN.org 9 CAP_1402.indd 1
2/5/13 11:13 AM
POETRY AND MEDICINE
Photographs, Stopwatches, and Countdown Timers The Magic Picture Frame by Daniel J. Bressler, MD, FACP The Magic Picture Frame I see the swirl of years go rushing by me Scenes of disappointment and acclaim Digitized and set in motion by me Now showing in the magic picture frame I watch the sudden scenes arise from darkness Shadow puppets thrilling to a flame A jumbled world of frolicking and starkness Bound up inside the magic picture frame Here my elders still are quick and agile Before the blades of time could wound and maim Oblivious that they’d become so fragile Preserved inside the magic picture frame Here’s a former sweetheart turning forty Tossing her bouquet and maiden name Her husband (now her ex) was suave and sporty Ironic smiles inside the picture frame Here’s a college pal naive and carefree Who later died in tragedy and shame Did he break those sorry bonds and tear free? Still-lifed in the magic picture frame.
When I review a medical chart, it often feels like I am thumbing through a scrapbook. A scrapbook contains notes, photos, and memorabilia from significant events in the life of an individual or family. Here is a picture of the trip to the Grand Canyon during the kids’ spring break. This is cousin Wendy’s gaudy wedding invitation. Here’s the thank-you letter that Bobby sent for his confirmation gift. Here’s a picture of Grandma blowing out her 80 birthday candles. And, of course, this is the invitation list to Uncle Henry’s memorial service. The medical chart also steps through significant events and “mementos” of a life. Here’s when we started you on allopurinol for gout. This is when you had the cholecystectomy complicated by cholangitis and 10 Oc tob er 2014
My grownup children here are seen as babies Their futures then impossible to claim A meshwork of contingencies and maybe’s Potentialed in the magic picture frame I look away and miss a year or twenty Yet know that they will circle back the same An endless loop of panoramic plenty Spooled within the magic picture frame I tally up the roll of dead and living A cheerless yet addictive parlor game Each captured shot a gift that keeps on giving Treasures of the magic picture frame If Heaven’s where the best of us live always Eternity’s celestial hall of fame Where our timeless selves go tramping through those hallways Heaven’s in the magic picture frame
acute renal failure. There’s the total knee replacement, here the community-acquired pneumonia that required a brief ICU stay; and from just last month here’s the admission for acute coronary syndrome and a stent. The human body functions as a stopwatch. Our heartbeat, like the second hand, bears witness to and defines the passage of time. It beats more than 100,000 times in one day, 40 million times in a year, and 3 billion times in an average lifetime. The slower metronome of our lungs counts out 20,000 breaths per day, 8 million per year, and a “mere” 600 million in a lifetime. If it weren’t so numerically awkward, I could reasonably say that I had my wisdom teeth out at 680 million heartbeats and my meniscus repair when I was 400 million breaths old. We find it more economical to count the passage of time in cosmologic increments, taking as our basic unit the earth’s circle round the sun. So too the body acts as a countdown timer—the kind used to tell us when the casserole is ready, when the basketball must be shot or the football snapped. Our work in medicine is often geared to adjusting the timer. The antibiotics for my patient’s pneumonia definitely prevented time from expiring prematurely, as did his cardiac stenting. We know, of course, that adding extra heartbeats or breaths or years is not the same as stopping the clock. Time continues to pass at exactly one second per second. Time is, for all of us, always running out. The old joke that “time is nature’s trick to keep everything from happening at once” seems to be at least as helpful as more formal and seemingly circular definitions. In the everyday world of “classical” physics (and hence the chemistry and biology on which modern medicine is based), time is a constant context in which physical objects move. In this context, time itself is intimately bound up with motion whether that be the cycle of a planet, the repetitive sway of a carefully measured pendulum, or the oscillation of cesium in an atomic clock. Classical time moves in one direction, from the past to the present to the future. A classical bell cannot be unrung, nor a classical clock made to reverse. The human biological self moves in the context of time through the stages of conception, growth, development, decline, and death. Our different organs move in a way we call “aging.” As they all move, they all age. Skin thickness, lens clarity, forced vital capacity, creatinine clearance, reaction time, intima medial
Skin thickness, lens clarity, forced vital capacity, creatinine clearance, reaction time, intima medial thickness, and bone density all mark the movement of specific parts of our biological selves through time. thickness, and bone density all mark the movement of specific parts of our biological selves through time. They also have become known through medical science as the variable clocks that help determine the length and quality of our lives. But the human biological animal is also the creatively conscious human being. Through imaginative consciousness our species has the capacity to conceptualize beyond the boundaries of its own physics and biology. In our imagination we are not limited by the context of classical linear time. In our minds, time takes on a fluid and flexible quality. We can juxtapose moments from our childhood with scenes from last week. Our mind’s eye can see people that our actual eyes have not glimpsed for decades. We can conceive ourselves and others freed from current readings on the biological countdown timer. We can dream up people as they were or how we might want them to be. Our minds, even in their everyday humdrum functioning, bend and fold time like a science-fiction writer steeped in modern postclassical physics. On the side table of my dining room sits a little digital picture frame. The removable memory stick drives a recurrent slide show of hundreds of photos from the past 30 years. Over and over it displays images of people looking out from across variable spans of time and space. These images both mimic and inform my consciousness. The frame is a digital scrapbook, a relentless mnemonic device and, as it turns out, a catalyst for poetry. It is an expression of the human imagination’s capacity for time travel, an advocate for nonlinearity, and an ambassador from the frontier where biology meets the imagination. The Magic Picture Frame is a set of notes from that frontier. Dr. Bressler, SDCMS-CMA member since 1988, is chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and a longtime contributing writer to San Diego Physician.
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SAN DI EGO PHYSICIAN.org 11
Bioethics
Listening to Your Dying Patient
How Do We Best Serve a Patient Who Says He Wants to Die? by James Santiago Grisolía, MD
American medicine values each human life, respecting its autonomy. Their autonomy causes conflicts — many times our patients fail to comply with our recommendations or make other bad health decisions. Yet we continue to serve them, even when their problems result from poor choices. Professional and personal ethics prevent us from collaborating in unethical acts — supporting criminal or self-destructive behavior, for example. Yet we still advocate for them and try to support each person, especially in their time of extreme or ultimate need. And often we can suggest positive choices, even when the patient cannot think of them in their despair. How do we, as physicians, best serve a patient who says he wants to die? We must begin by respecting the patient’s feelings, and respecting the trust that let them talk to us about it. Most of our value comes from 12 Oc tober 2014
sheer presence, being willing to be with the patient and to listen. First express sympathy, and then address the immediate question of suicide: “Do you have a plan?” etc. A violent or poorly thought-out death serves neither the patient nor her family. Other than offering support and solutions for immediate problems like pain control, you may need to schedule a longer appointment to deal with the greater, spiritual issues. Or look for other resources or caregivers to join your team. In Oregon, where physician-assisted suicide (PAS) has been legal since 1998, the top reasons to request PAS include “losing autonomy,” “being less able to engage in enjoyable life activities,” and “loss of dignity” (1). We know that untreated pain and depression often underlie the conversation, but in a comparable state, the issues are more existential than physical. This
existential crisis stems from the clash of false expectations with reality. Our society promises a world of constant victory, health, prosperity, and self-determination. Discovering that illness can mean suffering, loss of personal choice, and death seems strange and unexpected. Doctors and patients can distract themselves from confronting these issues by focusing on new treatments and medication decisions, but at certain times the existential and spiritual crisis cannot be deferred. And, unequipped as we may feel, often the physician is the only counselor with the experience to tackle these problems. Our colleagues in palliative care and hospice can be invaluable in clarifying values and providing solutions to practical problems in pain control, constipation, secretion management, etc. Pastoral care and talk therapists can offer superlative guidance, but sometimes our personal and medical relationship with the patient means the onus falls chiefly on us. Often an impending fatal illness creates a crisis of meaninglessness. Depression leads to despair, and suddenly the patient cannot think of anything worthwhile about his past or present life. Antidepressants alone will not fix this existential crisis, but neither will terminal sedation (2). Someone (maybe you) must do the hard work of uncovering the values that patient has lived by. These could include commitment to family and friends, productive work, supporting the arts or a political cause, commitment to animal welfare, enjoyment of travel or nature, etc. The next step is reflecting with satisfaction on past successes, whether raising a family, supporting a church, serving others, special trips or vacations. The last step is finding
they “don’t want to be a burden,” this could mean You may view the midwifing of the reluctance to accept help, as discussed above, or deathbed wisdom as above your pay fear of the loss of indepengrade; I certainly do. However, we dent action. Fear of losing can’t help accumulating experience, autonomy may turn out both with the patient before us and to be overblown. In the Netherlands, they follow through a lifetime of seeing how the doctrine of “precedent others have handled their crises. autonomy,” meaning, for example, that an early Alzheimer’s patient can request later euthanasia when how those values are still supported by the they deteriorate. However, in practice the patient’s current, limited lifestyle. Is it still mid-to-late Alzheimer’s patient is usually possible to be taken to the park or the ocean? content, with no memory of wanting to be Is it possible to see “being a burden” as a killed earlier. Under these circumstances, chance for others to give back to the patient patients mostly are allowed to live out their for all the service she has provided to others? natural lives, even in this very pro-euthanaI sometimes use the image of a “caring bank” sia country (3,4). where the patient has been making deposits You may view the midwifing of deathbed in her account by years of raising a family wisdom as above your pay grade; I certainly or doing for others … and now it’s time to do. However, we can’t help accumulating start making some withdrawals from that experience, both with the patient before us huge account! Certainly the caregivers must and through a lifetime of seeing how others assure the patient that all burdens are borne have handled their crises. Occasionally, just cheerfully, and often I’ve had to state this to in sympathetic listening, you will say somethe patient in front of family so they could thing that resonates with a patient or family chime in. member, something that triggers deeper When terminal patients complain that changes than you ever intended. Deathbed
religious acceptance most commonly follows a lifetime of devotion, but occasionally comes “from left field” as far as the patient and family are concerned. It often makes sense only in retrospect, sometimes the culmination of a lifetime of values that were not previously named. Neither the physician nor the family should impose their values on a troubled patient. Any deathbed epiphany should feel genuine and unforced, and should lead to greater peace and acceptance of the dying process. Dr. Grisolía, SDCMS-CMA member for 35 years, is board-certified in neurology. References: 1. Enouen S. W. Oregon’s Euthanasia Law. Accessed at www.lifeissues.org/euthanasia/oregons_law. 2. Bruce A. Boston P. Relieving existential suffering through palliative sedation: discussion of an uneasy practice. J Adv Nursing 67(12): 2732-2740, 2011. 3. Hertogh C. M, et al, Would We Rather Lose Our Life Than Lose Our Self? Am J Bioethics 7(4): 48-56, 2007. 4. Pereira J. Legalizing euthanasia or assisted suicide: the illusion of safeguards and controls. Curr Oncology 18(2): 38-45, 2011.
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SAN DI EGO PHYSICIAN.org 13
Risk Management
Do not wait until you have confirmed whether the event was an actual breach before contacting your insurance broker or carrier. Delays in reporting may allow the insurer to deny your claim.
Suspect a Data Breach? Do This Immediately by Matthew Soskins, PhD, Esq.
You listen to your attorneys, pay your taxes, floss, and comply with HIPAA by having a business associate addendum (BAA) with each of your business associates (BA). In general, a BA is any person or company, other than your actual employees, who provides services to your practice that involve access to protected health information (PHI). PHI is not just patient names and Social Security numbers, but also includes almost any information that could potentially identify a patient. The most common examples of BAs are billing companies, attorneys, accountants, and IT companies. One of the provisions in your BAA is that the BA must quickly notify you in the event of a breach, which only seems to happen on a Friday afternoon. So what do you do next? 14 Oc tober 2014
How you respond can make the difference between quickly getting past this incident, or spending your time and money helping regulators go through your offices with a fine-toothed comb. Here is what should be done in the event you are told of a data breach: Get as Much Information as Possible During the Initial Phone Call No matter how experienced you are with privacy issues, it is impossible to get everything you will eventually need in the first phone call. So the first thing to do in the call is to ask for and write down the name and contact information for the person calling you, the BA’s HIPAA Privacy and Security Officers (if they have them), and who will be your contact point at the BA for the inevi-
table follow-up conversations. From there, be sure to ask the following during the call: • What information may have been breached? • Whose information was it? • How did it happen? • Who has the information now? • What has already been done to mitigate? • Who else has been notified? • When was this discovered? • How was this discovered? In addition, you will want to find out if the BA has insurance and obtain copies of any policies and procedures the BA has regarding data privacy and security. If the BA’s subcontractor caused the breach, you will also need to obtain the same insurance and detailed breach incident information from this entity. Be sure to find out when the subcontractor became aware of the breach, when the BA was notified, and what agreements regarding data privacy and security exist between the BA and subcontractor. Report to Insurers Right Away Do not wait until you have confirmed whether the event was an actual breach before contacting your insurance broker or carrier. Delays in reporting may allow the insurer to deny your claim. In addition, early reporting can be helpful because your insurer may provide support to help investigate and mitigate the breach at its expense. Document Each Step in the Breach Event Investigation This is the most important, most often overlooked, and most boring step. It is critical to document each step and save all notes from phone calls and interviews. Even if you or your counsel determine that the event was not a breach, the documentation you save can be critical because a court, regulatory agency, or patient might disagree with you months or even years later. Your agreements with the BA, the BA’s level of sophistication, and whether the BA or a subcontractor was at fault for the breach event will usually determine who will primarily perform the investigation, and to what extent you can rely on an investigation
Risk Management performed by someone else. For example, if the breach event was the theft of a desktop computer from a law firm that provides healthcare law services to you, and the law firm states that it is investigating the breach and will provide you with full documentation of its investigation, then it would be reasonable to allow the firm to conduct the investigation and rely on the firm’s findings. Methodically Determine if a Breach Actually Occurred The federal and state definitions of “breach” differ from one another, change over time, and require separate analyses. Thus, we will first walk through the investigation steps for purposes of federal law (HIPAA and HITECH), and then supplement with discussion of California law. A helpful investigation blueprint that closely tracks federal law can be found at http://higgslaw.com/attarticles/ hipaa-data-breach-investigation-blueprint. The first step in investigating a breach event is determining whether unsecured PHI was improperly acquired, accessed, used, or disclosed. If the answer is no, then no breach has occurred. So, if a BA lost an encrypted CD containing PHI, but the password on the disk was strong and not written down, then it is reasonable to believe that no breach has occurred. The next step is to determine if one of the common exceptions applies, such as: • If the event was just an unintentional accessing of the medical records by an employee of the BA that was in good faith; • There was improper disclosure by an employee of the BA to another employee of the BA with no further disclosures; or • There is a good-faith belief that the unauthorized recipient would not reasonably have been able to view or retain the information, such as a nurse who hands a patient someone else’s discharge instructions and then discovers the problem and obtains them from the patient before the patient had a chance to look at them. If an exception applies, then there is no breach. Finally, assess the probability that the PHI was actually compromised based on the specific facts involved. You should thoroughly consider and document any factors that make it more or less likely that the PHI was actually improperly accessed, used, or disclosed in making this determination. Common factors include who received the PHI and whether they owe duties of confidentiality, if you know for sure whether the PHI was actually viewed or disseminated, and the like. Once this determination has been made, you have now concluded whether a reportable breach has occurred for purpose of federal law. 16 Oc tober 2014
Even if you were not the cause of the breach, you, rather than the BA, must report without unreasonable delay, and in no case later than 60 calendar days, after you knew or reasonably should have known of the breach. If a Breach Occurred, Report to the Feds First It’s important to note that even if you were not the cause of the breach, you, rather than the BA, must report without unreasonable delay, and in no case later than 60 calendar days, after you knew or reasonably should have known of the breach. The first step is to notify patients with a letter describing: • what happened, • the types of unsecured PHI involved, • steps patients should take to protect themselves, • what you are doing to investigate and mitigate the breach, and • contact procedures so patients can ask questions. If the breach involved 500 or more patients, you are required to report the incident to the Department of Health and Human Services at the same time you notify patients. You may also be required to report to the media in some circumstances. If the breach involves fewer than 500 patients, you can wait to report to DHHS until any time before March 1 of the following calendar year. It is strongly recommended that prior to sending the notification to patients, you call them, let them know about the breach and upcoming letter, and ensure that the phone number you provide them will be answered by someone knowledgeable and after business hours. If a patient gets home from work at 6 p.m. and sees a breach notification letter and has concerns, you do not want them to have to wait until the next morning to get their questions answered. Follow Through on Additional California Requirements There are two main areas of California law that can apply in situations in which a BA reports a breach to you. The first is the Confidentiality of Medical Information Act (CMIA) that, for breach reporting purposes, only applies to health facilities licensed by the California Department of Public Health, such as hospitals, home health agencies, and skilled-nursing facilities. Most physician practices do not have to perform separate reporting or investigation under CMIA, but if any of the PHI is from a patient of such a facility that you work with, you should inform the facility’s
privacy officer immediately. The second set of laws is the Consumer Privacy Protection laws (CPP) that apply to every business that has consumer data (including yours). Essentially, CPP defines a breach as an unauthorized acquisition of computerized data that compromises the security, confidentiality, or integrity of personal information. The investigation process is similar to that discussed above regarding HIPAA, and a sample blueprint can be found at http://higgslaw.com/attarticles/ consumer-data-breach-investigationblueprint. Importantly, California law does not itself recognize the existence of business associates, so if a business associate experiences a breach, they are the entity required to investigate and provide notice. Fortunately, if something is a breach under both laws, the notification you provide to patients per HIPAA is legally sufficient for California law. If the breach involved the data of more than 500 individuals, you must also provide notification to the California attorney general. After a breach, you may face fines, lawsuits, and negative media exposure. This is why it is important to get your insurance company on board sooner rather than later. You may need or want to take more steps to mitigate the damage, such as offering credit protection. You may also want to provide counseling services, credit monitoring, and such. Better yet, begin working on these issues before they occur. The HIPAA Security Rules require that you perform and document a risk analysis and create a risk management plan. Ask your insurer and/or legal counsel for a blueprint to help you through the process. This will cost less time and money than you might think. Documenting the risk analysis also lets you tell the story about the compliance efforts you have made if and when you need to. Oftentimes, having a well-documented risk analysis and mitigation plan can help providers avoid fines entirely in the event of a breach or audit. Matt Soskins is an attorney with Higgs, Fletcher & Mack, LLP, and specializes in healthcare, data privacy and security, and business arrangements and disputes. He can be reached at soskinsm@higgslaw.com.
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Risk Management
Be Cybersecure Protect Patient Records, Avoid Fines, and Safeguard Your Reputation
by Contributed by SDCMS-endorsed The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.
18 Oc tober 2014
Cybercrime costs the U.S. economy billions of dollars each year and causes organizations to devote substantial time and resources to keeping their information secure. This is even more important for healthcare organizations, the most frequently attacked form of business (1). Cybercriminals target healthcare for two main reasons: Healthcare organizations fail to upgrade their cybersecurity as quickly as other businesses, and criminals find personal patient information particularly valuable to exploit. The repercussions of security breaches can be daunting. A business that suffers a breach of more than 500 records of unencrypted personal health information (PHI) must report the breach to the U.S. Department of Health and Human Services’ Office for Civil Rights (OCR). This is the federal
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Risk Management body with the power to enforce the Health Insurance Portability and Accountability Act (HIPAA) and issue fines. To date, the OCR has levied more than $25 million in fines, with the largest single fine totaling $4.8 million (2). A healthcare organization’s brand and reputation are also at stake. The OCR maintains a searchable database — informally known as a “wall of shame” — that publicly lists all entities that were fined for breaches that meet the 500-record requirement (3). If you think you may not be fully compliant with HIPAA privacy and security rules, consider taking the following steps: • Identify all areas of potential vulnerability. Develop secure office processes, such as: »» sign-in sheets that ask for only minimal information »» procedures for the handling and destruction of paper records »» policies detailing which devices are allowed to contain PHI and under what circumstances those devices may leave the office. • Encrypt all devices that contain PHI (laptops, desktops, thumb drives, and centralized storage devices). Make sure
Cybercriminals target healthcare for two main reasons: Healthcare organizations fail to upgrade their cybersecurity as quickly as other businesses, and criminals find personal patient information particularly valuable to exploit. that thumb drives are encrypted and that the encryption code is not inscribed on or included with the thumb drive. Encryption is the best way to prevent a breach. • Train your staff on how to protect PHI. This includes not only making sure policies and procedures are HIPAAcompliant, but also instructing staff not to openly discuss patient PHI. • Audit and test your physical and electronic security policies and procedures regularly, including what steps to take in case of a breach. The OCR audits entities that have had a breach, as well as those that have
not. The OCR will check if you have procedures in place in case of a breach. Taking the proper steps in the event of a breach may help you avoid a fine. • Insure. Make sure that your practice has insurance to assist with certain costs in case of a breach. References 1. Visser S, Osinoff G, Hardin B, et al. Information security & data breach report — March 2014 update. Navigant. March 31, 2014. www.navigant.com/~/media/ WWW/Site/Insights/Disputes%20Investigations/Data%20Breach%20Annual%202013_Final%20Version_March%20 2014%20issue%202.ashx. Accessed June 17, 2014. 2. McCann E. Hospitals fined $4.8M for HIPAA violation. Government Health IT. May 9, 2014. www.govhealthit.com/ news/hospitals-fined-48m-hipaa-violation. Accessed June 24, 2014. 3. Breaches affecting 500 or more individuals. U.S. Department of Health & Human Services. www.hhs.gov/ocr/privacy/ hipaa/administrative/breachnotificationrule/breachtool.html. Accessed June 23, 2014.
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20 Oc tob er 2014
Join us to Honor James T. Hay, MD Founding President, San Diego County Medical Society Foundation Founder, Project Access San Diego And Celebrating 10 Years of Service to the Community
Celebration Ten 10 Years of Service toOur Community
Honorary Chairs Bob Hertzka, MD & Roxana Foxx Saturday, February 7, 2015 Six o’clock in the evening Del Mar Country Club Rancho Santa Fe VIP Tables of Eight $2,500 Friends Tables of Eight $1,600 Individual tickets $200 For more information contact Barbara.Mandel@sdcms.org 858.300.2780
Thank You to Our Physician Led Teams You are Role Models of Health Promotion to Your Staff and Patients! CPCMG East County - Stuart Cohen, MD Families4Health - Sherry Franklin, MD IGO Medical Group - Wendy Buchi, MD Kaiser Permanente Primary Care Raymond Lane, MD Max Vision - Mihir Parikh, MD Minimally Invasive Surgeons of North County - Karen Hanna, MD Movers & Shakers - Will Tseng, MD NCFMG - Craig Duck, MD Neighborhood HealthCare James Schultz, MD
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SAN DI EGO PHYSICIAN.org 21
Bioethics
HIPAA PERMITS DISCLOSURE OF POLST
TO OTHER HEALTHCARE PROVIDERS AS
Physician Orders for Life-Sustaining Treatm
EMSA #111 B
(Effective 10/1/2014)*
First follow these orders, then contact physician. Patient Last Name: HIP PER A copy of the signed POLST form isAA a legally MIT validS DISCLOSURE OF physician order. Any sectionPat notien completed t Informa implies tion Patient First Name: full treatment for that section. POLST complemen Name (last, first, ts an Advance Directive and is not intended middle): to Patient Middle Name: replace that document.
NECESSARY
ent (POLST)
Date Form Prepared:
POLST TO OT
Patient Date HEof R Birth: HEALT
HCARE PROV
Medical Record #: (optional) Date of Birth:
A
Healthcare Pro CardIopulmonary reSuSCItat Ion (CPR):vider Assisting
B
medICal InterventIonS: Relationship If patient is found with to Patient: a pulse and/or is breathing. Phone Number: o Full Treatment – primary goal of prolonging life by all medically
IDERS AS NE
CESSARY
Gender: If patient withas h no pulse not breathing. If patient is NOT in cardiopulmonary arrest, Form Preparand atiois n M F Check followTitle orders N/AC. in Sections Boand if POLST is com : o Attempt Resuscitation/CPR Add pleted by sign One (Selecting Section A requires selecting Full Treatment itionalCPR ing physician Phone Number: Conin in Section tac B) t Do Not o Attempt Resuscitation/DNR Name: (Allow Natural Death) o None
2014 POLST Form Revision Effective Oct. 1, 2014 by Karl Steinberg, MD, CMD
By now, most California physicians should know about POLST, the Physician Orders for Life Sustaining Treatment — it’s our pink friend. Since 2009, the form has translated a patient’s wishes into a real-life document that is an actionable doctor’s order so that those wishes will be followed by paramedics, emergency physicians, nursing home staff, and other healthcare professionals. More detailed than a pre-hospital DNR form, the POLST addresses CPR, tube feeding, and other interventions that can prolong life. It is primarily designed for patients who have chronic, serious, or progressive illnesses — those “we wouldn’t be surprised if they died in the next year or two” — although people of any health status may choose to create a POLST form. It does not take the place of an advance healthcare directive (AHCD), and ideally both documents should be formulated and in agreement. After a laborious process of public and professional evaluation and review, the California POLST Task Force recommended changes to the last POLST revision of 2011, and this year the revisions were approved by the state’s Emergency Medical Services Authority (EMSA). On Oct. 1, 2014, the new version of POLST became valid. The form is available at bit. ly/1B8yIY2. There are a number of changes to the form, the most obvious of which is that the choices in Sections A, B, and C now all start with the most aggressive care and end with the least aggressive care. Another important improvement in the 2014 POLST is that Section B now has goalrelated descriptions rather than statements 22 Oc tober 2014
Check One
Name:
effective Completing Directmeans. In addition to treatment described ions for Hea in SelectivePOL ST Treatment and Comfort-Focused Treatment, lthcare Provid use intubation, advanced airway interventions, •mechanical Completventilation, er ing a POLST and cardioversion as indicated. form is volunta provTreatment. iders, and prov o Trial Period of Full ry. California ides imm law requires that unity to those by a physicia o Selective Treatment – goal of treating n who a POLST form who comply in will medical issu conditions ewhile be followed by appropr avoiding • POLST doe d faith. In the burdensom e goo iate orde measures. In addition to treatment described healthcare rs that hospital sett not rep in Comfort-Foscused lace the use Treatment, consistent with treatment, are Advmedical ure IV antibiotics, ance Dire fluids as indicated. Do not intubate.ens and IVthe patient’s ing, a patient will be assess sistency, andpositive ctive. Wh May connon-invasive preferences. ed updateairway en avoid availab • POLSTuse Generally forms pressure. intensive le, appropriate care. the Advance o Request transfer ly to resolve any review com to must be only if plet comfort ed byneeds Dire cannot be ctiv a • A legahospital met in hea current con e location. and lthc flicts. POLST form are provider bas lly recognized o Comfort-Focused Treatmentan to ed on patient – primary of decisionmacomfort. Advancegoal ker may include preferences and Directivmaximizing Relieve pain and suffering with medication e, a cou oral med rt-a ly available by designa ical indications ppointed conserv as needed; useted oxygen, relaany suctioning, surroga tiveroutepers . manual of airway obstruction. Do not use will ator or guardia te, spouseand on Selective treatments whom theTreatment listed ,inorFull , registered treatment make dec and n, agent designa patient’s phy unless consistent dom isions in acc goal. Request transfer to hospital only with esti comfort ted c sicia part in ner, parent of n believes bes comfort needs orda ncebe • A legallyifreco cannot with met current theinpati a location. t ent’s exp gniz Additional Orders: ressed wishes knows what is in the patient’ minor, closest that the decisio ed decisionmaker may exe and values to s nmaker’s auth cute the POL the extent kno best interest and ST form only ority is effectiv • POLST mus wn. if the patient lack e immediately t be . s capacity or follow-up sign signed by a physician and has designated ature by physicia the patient or artIfICIally admInIStered nautrItIon decisionmaker nOffer • If in acc food translated: form ordance by mouth feasible to be valid. Ver and desired. with faciiflity/ is used with pati bal orders are community poli o Long-term artificial nutrition, including • Use offeeding ent or decisio Check acceptable with cy. tubes. original Additional Orders: nmaker, attach form is stro ngly encouraged o Trial period of artificial nutrition, including copy shofeeding it to the signed One uld be reta tubes. . Photocopies English POLST ined in patient’ and FAX o No artificial means of nutrition, form. s medical reco Usi ng POLfeeding including tubes. rd, on Ultra Pink es of signed POLST form ST s are pap lega er when possibl l and valid. A • Any incompl e. InformatIon and SIgnature ete section of S: POLST implies Section A: full treatment Discussed with: o Patient •(Patient for that Has Capacity) If foun d puls eless and not o Legally Recognized Decisionmaker section. brea sho thin uld g, no defibrillator be used on a o Advance Directive dated ________, available pati à ent Healthcare luding auto who has cho Agent Section B: and reviewed named(inc in Advance Directive: mated external senif “Do o Advance Directive not available Not Attempt Res defibrillators) • When com Name: uscitation.” or chest compres fort can o No Advance Directive sions Treatment,” sho not be achPhone: ieved in the curr uld ent be sett transferred to a setting able ing, the patient, including som Signature of Physician • Non-invasive positive airw to provide com eone with “Co ay pressure incl pressure (BiP My signature below indicates to the best of fort mfo (e.g ude my knowledgeAP) rt-F ., s that ,these ocused treatme and orders continumedical are consistent bag valv with the patient’s ous condition • IV antibiot e mask (BV and ay itive airw preferences. nt of a hip fracture). Print Physician Name: M) assisted resppos ics and hydratio pressure (CP Physician AP), bi-level pos n genPhone ons.Number: • Treatment erallyNumber: License are not “ComfoPhysicianirati itive airway of dehydration rt-Focused Trea prolongs life. • Depending tment.” If a patient des Physician Signature: (required) on local EMS ires IV fluids, indicate protocol, “Additio Reviewing POL “Selective Trea nal Orders”Date: written in Sec ST tment” or “Fu tion ll Treatment.” B may It is recommend not be implem Signature of Patient or Legally Recognize ed that ented by EMS d Decisionm aker POLST be revi I am aware that this form is voluntary. personnel. • ByThe signing this form, the legally recognized ewed periodic decisionmaker acknowledges resuscitative measures is consistent with the patient is tran ally. Revthat request regarding iewthis desires of,sfer is reco andred withfrom the best one • Thereknown interest of, mm the care patient who end is the subject sett is of the form. ed when: a substantial ing or care leve Print Name: change in the l to another, or • The patient’ patient’s health Relationship: (write self if patient) s treatment pref stat us, or erences change Modifying and . Signature: (required) Voiding POL ST • A patient with Date: capacity can, at any time, requ inte Mailing Address (street/city/state/zip): nt to revoke. It is recomm est alternative writing “VOID” ended that trea Number: nt or revoke a revocation be Office Use tme in large letters, Phone Only: POLST by any docume and signing and • A legally reco means that indi dating this line nted by drawing a line thro gnized decisio cates SEND FORM WITHkno ugh Sections . nmaker may PATIENT wn desires WHENEVE TRANSFE A through D, request RRED of the patiR OR to DISCHAR modify the GED ent or, if unknow *Form versions with effective dates of 1/1/2009 orde or 4/1/2011 rs, are This n, also in valid the patient’s bes collaboration form is approve with the physicia d by the Californ t inte rest s. ia Emergency n, based on the Medical Services For
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Previous versions of POLST will still be honored after the 2014 form goes into effect, so there is no need to redo a valid POLST. like “Comfort Care Only” or “Limited Additional Interventions.” The word choices of “Full Care,” “Selective Treatment,” and “Comfort-Focused Treatment” should clarify the overall goals of care and concentrate less on the specific interventions being discussed. All information relevant to the new POLST can be found at caPOLST. org/2014polst. There are downloadable versions of the new form in English, Armenian, Chinese, Farsi, Hmong, Japanese, Korean, Pashto, Russian, Spanish, Tagalog, and Vietnamese, and the form is available in Braille as well. However, the original form should be signed on the English version. A list of upcoming POLST education opportunities can found at coalitionccc. org/training-events/polst-education. Previous versions of POLST will still be honored after the 2014 form goes into effect, so there is no need to redo a valid POLST. However, if the form is being revised due to a change in the patient’s wishes or their health condition, the new
or a copy of the
T WHENEVE
Authority in coop eration with the form, visit www statewide POL ST Task Force. .caPOLST.or g.
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version should be used and the old form voided. Photocopies, scans, and faxes of POLST are valid, and they do not have to be on “Ultra Pink” cardstock to be actionable. POLST has been a great tool in our armamentarium to help honor our patient’s wishes since 2009. Please make an effort to discuss this important resource with your patients who would benefit from making their wishes known and having a doctor’s order to ensure those wishes are followed — whether they are for the most aggressive treatment available, for completely comfort-based palliative care, or something in between. Healthcare professionals with questions about POLST are encouraged to connect with the San Diego Compassionate Care Coalition at sandiegopolst@gmail.com, or contact the Coalition for Compassionate Care of California at info@capolst.org. Dr. Steinberg, a member of SDCMS-CMA for eight years, is chief medical officer of Shea Family Health, chair-elect of the Coalition for Compassionate Care of California, and a local nursing home and hospice medical director. Dr. Steinberg currently sits on both SDCMS’s board of directors and Bioethics Commission.
Risk Management
Physicians Given ‘SAFER’ Way to Implement and Use Electronic Health Records Contributed by SDCMS-endorsed The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.
Problems with electronic health record (EHR) implementation and use are common and can affect patient safety and increase liability risks. Examples of EHR problems include: • Not adequately addressing known problems with EHR use, such as “alert fatigue” as a result of too many alerts • Problems locating where lab and X-ray results are filed (or misfiled) • Difficulty correcting progress note entry errors • Unnecessary operational complexity • Failure to use a team approach involving physicians and other healthcare professionals in leadership positions to ensure that their clinical concerns are met • Unwillingness by vendors to modify their systems to meet the complex workflows of the real-world practice setting To assist in the implementation and use of EHRs, the Office of the National Coordinator for Health Information Technology 24 Oc tober 2014
It’s recommended that all physicians, medical groups, and healthcare institutions that are considering implementation or replacement of an EHR visit the SAFER Guides website and spend an hour becoming familiar with those guides that address the areas of greatest interest or concern. recently released a practical, useful, and comprehensive suite of tools: the Safety Assurance Factors for EHR Resilience (SAFER) Guides. It’s recommended that all physicians, medical groups, and healthcare institutions that are considering implementation or replacement of an EHR visit the SAFER Guides website and spend an hour becoming familiar with those guides that address the
areas of greatest interest or concern. These free guides — which can be downloaded or used online at www.healthit.gov/ safer — provide a well-organized work plan for tackling the organizational complexities of EHR implementation and use. In order to ensure that clinically important considerations are addressed, the guides apply a structured team approach involving everyone whose professional life will be permanently affected by the EHR. The guides are designed to help healthcare organizations conduct self-assessments to optimize the safe use of EHRs in the following nine areas, the last three of which should be of most interest to physicians: • High Priority Practices • Organizational Responsibilities • Contingency Planning • System Configuration • System Interfaces • Patient Identification • Computerized Provider Order Entry With Decision Support • Test Results Reporting and Follow-up • Clinician Communication The guides are designed to help deal with safety concerns created by the continuously changing landscape that healthcare organizations face. When using the guides, changes in technology, clinical practice standards, Meaningful Use, and/or HIPAA Security Rule requirements should be taken into account. Because the guides are designed to help organizations prioritize EHR-related safety concerns, clinician leadership in the organization should be engaged to assess whether and how any recommended practice affects the organization’s ability to deliver safe, high-quality care. To optimize EHR-related safety and quality, collaboration between clinicians and staff should lead to a consensus about the organization’s future path.
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classifieds PHYSICIAN POSITIONS available GENERAL, FAMILY, OR INTERNAL MEDICINE PHYSICIAN NEEDED IMMEDIATELY: This opening is an independent contractor position. We are a house call practice located in beautiful North San Diego County. We will also provide paid training on our EMR. 8–5 Monday– Friday, 10–12 patients per day and on-call pager 1 week every 3 weeks, telephone call only. No rounds or hospital duties. If interested please submit your CV to julie@sandiegomobiledoctor.com. We are very anxious to fill this position and we look forward to hearing from YOU! No agencies please. [286] RECRUITING FOR A FULL-TIME FP OR IM PHYSICIAN: San Diego Family Care is recruiting for a full time family practice or internal medicine physician interested in working in a federally qualified community health center (FQHC) in the Linda Vista area of San Diego. The position requires at least a 32-hour/week commitment. Must be flexible and team oriented. May be required to work an evening or Saturday on occasion or, if preferred, could be part of regular scheduled rotation. Salary commensurate with experience and great benefits. Requirements include current California and DEA licenses / CPR certification, plus good standing with respective board / association. Candidates may be eligible to apply for federal loan repayment. If interested, please send CV to awalton@ lvhcc.com. [284] PRIMARY CARE PHYSICIAN (PART TIME) (URGENT CARE — PACIFIC BEACH): We are seeking a part-time primary care physician for a well-established, busy primary care family practice / urgent care medical practice 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 send your CV in confidence for consideration to pbyrnes@andersonmedicalcenter.com. Compensation: excellent pay rate. [278] CARDIOLOGIST NEEDED: To cover busy outpatient practice for periodic vacations and time off scheduled from November 2014 through April 2015. Email: albertochaviramd@yahoo.com. Phone: (760) 510-1808. Address: 334 Via Vera Cruz, Suite 257, San Marcos, CA 92078. [277] LOOKING FOR A PART-TIME PHYSICIAN: Well-established (and growing) family practice office centrally located in the Mission Valley area is looking for a part-time physician to join their practice. Must have current licensure, be board certified, and have experience in family medicine. The ideal candidate would be available to work three days a week, including some Saturdays and 1–2 evenings per week. Salary to be determined based on hours and productivity. Please send current CV to danielle.uhl@mfpmg.com. [276] PHYSICIANS WANTED FOR OUR GROWING ORGANIZATION: Full, part-time, or perdiem 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] PSYCHIATRY PHYSICIAN OPPORTUNITIES: South Bay practice seeking a B/C, B/E psychiatrist licensed to practice medicine in the state of California. Opportunity for clinical research / clinical trial duties in an outpatient office setting. Professional liability insurance required. Contract salary of $200,000, or commensurate with experience. Please send CV/resume to pbhatiaxj@gmail.com. [274] LOOKING FOR EXPERIENCED GENERAL PRACTICE / EMERGENCY MEDICINE PHYSICIAN: Full-time or part-time position available for experienced general practice / emergency medicine physician in a busy urgent care center. Must be available to work days, evenings, weekends, and holidays. Please send your CV along with references to lohara@san.rr.com or fax to (858) 274-9614. Pacific Beach Urgent Care established since 1982. Open weekdays 8–8 / weekends & holidays 8–4. [271] PSYCHIATRISTS NEEDED: Full-time or parttime positions available for a well managed program at San Diego County correctional facilities. Telepsychiatry position also available. Flexible hours with very competitive pay. Send CV to steve@cpmedgroup.com or call (619) 885-3907. [272] PRIVATE PRACTICE, PART-TIME IM/FP OPPORTUNITY: Unusual and exceptionally attractive private practice, primary care opportunity in beautiful North San Diego County. Well-established, collegial, single-specialty internal medicine group with >30 years in the community, exceptional office staff, and very high quality patient care set this far apart from many other situations. Option for 1–2 days/week with flexible scheduling; very attractive opportunity as an add-on to other part-time work. Interested in board-certified IM or FP applicants with EHR experience. Please email CV to portofino3@aol. com or call (619) 248-2324. [263] 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) 569-2590. Visit www.DoctorsExpressSanDiego.com for more information. [229a]
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 Oc tob er 2014
PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com) is a fast-growing 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-PERWEEK 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) 5045830 or at venk@gpeds.sdcoxmail.com. Salary $ 102–108,000 annually (equal to $130–135,000 full-time). [778] PRACTICEs FOR SALE IM / PRIMARY CARE PRACTICE FOR SALE: Internal medicine /primary care practice in Pacific Beach, San Diego with 33 years established practice is ready for sale. The practice is equipped with physiotherapy machines and has approximately 750 active patients. Physician is retiring and will be willing to assist younger practitioner to get established. Very easy and reasonable conditions. For further information, please get in touch with Dr. Ronaghy at office: (619) 275-2700; cell: (619) 840-4466; or email: ronaghy1@gmail.com. [287] PRACTICE FOR SALE: Well-established general practice for sale, two blocks from Scripps Chula Vista Hospital. Email lazyjackmac@gmail. com or call (619) 770-8232 after hours. [285] DERMATOLOGY SOLO PRACTICE FOR SALE: Mature physician is retiring December 2014 after practicing 36 years in coastal San Diego County on the campus of Scripps Memorial Hospital, Encinitas, California 92024. Professional services provided have been medical dermatology and minor dermatologic surgery. Doctor has limited his patient base to original Medicare and fee for service. New owner could add managed care and cosmetic services if desired. Office space is leased from Scripps Real Estate. Turnkey sale could be arranged. Reply to email class259@hotmail.com or cell phone (760) 666-0571. [275]
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]
BANKERS HILL PRIMARY CARE / HEALTHCARE PROFESSIONAL & RESEARCH OFFICE SPACE TO SUBLEASE 50-year established primary care practice and clinical research office, with currently two internists, have space to sublease to another primary care or primary care / subspecialist, or other independent healthcare professional, to help curb overhead and, if primary care, help with acute overflow patients’ needs. Also can provide opportunity to get into clinical research. Contact Jeff at crf@att.net. [265]
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. [288] 3998 VISTA WAY, IN OCEANSIDE: Four medical office spaces approximately 1,300–2,800SF available for lease. Close proximity to Tri-City Hospital with pedestrian walkway connected to parking lot of hospital, and ground-floor 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] SPACE AVAILABLE FOR BOARD-CERTIFIED INTERNIST interested in developing an East County practice. Contact Debbie at debbiepmid@yahoo.com or at (619) 287-7991. [283] MEDICAL OFFICE IN LA MESA — LOW PRICE! Fully functional medical office, ready for move in. In perfect condition. Fully furnished or empty, depending on your needs. Large reception area, one office, two exam rooms, restroom. Lots of storage space. Internet, phones — installed. Free patient parking. Close to public transportation and freeways. 969SF. $1,500/ month. Contact ucsurgeon@gmail.com. [266] DEL MAR / CARMEL VALLEY MEDICAL OFFICE FOR SUB-LEASE: Available October 2014 (4765 Carmel Mountain Rd., San Diego, CA 92130). 1,000SF. Two treatment / consultation rooms / office reception / photography room / break room. Unlimited patient free parking. Call (858) 4814888 or email mobyrne61@gmail.com. [252]
AVAILABLE: Vascular & General Surgeons have space available. One room consult office available, with one or two exam rooms, to a physician or team. Located on the campus of Scripps Memorial Hospital, The Scripps Ximed Medical Center is the office space location of choice for anyone seeking a presence in the La Jolla/UTC area. Reception and staff may be available. Complete ultrasound lab on site for scans or studies. Fullday or half-day timeslots. For more information, call Irene at (619) 840-2400. [154] NORTH COAST HEALTH CENTER, 477 EL CAMINO REAL, ENCINITAS, OFFICE SPACE TO SUBLEASE: Well-designed office space available, 2,100SF, at the 477-D Bldg. Occupied by Vascular & General Surgeons. Excellent and central location at this large medical center. Nice third-floor window views, all new exam tables, equipment, furniture, and hardwood floors. Full Ultrasound lab with tech on site, doubles as procedure room. Will sublease partial suite, one or two exam rooms, half or full day. Will consider subleasing the entire suite, totally furnished, if there is a larger group interest. Plenty of free parking. For more information, call Irene at (619) 840-2400 or at (858) 452-0306. [153] 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] POWAY / RANCHO BERNARDO — OFFICE FOR SUBLEASE: Spacious, beautiful, newly renovated, 1,467SF 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 1,900SF 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: Two 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 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. [289] NURSE PRACTITIONERS WANTED FOR OUR GROWING ORGANIZATION: See ad #046 under “PHYSICIAN POSITIONS AVAILABLE.” PSYCHIATRIC NURSE PRACTITIONER NEEDED: For part-time or full-time work at San Diego County correctional facilities. Flexible hours and very competitive pay. Send CV to steve@ cpmedgroup.com or call (619) 885-3907. [273] 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) 569-2590. Visit www.DoctorsExpressSanDiego.com for more information. [229b] NURSE PRACTITIONER: Needed for housecall physician in San Diego. Full-time, competitive benefits package and salary. Call (619) 9925330 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) 9925330 or email drhunt@thehousecalldocs.com. Visit www.thehousecalldocs.com. [038] MEDICAL EQUIPMENT MEDICAL CHART RACKS FOR SALE: We have five seven-foot-tall chart racks, each one three feet wide with seven shelves. They are sturdy and tan or putty-colored. Price negotiable. Call Linda at (760) 724-8749. [267]
Place your ad here Contact Dari Pebdani at 858-231-1231 or DPebdani@sdcms.org
SCRIPPS XIMED MEDICAL CENTER BLDG, LA JOLLA — OFFICE SPACE TO SUBLEASE SAN DI EGO PHYSICIAN.org 27
Personal & Professional Development
“Facebook Friend” New Definition or Misnomer?
by Helane Fronek, MD, FACP, FACPh
Several years ago, I was involved in a program with nine participants located around the globe. Wanting to create opportunities for connection, the group decided to form a Facebook page — a private webpage on which only we could place messages, post questions, and offer ideas for one another. The problem was that one of us wasn’t on Facebook. As you might have guessed, I was that person. Yielding to my colleagues’ pressure, I joined Facebook (much to the concern of my children!) and was suddenly asked by many Facebook users to be their “friend.” While I contributed to the discussions on the program page, I stopped checking it once the program ended. So I was surprised when, on my next birthday, I received numerous “Happy Birthday!” messages from my “Facebook friends.” Wanting to express my gratitude that they had thought of me, I called each person. None of them called back. What is this thing called a “Facebook friend,” and what does it say about the value and meaning of friendship today? We all have many levels of friendship: the expanse of people at each level becomes increasingly narrow to form a sort of pyramid of friendship. At the bottom, we have lots of “friends” we greet as we pass them in the hallways at work or in our neighborhood. Many people would actually call these “acquaintances” rather than “friends.” We have “friends” we enjoy spending time with and with whom we will 28 Oc tober 2014
Many of us let our friendships erode as we become buried in charts, journals, and administrative tasks. We let this truly important part of our lives slip through our fingertips.
talk about some things but not others. One level up from that, there’s a group we can count on to take us to the airport, feed our cat when we’re away, and share many of our concerns with. At the very top are the few people — our “peeps,” as one of my friends calls them — who will sit with us at the hospital when our spouse has surgery, keep our confidences, help us sort out our real dilemmas until one o’clock in the morning, and remember when we have a big event and call to wish us good luck. Research shows that people who have friends feel happier and more fulfilled. Those with friends live healthier and longer lives. I doubt the studies were referring to “Facebook friends.” And yet, through the course of our medical training and careers, many of us let our friendships erode as we become buried in charts, journals, and administrative tasks. We let this truly important part of our lives slip through our fingertips.
Consider your own friendship pyramid. Starting from the top, make a plan to contact each one of your “peeps.” Let them know what’s happening with you, and find out how they are. That simple connection, all by itself, may enrich your life immeasurably. After that, contact those on your next level. Especially before we enter the hectic holiday season, take time to reach out to those people who mean the most to you. You know, those people we call friends. 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.
Tomorrow is based on what you do today. No matter what happens in your future, you need to be ready for it. You need to set goals for it, save for it and invest carefully. You need to make fiscal responsibility a personal value. Most of all, you need a strategy. As your Financial Advisor, I’ll work with you to create a strategy — one based on the realities of both your life and the financial world. Meet with me, and let’s get your future started.
Sandra Goins CERTIFIED FINANCIAL PLANNER ™ Financial Advisor 101 W. Broadway San Diego, CA 92101 619-238-6232 Sandra.Goins@morganstanley.com
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