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

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Contents

Volume 101, Number 11

MANAGING EDITOR: Kyle Lewis EDITORIAL BOARD: Sherry L. Franklin, MD, James Santiago Grisolía, MD, Theodore M. Mazer, MD, Robert E. Peters, PhD, MD, David M. Priver, 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

feature

Proposition 46 Soundly Defeated

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 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

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

departments 4 Briefly Noted: Calendar • New and Returning Members • Volunteer Opportunities • And More … 10 Communication Is Key to Improving Diabetic Patient Outcomes and Reducing Liability

Soft Cheeses From Mexico: Could This Be Making Your Patients Sick? Y WILMA J. WOOTEN, MD, MPH, B JESSICA ADAM, MD, MPH, AND JUSTINE KOZO, MPH

Physician Marketplace: Classifieds

BY THE DOCTORS COMPANY

28 Work-Life Choices: What Are Yours? BY HELANE FRONEK, MD, FACP, FACPH

Who Should Care About Ebola?

BY GONZALO BALLON-LANDA, MD

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 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

New Immunization Recommendations: Adults Getting Children’s Vaccines and Other New Approaches

Y ROBERT E. PETERS, MD, PHD, AND B MARK H. SAWYER, MD

Pertussis: San Diego County Update

Y ERIC MCDONALD, MD, MPH, AND B KAREN WATERS-MONTIJO, MPH

2 Novem b er 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.]

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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.

Pain Management Strategies to Decrease Liability Risk (seminar/ webinar) NOV 20: 11:30am–12:30pm

Cma Webinars and Events CMAnet.org/events Coordinated Care Initiative (CCI): What Physicians Need to Know (webinar) DEC 2: 12:00pm–1:00pm Coordinated Care Initiative (CCI): What Physicians Need to Know (webinar) DEC 3: 6:00pm–7:00pm CMA Solo and Small Group Practice Forum Meeting DEC 4: Attention physicians in practices with 1–4 members: The CMA House of Delegates (HOD) is in San Diego this year and so is the Solo and Small Group Practice Forum (SSGPF) Annual Dinner. The SSGPF, which represents

your interests at CMA, will be meeting at Edgewater Grill in Seaport Village on Thursday, December 4, at 5:30pm. The dinner is graciously sponsored by the Cooperative of American Physicians. Come meet your HOD representatives, say thanks to California legislators who support organized medicine’s position on scope of practice, and air your own ideas. Email mcouris@alum. mit.edu to RSVP.

Community Healthcare Calendar

To submit a community healthcare event for possible publication, email KLewis@SDCMS.org. Events should be physicianfocused and should take place in or near San Diego County. Essential Tools in Serving Diverse Populations NOV 18 (Scottish Rite Event Center on Camino Del Rio South, registration open in September) Update in Rheumatology 2014: Highlights From the ACR and EULAR Meetings DEC 13 (https://cme.ucsd. edu/rheumatology/)

infectious disease

SDCMS Convenes Countywide Meeting to Discuss Ebola:

On Monday, Oct. 20, SDCMS convened nearly 100 chiefs of staff, representatives from the County, politicians, and other infectious disease specialists to discuss Ebola, to share preparation plans for an Ebola patient, and to ask questions of each other. SDCMS has ensured all attendees now know each other and are able to easily communicate with each other. The SDCMS GERM Commission – the Infectious Disease leaders in San Diego County — will continue to address the disease from a clinical perspective.

YOUR SDCMS FOUNDATION

What Has the SDCMS Foundation Done for San Diego County Lately? 4 novem b er 2014

While the SDCMS Foundation is best known for the work of its Project Access San Diego (it changed the lives of 39 people at this past Oct. 25 Surgery Day), it is also involved in many other health improvement initiatives: • Its colorectal cancer screening program assists community health centers to boost their screening rates; one of the clinics boosted from 16% to 55% in one year. • It has provided more than 2,000 free clinical breast exams and mammograms to uninsured women in the past 12 months. • Last flu season, 500 people received free flu shots; the Foundation’s goal this season is 750. • It is launching its Jump Start for Health diabetes prevention program aimed at

•

pre-diabetics presenting at UC San Diego emergency department. Medical students and new residents at UC San Diego School of Medicine receive support from the SDCMS Foundation through small scholarships and trips to Sacramento for advocacy training. 360 private practice physicians received technical assistance to adopt EHRs and achieve Meaningful Use Stage 1. Retired physicians continue to earn CEUs and maintain professional relationships through its Retired Physicians Society. Newly discharged military needing assistance to navigate the healthcare system are paired with retired physicians through its Physician Advocates for Veterans (PAVE) program.

/////////////////////////////////////////////////////////////////////////////////////////////////// errata sheet

Published by the San Diego County Medical Society (SDCMS) Delete Listing for the Following Physician: • Robertson, Cynthia A. MD

Update Listings for the Following Physicians: • Adams, Charles A. MD {p} T: 7607539500 F: 7607530785 A: 285 N El Camino Real, Suite 219, Encinitas 92024 N: 1083608533 • Brown, Douglas E. MD {cd/im} T: 8587643150 F: 8587649083 A: 3811 Valley Centre Drive, San Diego 92130 N: 1750345112 • Chahal, Nittly S. MD {im/plm} T: 6192704919 F: 7602709109 A: 7901 Frost Street, San Diego 92123 N: 1164682480 • HACKER, SCOTT ALAN MD MD {ors} T: 6192869480 F: 6192869468 • W: www. drscotthacker.com A: Alvarado / Helix Orthopedics and Sports Medicine, 5555 Reservoir Drive, Suite 104, San Diego 92120 • 8860 Center Drive, Suite 350, La Mesa 91942 N: 1750450805 [art/knees/osm/ shous] • HOANG, VY UYEN MD {pd} T: 6194422560 F: 6194427836 A: 250 East Chase Avenue, Suite 108, El Cajon 92020 N: 1649575135 • KOBAYASHI, KAREN NAOMI DO {obg} T: 6192678313 F: 6194722008 A: 655 Euclid Avenue, Suite 409, National City 91950 N: 1497929517 • KOONINGS, PAUL PHILIP, MD, FACOG {go/obg} T: 6195282593 F: 6195283904 W: kp.org A: 4647 Zion Avenue, San Diego 92120 N: 1689733214 • LEV, RONEET, MD {em} T: 6196863800 F: 8586750606 A: 4077 Fifth Avenue, Department Emergency Medicine, San Diego 92103 N: 1144266123 [clr/ems/pmd/pubh] • MOSELEY, WILLIAM G. MD {u} T: 6192600060 F: 6192996001 A: 3969 Fourth Avenue, Suite 202, San Diego 92103 N: 1568564276 • Reddy, Sumana MD {ai} T: 6193776565 F: 6194502111 A: 8860 Center Drive, Suite 320, La Mesa 91942 N: 1053300251 • SEBRECHTS, CHRISTOPHER PAUL MD {dr} T: 8585650950 F: 8585652863 W: sandiegoimaging.com A: P.O. Box 23540, San Diego 92193 N: 1487628558 [nm] • Shailam, Sunita MD {fp} A: 427 C Street, Suite 216, San Diego 92101 N: 1174625933 • Witczak, Izabela MD T: 7607366767 F: 7607366782 A: 150 Valpreda Road, San Marcos 92069 N: 1184735201

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SAN DI EGO PHYSICIAN.org 5

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

Welcome New and Returning SDCMS-CMA Members! New Members John G. Apostolides, MD, FACS Plastic Surgery San Diego (619) 222-3339 Christopher V. Crosby, MD, FAAD, PhD Dermatologic Surgery La Mesa (619) 462-1670 Sivaraman K. Gounder, MD Internal Medicine San Diego (908) 361-0185 John S. Hammes, MD Nephrology San Diego (619) 299-2350 Shannon L. Hart, DO Obstetrics and Gynecology Escondido (760) 745-1363 Paul W. Hinshaw, DO Obstetrics and Gynecology Escondido (760) 745-1363 Srinivas S. Iyengar, MD, FACS Ophthalmology Oceanside (760) 757-1144

Henry S. Kane, MD Child and Adolescent Psychiatry Camp Pendleton (760) 725-1555 Anas Kayal, MD Nephrology Oceanside (858) 499-1900 Sheila M. Krishna, MD Dermatology Oceanside (760) 758-5340 James E. Lamar, MD, MPH General Preventive Medicine San Diego (639) 532-5502 John W. Love, MD Emergency Medicine San Diego (639) 532-5208 Fharak M. Chip, MD Nephrology National City (619) 475-4900 Nicole Mau, MD Dermatology Oceanside (760) 758-5340 Dan M. Meyer, MD Thoracic Surgery La Jolla (858) 455-6330

Navinder S. Sawhney, MD Clinical Cardiac Electrophysiology Escondido (858) 657-5310 Helen J. Sohn, MD General Surgery La Mesa (619) 462-8100 Miranda R. Sonneborn, MD Family Medicine San Diego (858) 499-2703 Raymond H. Summers, MD Pathology San Diego (619) 229-3135 Joseph C. Tulagan, MD Pediatrics National City (619) 382-3350 Catherine L. Worden, MD Obstetrics and Gynecology Escondido (760) 745-1363 Henry Yuan, MD Nephrology Chula Vista (619) 427-1144 RETURNING MEMBERS Deidre A. Buddin, MD Dermatology San Diego (858) 558-0677 Arman Faravardeh, MD Nephrology La Mesa (619) 461-3880 Kristy A. Lamb, MD Psychiatry La Jolla (619) 543-6440

Then indecision brings its own delays, And days are lost lamenting o’er lost days. Are you in earnest? Seize this very minute; What you can do, or dream you can, begin it. — Johann Wolfgang von Goethe, German Writer and Statesman (1749–1832)

6 novem b er 2014

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. [282] 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 UC San Diego first- and second-year medical students in their Ambulatory Care Apprenticeship Program. This is a longitudinal one-afternoon-every-other-week 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. [281] HUMANITARIAN TEAMS NEED MEDICAL VOLUNTEERS FOR HAITI: The Seattle-King

quote of the month

“

giving back

”

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. It coordinates 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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New Percutaneous Mitral Valve Repair Now available to patients outside of clinical trials, the MitraClip® system is a minimally invasive alternative for degenerative mitral regurgitation patients at prohibitive risk for traditional surgery.

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.

SAN DI EGO PHYSICIAN.org 7

micra

6 4 n o i t i s o p o Pr

e D y l d n Sou

by J. Steven Poceta, MD, President, SDCMS

8 novem b er 2014

On Nov. 4, the voters of California spoke loudly and definitively, sending the trial lawyers’ Proposition 46 to defeat by a vote of 68% to 32%. The message is clear: Californians simply don’t want to increase healthcare costs and reduce health access so trial attorneys can file more lawsuits. ¶ An increase in the Medical Injury Compensation Reform Act (MICRA) cap on non-economic damages has been rejected in California again and again: 10 times in court, five times in the Legislature, and now overwhelmingly by voters. This idea now has its own dedicated spot in California’s political trash heap.

d e t a e fe But this time we energized the membership of SDCMS and CMA as a whole to fight the fight together, as one unified voice of medicine, representing the patients we so deeply care about and the care that we have committed to provide them. Despite the trial attorney proponents’ attempt to sweeten the deal by adding provisions that polled well — physician drug testing and mandatory checking of a prescription database — voters said NO on election night. As people throughout the state heard from physicians and No-on-46 coalition members about the real intentions of the measure’s proponents, there was resounding opposition. One of the secret weapons of this effort was the size and diversity of our coalition. We helped amass one of the largest and most diverse campaigns in California history. The breadth of the coalition — which includes labor, business, local government, health providers, community clinics, Planned Parenthood, ACLU, NAACP, taxpayers, teachers, firefighters, and more — underscores just how important affordable, accessible healthcare is to every Californian. In addition to the groups on the ground talking to voters about the deception and trickery behind Prop. 46, every major editorial board in California opposed the initiative. The Los Angeles Times said, “As worthwhile as [Proposition 46’s] goals may be, the methods the measure would use to achieve them are too flawed to be enacted into law.” The San Francisco Chronicle decried Prop. 46, saying that the measure “overreached in a decidedly cynical way.”

We energized the membership of SDCMS and CMA as a whole to fight the fight together, as one unified voice of medicine, representing the patients we so deeply care about and the care that we have committed to provide them. The Orange County Register, U-T San Diego, San Jose Mercury News, Monterey County Herald, Sacramento Bee, and dozens of other newspapers echoed these sentiments. The efforts of the California Medical Association and the county medical associations across the state are a tremendous showing of what we can do for the future of healthcare, the quality of medicine, and the dedication to patients everywhere. Working together to spread the truth about Prop. 46, building coalitions across communities, and standing strong as one united voice are what helped carry us to victory. This was one of the most contentious and high-stakes ballot fights in California history, and we rose to the occasion. We must use this unity moving forward and showcase to our colleagues the value that the San Diego County Medical Society and California Medical Association bring to our great profession, and stay united for whatever comes our way next.

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Risk Management

Communication Is Key to Improving Diabetic Patient Outcomes and Reducing Liability Contributed by SDCMS-endorsed The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

Because diabetes has the potential for serious complications and requires immense involvement by patients and physicians for successful outcomes, healthcare professionals who treat diabetic patients may be at risk for malpractice lawsuits. In a study of claims closed from 2007 to 2013, The Doctors Company identified four common allegations made by patients with diabetes: 10 novem b er 2014

1. improper management of treatment: 37% 2. failure or delay in diagnosis: 31% 3. failure to treat: 9% 4. improper management of medication regimens: 6% Diabetic patients’ treatment is often managed by a multidisciplinary care team, which may include a primary care physician, endocrinologist, dietician, ophthalmologist, podiatrist, and dentist. When patients file

claims, it’s not uncommon for them to name the entire care team in the complaint, alleging failure to properly diagnose, supervise, monitor, and/or treat their disease. To promote patient safety, the healthcare team should engage the patient in collaborative care planning and problem solving to produce an individualized care plan as well as team support when problems are encountered. Other ways to promote patient safety and mitigate the risk of malpractice claims related to diabetes care are: Communicate: Talking openly with diabetic patients about their condition and encouraging them to take an active role in decision-making enhances patient safety. • Overcome patients’ fears about their disease by taking time to answer questions. • Discuss all associated risk factors, including weight gain. The American Medical Association and American Diabetes Association have resources available to help physicians talk to their patients about weight and diabetes. • Provide written instructions and information about adverse effects for prescription drugs and complex prescription drug regimens. • Communicate with the patient and prepare written information in the language and at the literacy level that the patient understands. • Ask patients to repeat the information shared, not just whether they understand what they have been told. Educate: Educate patients about the importance of self-management to help increase their compliance and to reduce the risk of patients attributing their injuries to substandard care. Diabetic patients should be able to articulate the importance of lab tests, medication management, diet, and exercise. Barriers to self-management, such as financial issues or lack of social support, healthcare literacy, and patient-caregiver relationships, should be assessed. Document: Document any and all patient interactions and discussions regarding the patient’s condition, including diagnosis, specialist referrals, and treatment options. Manage care: Implement a program that ensures timely follow-up when a patient fails to schedule an appointment, misses an appointment, or cancels an appointment and does not reschedule. Failure to follow up and provide intensive patient management can lead to missed or delayed diagnoses, accelerated disease symptoms, morbidity, and/or mortality.

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infectious

disease

Who Should Care About

Ebola? By Gonzalo Ballon-Landa, MD

12 novem b er 2014

Everyone should, of course — and on current evidence, everyone does. At this point, nearly every hospital and clinic has dealt with panicked patients, families, and even healthcare professionals. Consider a dentist’s office where a boy arrived for his regular tooth cleaning. When asked, he denied any recent travel, but admitted that he was originally from Sierra Leone. Never mind that he was not sick, nor had he traveled or had contact with anyone who traveled — the entire office evacuated, except for a few individuals who donned hazmat suits to complete the interview. Consider the mother of three children who presented to the ER with fever and diarrhea, and who reported contact three weeks earlier with missionaries who recently returned from Liberia. Rightfully, this case triggered the rapid mobilization of considerable public health resources; however, when officials finally tracked down the missionaries in Michigan, they discovered that the missionaries had come from Algeria, not Liberia, and therefore had posed no exposure risk. Finally, consider also a local dental hygienist who recently returned from a medical mission in Kenya, 3,000 miles away from the epidemic. Upon her return, her employer forbade her from working until she completed the 21-day quarantine that Ebola demands. Each of these real-life anecdotes has engendered substantial financial, social, and emotional burdens, and each is the byproduct of media-fueled hysteria. FDR’s inaugural address admonition rings loudest: “We have nothing to fear but fear itself.” Nevertheless, the largest Ebola virus epidemic in history is no laughing matter. It threatens to kill many more people in the affected areas of West Africa, and many efforts to curtail it are stymied by serious challenges. The virus kills around half of the people it infects, and we don’t know how many potential hosts are susceptible; there is a chance for severe mayhem there.

  

n October 1520, a great epidemic occurred in the Aztec capital, which was under siege by Hernán Cortés. It was caused by the smallpox virus, and the epidemic was dubbed by the locals the huey ahuizotl (great rash). The invaders inad-

vertently introduced it. Although some accounts blame an African slave who belonged to one Diego de Narvaez, others attribute this to classic shifting of the blame from the part of the Spanish. Regardless of the identity of the index case, this epidemic, depending on the account, decimated 30–40% of the Aztec empire. Yet this is not 1520, and Ebola is not smallpox. It is unlikely that this virus will cause havoc outside of Africa, although it could do so in other underdeveloped areas. There have been some 25 outbreaks of Ebola Hemorrhagic Fever (EHF) in Africa since the first report in 1976 (Table 1). They have all resolved within months.

  

ncluded below is an email from an infectious disease (ID) specialist in Dallas. He published it on the Emerging Infections Network (EIN) listserv to publicly share his experience. It may give a fuller picture of caring for Ebola in the community. He writes, I have been reading with interest all the chatter on EIN about managing Ebola patients. I am an ID physician at THR-Presbyterian Dallas hospital. While I did not directly care for any of the three Ebola patients, three of my partners did, and I was abreast of most of the goings on at our hospital. It has been a memorable and enlightening experience. I’d like to share some of our experiences in the hope that you may better prepare yourself and your institution on the chance that an Ebola patient shows up in your hospital. These opinions and observations are purely my own. They do not reflect the views of our hospital, my other partners, or the CDC.

Determine First and Foremost if Your Hospital Has the Capacity to Care for an Ebola Patient: Caring for an Ebola patient is not business as usual. The toll on a hospital can be substantial. Once it became known we were housing Ebola patients, our census plummeted. Elective surgeries, clinic visits, and deliveries disappeared. Our ER was placed on divert. We had to dedicate the entire medical ICU to house the Ebola patients. Several staff members caring for the first patient have been furloughed for three weeks from last contact. Two of my own partners are removed from patient contact, and a third may be too. Needless to say, the financial burden is huge, and the impact on daily operations is substantial. Talk to your senior management team and make sure they are willing to endure the cost and disruption in services. Build a Volunteer Team Who Will Be the Exclusive Caregivers: It is impossible to train the entire hospital staff in proper isolation methods. Keep the number of contacts with the patient to the bare minimum. Consultants can relay their opinions (without direct patient contact) after doing a chart review and discussing with the primary caregivers. Goes without saying, suspend through-traffic in the isolation zone. The volunteer team should include, at the minimum: an ID physician, ICU physician, ER physicians, respiratory techs, renal staff and dialysis techs, nurses, lab staff, radiologist/techs, and environmental staff. These folks should be willing to care for the patient and ready to face the downstream effects of care. This includes the risk of getting infected, the risk of being furloughed, the risk of transmitting disease to their family members, the risk of social ostracism of themselves and their family. (Staff have been asked to stay away from church, children have been disinvited from parties, etc.) I think you owe it to the staff that they fully comprehend what can happen. A few of our doctors and nurses had emotional meltdowns after they cared for the patient. Hippocratic Oath notwithstanding, you need to make sure the volunteers have the emotional fortitude to do the job. Once this team is collected, begin practice drills. Certify that each team member is fully capable of donning and doffing their gear. No one should be allowed near the patient without demonstrating proficiency in correct protocol. Putting on the gear is a pain. Taking it off correctly is a supreme challenge. Wearing it is unbearable after a while. Nurses will need frequent rotations (probably every 3–4 hours). That is about the limit one can endure under the gear. Decide beforehand if your team will consider invasive procedures such as intubation, dialysis, or CPR. We performed the former two in our patient. We felt CPR would be too high a risk for staff and had our patients sign DNR orders. Practice doing the procedures in the PPE. It’s quite challenging. SAN DI EGO PHYSICIAN.org 13

Table 1. Ebola Case Fatality Attack Rates Before 2013 — Ebola Zaire Strain Most Virulent With High # Fatalities Year

Country

Ebola Virus Species

Cases

Deaths

Case Fatality

2012

DRC (Congo)

Bundibugyo

51%

2012

Uganda

Sudan

57%

2012

Uganda

Sudan

71%

2011

Uganda

Sudan

100%

2008

DRC (Congo)

Zaire

44%

2007

Uganda

Bundibugyo

149

25%

2007

DRC (Congo)

Zaire

264

187

71%

2005

Congo

Zaire

83%

2004

Sudan

41%

2003 (Nov.–Dec.)

Congo

Zaire

83%

2003 (Jan.–Apr.)

Congo

Zaire

143

128

90%

2001–02

Congo

Zaire

75%

2001–02

Gabon

Zaire

82%

2000

Uganda

Sudan

425

224

53%

1996

South Africa (ex-Gabon)

Zaire

100%

1996 (July–Dec.)

Gabon

Zaire

75%

1996 (Jan.–April)

Gabon

Zaire

68%

1995

DRC (Congo)

Zaire

315

254

81%

1994

Cote d’Ivoire

Taï Forest

1994

Gabon

Zaire

60%

1979

Sudan

65%

1977

DRC (Congo)

Zaire

100%

1976

Sudan

284

151

53%

1976

DRC (Congo)

Zaire

318

280

88%

14 novem b er 2014

When the Ebola patient arrives, the Ebola team should be reassigned from all other clinical duties. Do not have them going around seeing other patients. In case of exposure, it just overwhelms contact tracing activities. University hospitals, with salaried staff, can reassign doctors to be exclusive caregivers. Community hospitals, like THR-Presbyterian, are staffed by private practice doctors. Those physicians need to be compensated or they will endure substantial revenue losses. (All care given to our first patient was pro bono.) Management should have a system in place to compensate these doctors. Hash this out beforehand! Consider housing arrangements for the Ebola team. Some caregivers may be reluctant to go home to their families until the risk of contagion is passed. It should be the responsibility of the hospital to provide room and board. Our staff has received notice from the County/CDC restricting patient contact, visiting public places, or traveling. Yet it’s okay for them to go home to their families? ER Issues: With all the heightened awareness, I hope everyone is modifying his or her ER assessment forms. Travel to West Africa (and yes, to Dallas) should be on the list. If you are bursting with confidence that your ER would never miss a case, well, test your premise out with a few fake patients with rehearsed stories. Try different scenarios and random shifts. You may not like what you find. Also, be aware, there is a heavy stigma associated with Ebola in West Africa. A patient may be evasive in admitting they have Ebola or have come in contact with Ebola. They may fear deportation or incarceration for themselves or their family. Make arrangements for appropriate isolation of the patient in the ER. It can take a day or so to get PCR tests back from the state lab. The patient will need to be kept in quarantine till cleared. Work with your ER staff to figure out the smoothest movements within the ER without exposure of other staff and patients. Also practice transportation of patients from the ER to the inpatient unit. Lab Issues: Try to keep lab draws to the minimum. Your lab can become inundated with blood and other specimens that have to be handled specially. Coordinate with the State lab and CDC regarding how to handle and dispose of specimens. Ebola virus PCR tests are performed at the CDC and, for us, in Austin, Texas. Turnaround time is way too long. Especially with the flu season coming along and a paranoid public convinced they have Ebola and not the flu. The looming ER crisis is concerning. See if your state or CDC will allow your lab to process specimens on site. You will also need space in the ER to isolate patients till the results are in. Waste Disposal: CDC has good guidelines about collection of biohazard waste. Dispos-

ing of it is another matter. Do you have onsite incineration capacity or is your hospital one that subcontracts biohazard waste disposal? If the latter, then have the contractor provide input in your planning meetings. Know what your municipal, state, federal requirements are. Are there any Department of Transportation restrictions to movement of hazardous material, etc. Ebola Medicines: As you all know, there really isn’t any proven treatment for Ebola. But are you really going to stand by and not attempt to give at least one of the three experimental medicines? Remember, all require an IND request from the FDA. If you have not applied for an IND request before, you are in for a shock. It can take substantial hours of your time. Usually the privilege falls upon the ID doctor caring for the patient (as though he or she has nothing better to do). Delegate the work to a colleague or recruit the hospital research corporation to assist in filing the request. Also work out an emergency IRB approval for these medicines and a consent form. Have this set up well in advance, or else it may delay administering the drugs. Media: As inevitable as death and taxes. Speak the truth and with proper knowledge of the facts. Preferably someone from the direct care team — either the ID doc, or the ICU physician — should be present to answer patient care questions. Don’t leave a poor

hospital administration representative, who is not facile with the electronic records, out to the wolves. Clamp down on leaks. No cell phones or cameras. Staff will be tantalized by large sums of money to provide insider photos and details. Patient privacy is paramount. Have your IT constantly survey the electronic records for unauthorized access to the charts. Surrogate Decision-making: While this can be an issue even with local U.S. citizens, it can be very challenging for folks coming from West Africa. There are cultural differences in who can be a decision-maker. Patients may come from families already decimated by Ebola. Be culturally respectful. Pin down the chain of command as soon as possible. Someone other than the patient may need to give permission for experimental treatments, dialysis, or intubation. These are some early observations. Ebola can easily be handled in any U.S. hospital. I am quite sure of that, even after all that has transpired here in Dallas. Both our hospital and the state and federal authorities have learned a lot in a real-time situation. I hope the CDC will come back with more pragmatic and robust suggestions for care and infection control. Maybe develop a CDC SWAT team that swoops in and verifies the local capacity of the hospital within 24 hours of confirmation of diagnosis.

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16 novem b er 2014

There is a negligible chance that you would be the first person to come in contact with a suspected case of imported Ebola. If you are, here are the steps you should take:

1. 2. 3.

Don protective equipment: gowns, double gloves, N95 masks, shoe booties, and full-face goggles. Call San Diego County epidemiology at (858) 565-5255. Most patients will be held in ED-designated areas for isolation and observation, if nothing else. The great majority of these will turn out to be not Ebola.

More information can be found at http://emergency.cdc.gov/ han/han00366.asp. Dr. Ballon-Landa, a 33-year member of SDCMS-CMA, is board certified in internal medicine and infectious disease and is chair of SDCMS’ Group to Eradicate Resistant Microorganisms (GERM) Commission.

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infectious

disease

New Immunization

Recommendations Adults Getting Childrenâ&#x20AC;&#x2122;s Vaccines and Other New Approaches By Robert E. Peters, MD, PhD, and Mark H. Sawyer, MD

18 novem b er 2014

We are entering the decade of adult immunizations. Childhood immunizations have exploded over the past two decades, and immunization coverage rates for children are generally good. Now it is time to get our adult population better immunized. We can start, of course, by doing a better job of immunizing with our longstanding adult vaccines, such as influenza vaccine, pneumococcal polysaccharide vaccine, and zoster vaccine. In addition, there are now new recommendations that adults receive conjugated pneumococcal vaccine and that individuals with diabetes receive hepatitis B vaccine.

The last relatively new immunization recommendation is for patients with diabetes who we now know are at increased risk for acquiring hepatitis B infection.

We also have a new HPV vaccine coming in 2015. For young children, there is a new preference for use of the live attenuated nasal influenza vaccine this winter. Here is a quick summary of some important new immunization recommendations. The conjugated 13-valent pneumococcal vaccine (Prevnar) has been used in children for many years with great success. Not only has this vaccine reduced rates of invasive pneumococcal disease in children dramatically, it has also had the indirect effect of protecting adults because they are less likely to be exposed to a child carrying pneumococcus in their nasopharynx. Despite that, the pneumococcus still causes thousands of cases of both invasive disease and non-bacteremic pneumonia in adults in the United

States, particularly in those 65 years of age and above. For years we have immunized seniors with the 23-valent pneumococcal polysaccharide vaccine (Pneumovax) to try to decrease these outcomes but with only modest success. In August 2014 the CDC’s Advisory Committee on Immunization Practices issued a new recommendation that we start routinely using the conjugate vaccine (Prevnar) in addition to the polysaccharide vaccine (Pneumovax) for all individuals 65 years of age and above (MMWR 2014;63:822-825). This recommendation is based on a large study recently completed in the Netherlands demonstrating significant reductions in both invasive disease and non-bacteremic pneumonia caused by the serotypes in the vaccine among those vaccinated. In order to achieve the optimal immune response, seniors should be immunized first with the conjugate vaccine (Prevanar) starting at age 65 years, followed 6–12 months later by a booster dose with the polysaccharide vaccine (Pneumovax). For your patients who have already received the polysaccharide vaccine, the conjugate vaccine is still recommended but with a minimum of one year between the two vaccines. This all creates a challenge for you and your staff to stock both vaccines, know the intervals between the vaccines, document carefully which vaccines have been given to each patient, and to educate your patients about the need for two different pneumococcal vaccines. Younger adolescent and adult populations at high risk for pneumococcal vaccine also benefit from this two-vaccine approach to pneumococcal vaccination (MMWR 2012;61:816-819, MMWR 2013;62:521-524). These include patients with immunocompromising conditions such as HIV infection or malignancy, and patients with functional or anatomic asplenia, CSF leaks, or cochlear implants. The other brand-new immunization recommendation applies to influenza vaccine for children 2 through 8 years of age. While the recommendation continues that all children six months of age and older be immunized every year with influenza vaccine, for the 2 through 8 year olds there is now a stated preference that they receive the live at-

tenuated (nasal) vaccine (Flumist) (MMWR 2014; 63:691-697). This recommendation is based on several studies that show better protection with the nasal vaccine for this age group. When both vaccines are available, providers should give the nasal vaccine preferentially. However, it is extremely important not to miss opportunities to provide influenza vaccine, so if your office only has the injectable vaccine, that should be used rather than waiting for a later opportunity to give the nasal vaccine. Also important is the fact that for older children and adults there is no clear data demonstrating that one vaccine is superior to the other, so, for these groups, you can continue to use either vaccine based on your and the patient’s preference. The last relatively new immunization recommendation is for patients with diabetes who we now know are at increased risk for acquiring hepatitis B infection, mostly through inappropriate use of shared blood glucose monitoring equipment. This is a particular problem in assisted-living and long-term care facilities. Because of this newly identified risk, newly diagnosed patients with diabetes who are under 60 years of age should be getting the threedose hepatitis B vaccine to protect them (MMWR 2011;60:1709-1711). Older patients can also be immunized, but their immune response may be less, so the target population for this recommendation is patients with newly diagnosed diabetes who are under 60 years of age. More vaccines are coming. There should be a new 9-valent human papilloma virus vaccine available in 2015, which will provide us a way to prevent even more cancers caused by this virus. Work is underway on other new vaccines, with a focus on adults. While we wait for these exciting developments, let’s all increase our efforts to deliver the vaccines we have right now. Vaccines are one of the most cost-effective prevention strategies we have. Use them! Dr. Peters, SDCMS-CMA member for 17 years, is board-certified in family medicine and sits on SDCMS’ GERM Commission. Dr. Sawyer is with the UCSD School of Medicine and Rady Children’s Hospital, and sits on SDCMS’ GERM Commission as well. SAN DI EGO PHYSICIAN.org 19

infectious

disease

Pertussis San Diego County Update By Eric McDonald, MD, MPH, and Karen Waters-Montijo, MPH San Diego and other California counties are now experiencing a pertussis epidemic that began in late 2013. The ongoing cases are requiring significant resources from medical providers, public health, and families as they work together to combat an illness that just a few years ago seemed a well-controlled childhood disease. Outbreaks have been reported in elementary, middle, and high schools throughout the county and the state. For the first nine months of 2014, the San Diego County Health and Human Services Agency has confirmed 1,429 cases, with a countywide rate of 44.9 cases per 100,000. During the 2010 pertussis epidemic, 1,179 local cases were reported. Overall pertussis rates have been highest for infants less than one year of age and adolescents 10–17 years of age. Thirty San Diegans have been hospitalized, but none have died. As of Sept. 15, 2014, the California Department of Public Health (CDPH) has re20 novem b er 2014

ported 8,278 cases with onset this year, with a statewide rate of 21.7 cases per 100,000. Of the reported cases statewide, 288 have been hospitalized, with 68 (24%) requiring intensive care. Case counts are updated every two weeks at the CDPH pertussis webpage: www. cdph.ca.gov/HealthInfo/discond/Pages/ Pertussis.aspx. Sadly, one death has been reported for 2014 in an infant who was five weeks old at the time of disease onset. There were two additional deaths in 2014 with disease onset in 2013. Both infants were less than two months of age when symptoms began. Pertussis is cyclical and peaks every 3–5 years as the numbers of susceptible persons in the population increase due to waning immunity following both vaccination and disease. Acellular pertussis vaccines in current use cause fewer reactions than the whole-cell vaccines, but they appear not to protect as long. Approximately 84% of cases reported in the current epidemic are fully immunized. Nevertheless, it is important to continue promoting the current recommendations for vaccine to avoid more severe impacts from pertussis. To manage this epidemic, the focus is on preventing infant morbidity and mortality. Young infants have the greatest risk for hospitalization and death from pertussis. Consequently, maternal immunization during pregnancy and immunization of family

members when new babies are born are critical. Every pregnant woman should get a Tdap in the third trimester of every pregnancy. The preferred time for pregnancy immunization is between 27 and 36 weeks of gestation, although immunization during other stages of pregnancy is safe. Pertussis antibodies transferred from vaccinated mothers to their infants will help protect them until they are old enough to be vaccinated. Women should be immunized regardless of prior Tdap history. Current data show that only 30% of pregnant women in California are receiving Tdap vaccine. It is important to convey to parents with newborns that the primary DTaP vaccine series is essential for reducing severe disease in young infants and should not be delayed. DTaP can be given to infants at an accelerated schedule, with the first dose given as early as six weeks of age. Even one dose of DTaP may offer some protection against fatal pertussis disease in infants. It may be many years before a new vaccine is available that conveys a longer lasting immunity to pertussis. As such, a “new normal” of higher rates of illness may persist in San Diego, the state, and the nation for some time. However, physicians working with families and public health professionals can mitigate the current epidemic by following these recommendations: • Encourage all individuals, especially pregnant women, to be up to date with current pertussis vaccination recommendations. • Assure that all healthcare employees are immunized against pertussis with Tdap. • Inquire about recent possible pertussis exposures in schools or community settings, and consider pertussis regardless of vaccination status when evaluating patients with respiratory symptoms. • Consider pertussis regardless of age when patients present with unexplained, persistent cough illness. Pertussis symptoms are generally milder in teens and adults, especially in those who have been vaccinated. • Be aware that the diagnosis of pertussis can be a challenge in young infants given that the cough may be undetectable or mild and fever is usually not present. Mild illness may quickly transform into respiratory distress and include apnea, hypoxia, or seizures. Delays in treatment may increase the risk of fatal illness in young infants, especially those younger than three months of age. More information about diagnosing pertussis in young infants is available at www.cdph.ca.gov/HealthInfo/discond/ Documents/CherryPertussisInYoungInfants2011-06-20.pdf.

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• Obtain a nasal aspirate (preferable) or nasopharyngeal swab for PCR testing and/ or culture when pertussis is in the differential diagnosis. Serologic tests are not recommended. • Initiate antibiotic treatment prior to obtaining test results in patients with a clinical history suggestive of pertussis or with risk factors for severe complications. Azithromycin is the preferred antibiotic because of efficacy and compliance and it is covered by Medi-Cal for both treatment and prevention of pertussis. • Instruct all patients diagnosed with pertussis to stay home from school or daycare until they have completed five days of antibiotics, and to avoid contact with infants and others susceptible to the disease. • Provide post-exposure prophylaxis (PEP) to all household contacts, caregivers, and other persons who have had direct contact with respiratory, oral, or nasal secretions from a symptomatic case, again regardless of vaccination status. PEP antibiotic treatment is the same as treatment for disease and should not be shortened. Additional diagnosis and treatment information may be found at www.cdph. ca.gov/HealthInfo/discond/Documents/CDPH_Pertussis_Quicksheet.pdf. For further information about pertussis, Tdap vaccine, and other vaccine-preventable diseases, please contact the HHSA Immunization Program at (866) 358-2966.

Table 1. Pertussis Cases by Calendar Year of Occurrence, San Diego County 2009–2014 YTD (as of 09/30/14)

1500

1,429 1200

1,179 900

600

431

400

300

164

144 0

2009

2010

2011

2012

2013

2014 YTD

Table 2. County of San Diego Pertussis Cases by Episode Month, 2009–2014 Calendar YTD (as of 09/30/14)

300

Dr. McDonald, SDCMS-CMA member for the past six years, has a three-year tenure with the County of San Diego and currently serves as the medical director of the HHSA Epidemiology and Immunization Services Branch (EISB) in the local health department. Ms. WatersMontijo serves as the chief of EISB and has worked for the county for the past 12 years.

250

200

150

100

JAN

FEB 2009

22 novem b er 2014

MAR

APR 2010

MAY JUNE

JUL

2011

2012

AUG

SEP 2013

OCT

NOV

2014 YTD

DEC

infectious

disease

Soft Cheeses From Mexico By Eric McDonald, MD, MPH, and Karen Waters-Montijo, MPH

Could This Be Making Your Patients Sick?

Note: The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

By Wilma J. Wooten, MD, MPH, Jessica Adam, MD, MPH, and Justine Kozo, MPH

to as queso fresco, is a popular, traditional, but potentially harmful food product consumed frequently in Hispanic communities. This highly favored cheese often is made with unpasteurized milk or stored unrefrigerated during transit; consequently, it can harbor harmful bacteria that can lead to foodborne illnesses and severe consequences among

24 novem b er 2014

Fresh cheese, commonly referred

persons with immunocompromised systems, pregnant women, children, persons with comorbidities, and older persons. Common bacteria isolated in these products include Salmonella, Listeria monocytogenes, and Mycobacterium bovis. Illnesses from these bacteria can result in fever, miscarriage, tuberculosis, and even death (1,2). The Centers for Disease Control and Preventionâ&#x20AC;&#x2122;s Morbidity and Mortality Weekly Report estimates that the incidence of L. monocytogenes (listeriosis) is ~24 times higher among pregnant Hispanic women. In that same report, four (33%) of 12 listeriosis outbreaks were linked to Mexicanstyle cheeses (3). In the San Diegoâ&#x20AC;&#x201C;Tijuana border region, considerable quantities are imported from Mexico, and this cheese is then sold or shared among families and other social networks (1,2). During 2004, two outbreaks of Salmonella disease occurred in San Diego County, resulting in 14 and 49 cases, respectively. The suspected exposure was unpasteurized cheese from Mexico, purchased from street vendors (1). In 2009, the Food and Drug Administration led a three-month enforcement and education effort at the San Ysidro Port of Entry to quantify the amount of cheese imported across the border and to provide information to border crossers regarding the health risks associated with queso fresco. During that period, >65,000 pounds of cheese were assessed, the majority of which were not labeled correctly or being stored at safe temperatures (4). Recently, the County of San Diego Public Health Services (PHS) Division in Health and Human Services Agency (HHSA) partnered with CDC to investigate the health risks from unpasteurized dairy products among Hispanics in San Diego and Los Angeles Counties and to identify public health messages about queso fresco for populations at risk. Activities included surveys of knowledge, attitudes, and behaviors, as well as focus group feedback about queso fresco. Preliminary findings indicate participants frequently consumed dairy products brought from Mexico. Many did not have a clear understanding of the pasteurization process and its association with cheese safety, or that bacterial contamination of queso fresco can lead to serious illness or miscarriage. Focus group participants indicated that physicians are a trusted source of information and food safety messages. Clinicians are encouraged to recognize their value as reliable sources of food safety messages and address such concerns with their patients, especially groups at high risk (e.g., pregnant women, children, and persons who are immunocompromised). Many organisms can cause foodborne illness; clinicians should be alert to the potential for a foodborne etiology among such patients and perform diagnostic testing. Suspected foodborne illness

should be reported to the local health department; clinicians should anticipate that any person with foodborne illness might be part of a more widespread disease outbreak. The Queso fresco Task Force The County Office of Border Health (see sidebar), within HHSA PHS, coordinates quarterly Queso fresco Task Force meetings. Established in 2003, the Task Force’s objective is to share information, discuss strategy, and provide education to the public to reduce the adverse public health impact of unpasteurized soft cheese commonly imported from Mexico. Member organizations represent different government sectors (e.g., law enforcement, ports of entry, public health, border health, and food and agriculture). For more information on this topic, please contact Justine Kozo, chief of the Office of Border Health, at (619) 692-6656 or at justine.kozo@ sdcounty.ca.gov. Dr. Wooten, SDCMS-CMA member for the past nine years, is the San Diego County public health officer and has worked for the County of San Diego for 13 years. Dr. Adam is a CDC Epidemic Intelligence Service (EIS) officer, stationed with PHS. CDC’s EIS Program is a

two-year postgraduate program of service and training in applied epidemiology (additional information is available at www.cdc.gov/eis/ index.html). Ms. Kozo has been the Chief of the Office of Border Health in HHSA/PHS for the past 2 1/2 years. References: 1. Kinde H, Mikolon A, Rodriguez-Lainz A, et al. Recovery of Salmonella, Listeria monocytogenes, and Mycobacterium bovis from cheese entering the United States through a noncommercial land port of entry. J Food Prot. 2007; 1:47–52. 2. Thornton AJ, Waterman SH. Crossing borders: unpasteurized cheese a public health challenge for Hispanic and US–Mexico binational communities. Clin Infect Dis. 2013; 57: v–vi. 3. CDC. Vital signs: Listeria illnesses, deaths, and outbreaks — United States, 2009–2011. MMWR Morbidity and Mortality Weekly Report. 2011 Jun 10;60(22):749-55. 4. Nguyen A, Cohen N, Hongjong G, et. Al. Knowledge, attitudes, and practices among border crossers during temporary enforcement of a formal entry requirement for Mexican-style soft cheeses, 2009. J Food Prot 2014; 77:1571–8.

The San Diego County Office of Border Health The County Office of Border Health facilitates communication and collaboration among local, state, and federal organizations working along the U.S.–Mexico border region. Since its creation in 1993, the office has worked on multiple endeavors, from participating in developing a cross-border laboratory specimen transfer protocol to setting up vaccination clinics in nontraditional settings to provide care for vulnerable populations during the 2009 influenza A (H1N1) pandemic and the 2010 pertussis epidemic. The Office of Border Health and the Epidemiology and Immunization Services Branch share space at the County Health Services Complex on Rosecrans Street in San Diego. Additionally, personnel from the Centers for Disease Control and Prevention’s U.S.–Mexico Unit are located in this facility.

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SAN DI EGO PHYSICIAN.org 25

classifieds PHYSICIAN POSITIONS available Superb Internal Medicine Opportunity: Internist (BC, BE) coastal North County available July 2015. Single specialty seven physician internal medicine group, well established and respected. With 30 years in the community, outpatient care only, minimal call, salary guarantee, income well over median range for internal medicine. Send CV to pkljol51@aol.com or call (760) 846-0464. [297] MEDICAL WEIGHT CLINIC NEEDS PARTTIME MD: Doctors Weight Clinic has an opening for a part-time physician in two of our locations. We have been in business for over 40 years with eight clinics. We provide FDAapproved medication, injections, and diet counseling. If this is a medical service that you would be interested in, please contact Joyce Simpson at (619) 669-1808. [292] 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 per-diem flexible schedules available at locations throughout San Diego. A national leader among community health centers, Family Health Centers of San Diego is a private, nonprofit community clinic organization that is an integral part of San Diego’s healthcare safety net. Since 1970, our mission has been to provide caring, affordable, high-quality healthcare and supportive services to everyone, with a special commitment to uninsured, low-income, and medically underserved persons. Every member of our team plays an important role in improving the health of our patients and community. We offer an excellent, comprehensive benefits package that includes malpractice coverage, NHSC loan repay eligibility, and much, much more! For more information, please call Anna Jameson at (619) 906-4591 or email ajameson@fhcsd. org. If you would like to fax your CV, fax it to (619) 876-4426. For more information and to apply, visit our website and apply online at www.fhcsd.org [046]

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) 504-5830 or at venk@gpeds.sdcoxmail.com. Salary $ 102–108,000 annually (equal to $130–135,000 full-time). [778] PRACTICES FOR SALE

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] PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com) is

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 novem b er 2014

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]

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 AVAILABLE IMMEDIATELY: 14ft x 12ft sunny room in a four-room office suite shared by a physician, several chiropractors, and an acupuncturist. Located upstairs in Cardiff Town Center at the corner of San Elijo Avenue and Birmingham Drive one-half mile off I-5 and across Coast Highway 101 from San Elijo State Beach. Take advantage of Seaside Market, numerous restaurants, a post office, and a public library either onsite or across the street. Call (760) 436-7464. [294] 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]

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) 8402400 or at (858) 452-0306. [153]

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]

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) 4557535 or (858) 320-0525 and ask for the secretary, Sandy. [127]

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]

NURSE PRACTITIONERS WANTED FOR OUR GROWING ORGANIZATION: See ad #046 under “PHYSICIAN POSITIONS AVAILABLE.”

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] 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] 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) 481-4888 or email mobyrne61@gmail.com. [252] SCRIPPS XIMED MEDICAL CENTER BLDG, LA JOLLA — OFFICE SPACE TO SUBLEASE 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. Full-day 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,

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 NURSE PRACTITIONER: Internal medicine, part-time position available. Seeking nurse practitioner with primary care and EHR experience. Private practice located in beautiful North San Diego County, single specialty group, collegial work environment. Please contact (619) 248-2324 or email resume to portofino3@aol.com. [296] PA NEEDED FOR DERMATOLOGY AND COSMETIC SURGERY PRACTICE IN ENCINITAS: Experience in general dermatology a must! Applicant must be knowledgeable in diagnosing and treating common dermatologic conditions, possess excellent interpersonal skills, be a caring and empathetic provider, and possess the highest of ethical standards. Being a team player and having a positive attitude is essential for success! Please send your CV and salary history to dana@doctorlashgari.com. We look forward to hearing from you! [290] 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,

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) 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) 9925330 or email drhunt@thehousecalldocs. com. Visit www.thehousecalldocs.com. [038] NONPHYSICIAN POSITIONS WANTED RECENTLY GRADUATED CERTIFIED MEDICAL ASSISTANT SEEKS PART-TIME POSITION IN NORTH COUNTY SAN DIEGO: Experienced in wound care, plastic surgery, orthopedics, surgical settings. Very knowledgeable, hard-working, dependable, team player, superb patient rapport, willing and eager to learn. Special interests in surgical setting or urgent care. Available afternoons or nights. Excellent references! Contact Carol at (442) 444-0621 or at cameer@juno.com. [293] MEDICAL EQUIPMENT PHYSICAL THERAPY EQUIPMENT FOR SALE: Recently closed PT clinic is selling all existing equipment, therapy tables, supplies. Please email lisas@sdsm.net if you are interested. [291]

Place your ad here Contact Dari Pebdani at 858-231-1231 or DPebdani@sdcms.org SAN DI EGO PHYSICIAN.org 27

Personal & Professional Development

There is no such thing as work-life balance — there are work-life choices, and each choice has consequences.

Work-Life Choices What Are Yours? by Helane Fronek, MD, FACP, FACPh

Work-life balance is on the minds of many physicians, as we struggle with increasing data entry, insurance reporting requirements, and the ever-increasing knowledge we need to acquire and integrate into our practices. A Google search of “work-life balance” yields 150,000,000 entries. It’s clear that we haven’t found the answer to this dilemma! This is partly because we mistakenly imagine that “balance” is a state of perfect equilibrium, rather than a dynamic state requiring frequent assessment of changing priorities and shifts in our activities based on those changes. Another reason balance seems elusive is that, as Jack Welch, the success28 novem b er 2014

ful former CEO of General Electric, likes to say, there is no such thing as work-life balance — there are work-life choices, and each choice has consequences. This places the responsibility and the power directly in our court. For this reason, the participants in SDCMS’ workshop on Work-Life Balance this past Oct. 11 began with a guided meditation to create a vision of what their balanced life would be like, and how they would be different in that ideal life. Participants noticed a variety of activities that they yearned for and found a greater sense of peace and choice in these lives, signaling the direction of the change they were seeking. This

was followed by activities to discover what creates balance — our true values — those principles or activities that make life worth living and make it our life and not someone else’s. We are often surprised at what creates the most precious events of our lives — the awe of nature, our empowerment of others, completion of a difficult task. It’s sobering to realize that these values are no longer showing up in our lives as frequently as we would like. We finished with a series of tools to help us create the lives we yearn for: communication skills, a protocol to delegate effectively, and comfortable ways to say “no” that honor our values while showing respect to those

we must disappoint. The commonality of concerns was striking — one primary care physician was surprised that specialists felt the same stress she did. This realization enhances our sense of community, diminishes our isolation, and increases our compassion for our colleagues. Another physician appreciated the guided meditation and will perhaps add this to his busy life. Meditation, or any form of mindfulness practice, has been shown to positively impact productivity and performance, decrease stress and burnout, and build resilience. Participants also saw that significant shifts begin with small transitions and were encouraged to pick one or two changes to start. Most appreciated taking three hours to look at their lives in a safe environment in which to voice concerns and frustrations, where the emphasis was not on continuing to feel like a victim but on finding opportunities for taking charge and wielding the power that we each have to create lives of greater fulfillment. Given the success of the workshop, SDCMS plans to offer it again in 2015. Look for the announcement in “News You Can Use” in the next few months. 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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