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august
Contents
Volume 102, Number 8
EDITOR: James Santiago Grisolía, MD MANAGING EDITOR: Kyle Lewis EDITORIAL BOARD: Sherry L. Franklin, MD • James Santiago Grisolía, MD • Theodore M. Mazer, MD • Robert E. Peters, MD, PhD • David M. Priver, MD MARKETING & PRODUCTION MANAGER: Jennifer Rohr SALES DIRECTOR: Dari Pebdani ART DIRECTOR: Lisa Williams COPY EDITOR: Adam Elder OFFICERS President: William T-C Tseng, MD, MPH President-elect: Mihir Y. Parikh, MD Secretary: Mark W. Sornson, MD Treasurer: David E. J. Bazzo, MD, FAAFP Immediate Past President: J. Steven Poceta, MD GEOGRAPHIC and GEOGRAPHIC ALTERNATE DIRECTORS East County: Susan Kaweski, MD (Alt.) • Jay P. Mongiardo, MD • Alexandra E. Page, MD • Venu Prabaker, MD Hillcrest: Gregory M. Balourdas, MD • Kyle P. Edmonds, MD (Alt.) • Thomas C. Lian, MD Kearny Mesa: Sergio R. Flores, MD • John G. Lane, MD • Anthony E. Magit, MD (Alt.) • Eileen R. Quintela, MD (Alt.) La Jolla: Geva E. Mannor, MD, MPH • Marc M. Sedwitz, MD, FACS • Wayne C. Sun, MD (Alt.) North County: Neelima V. Chu, MD (Alt.) • Michael A. Lobatz, MD • Eileen S. Natuzzi, MD • Patrick A. Tellez, MD South Bay: Elizabeth Lozada-Pastorio, MD (Alt.) • Reno D. Tiangco, MD • Michael H. Verdolin, MD
features
12
She Said, He Said, He Said: Who Decides?
10
Y PAULA GOODMAN-CREWS, MSW, B LCSW
18
The Role of the Hospital-based Physician in Organ Donation Y ROBERT W. STEINER, JR, MD, AND B DONALD B. STOUDER, DMIN, PCS
departments 4
Briefly Noted: Calendar • Welcome New & Returning Members • Volunteer Opportunity • Medicine & Poetry • Featured Member • Save the Date: Nov. 18 Physician Networking Opportunity & Mixer • And More …
8 Exclusions (4th in Our Series on Compliance Programs) BY HEIDI KOCHER, ESQ.
AT-LARGE and AT-LARGE ALTERNATE DIRECTORS Lase A. Ajayi, MD • Karrar H. Ali DO, MPH • Steven L-W. Chen, MD, FACS, MBA (Alt.) • Stephen R. Hayden, MD • Phil Kumar, MD (Alt.) • Vimal I. Nanavati, MD, FACC, FSCAI (Alt.) • Robert E. Peters, MD, PhD (Alt.) (Delegation Chair) • Carl A. Powell, DO (Alt.) • Peter O. Raudaskoski, MD • Kosala Samarasinghe, MD • Thomas J. Savides, MD • James H. Schultz Jr., MD, MBA, FAAFP (Board Rep) • Karl E. Steinberg, MD, FAAFP (Alt.) • Erin L. Whitaker, MD (Alt.) • Marci M. Wilson, MD (Alt.) • Holly B. Yang, MD (Board Rep) OTHER VOTING MEMBERS Communications Chair: Sherry L. Franklin, MD Young Physician Director: Edwin S. Chen, MD Resident Physician Director: Michael C. Hann, MD Retired Physician Director: Rosemarie M. Johnson, MD Medical Student Director: Sandeep Prabhu OTHER NONVOTING MEMBERS Young Physician Alternate Director: Heidi M. Meyer, MD Resident Physician Alternate Director: Quinn C. Meisinger, MD Retired Physician Alternate Director: Mitsuo Tomita, MD SDCMS Foundation President: Albert Ray, MD (CMA Trustee, AMA Delegate) CMA Speaker: Theodore M. Mazer, MD (AMA Alternate Delegate) CMA Past Presidents: James T. Hay, MD (AMA Delegate) • Robert E. Hertzka, MD (Legislative Committee Chair, AMA Delegate) • Ralph R. Ocampo, MD, FACS CMA Trustee: Bob E. Wailes, MD AMA Alternate Delegate: Lisa S. Miller, MD
10
Boost Patient Safety: How Doctors Can Reduce Risks With Vaccinations
BY THE DOCTORS COMPANY
26
Physician Marketplace: Classifieds
28
28 2
august 2015
The Ethics and Heart of Accountability
BY HELANE FRONEK, MD, FACP, FACPh
Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org. All advertising inquiries can be sent to DPebdani@SDCMS.org. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]
/////////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.
ICD-10-CM Code Set Boot Camp (course) AUG 27–28: 8:00am– 5:00pm HIPAA Compliance in the Age of EHRs (webinar) SEP 10: 12:15pm–1:15pm Resident & Retired Physician Networking Opportunity and Mixer (social) SEP 18: 5:00pm– 8:00pm 10th Annual San Diego Emergency Care Summit (conference) OCT 15: 7:00am– 3:30pm All Physician Networking Opportunity & Mixer (social) NOV 18: 5–8pm at the Handlery Hotel in Mission Valley
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. The California Heart Rhythm Symposium SEP 11–12 at The Omni in San Diego Early Childhood Mental Health “We Can’t Wait” Conference SEP 17–19 at the Crowne Plaza Hotel in San Diego New Advances in Inflammatory Bowel Disease SEP 19–20 at the Hilton San Diego/Del Mar Advanced Therapeutic Interventions to Optimize Obesity and Diabetes Care SEP 25–26 at the San Diego Marriott La Jolla Transforming Medicine: Evidence-Driven mHealth SEP 30–OCT 2 at the Scripps Institution of Oceanography, Seaside Forum, La Jolla
Scripps Cancer Care Symposium: A Nursing & Advanced Practice Provider Collaboration OCT 2–3 at the Doubletree San Diego Mission Valley People, Planet, Purpose: Global Practitioners United in Health & Healing OCT 24–29 at Paradise Point Resort, San Diego
UC San Diego Perinatal Symposium OCT 30 at the San Diego Marriott Del Mar SCOPE of Pain: Safe and Competent Opioid Prescribing Education NOV 6 at the Catamaran Resort Hotel and Spa, San Diego The 2015 San Diego Day of Trauma NOV 6 at the Kona Kai Resort, San Diego Surgical Stabilization and Rehabilitation of the Unstable Shoulder NOV 18 at Scripps Green Hospital
VOLUNTEER opportunity SDCMS Foundation Project Access: Volunteer specialty physicians are needed for the following specialties: gynecology, pulmonology, urology, general surgery, ENT or head and neck, ophthalmology, GI, rheumatology, and endocrinology. We are seeking these specialists throughout all regions of San Diego. Commitment can vary by practice. The mission of the SDCMS Foundation’s 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 Barbara Mandel at (858) 300-2780 or email Barbara.Mandel@SDCMS.org, or visit our website at www.SDCMSF.org.
august 2015
“
“Don’t ever take a fence down until you know why it was put up.
Cardiovascular Interventions OCT 27–30 at the Hilton La Jolla Torrey Pines
giving back
4
quote of the month
”
— Robert Frost, Poet, Playwright (1874–1963)
SDCMS-CMA Membership
Welcome New and Returning SDCMS-CMA Members! New Members Nancy F. CrumCianflone, MD, MPH Infectious Disease Poway (619) 298-1443 Nathan P. H. Freeman, MD Family Medicine San Diego (619) 499-2600 Garth R. Jacobsen, MD General Surgery San Diego (858) 784-1898 Enchanta LM Jenkins, MD Obstetrics and Gynecology Fallbrook (760) 622-2985 Scott K. McClatchey, MD Pediatric Ophthalmology San Diego (619) 532-6700 Amir D. Meram, MD Family Medicine La Mesa (888) 664-8297
Chad R. Newell, MD Pediatrics San Diego (800) 290-5000 Bianca A. Tribuzio, DO Pain Medicine San Diego (858) 653-6137 James J. Urbanic, MD Radiation Oncology Carlsbad (858) 246-0500 RETURNING Members Kenneth A. Altschuler, MD Family Medicine La Mesa (858) 499-2715 Sabrina G. Fabi, MD Dermatology San Diego (858) 657-1002 David M. Kupfer, MD Plastic Surgery San Diego (858) 560-0242 Susan E. Trompeter, MD Internal Medicine Rancho Santa Fe (858) 552-8585
///////////////////////////////////////////////////////////////////////////////////////////////////
TrusT
medicine & poetry
Why Are We Here?
By Dolores H. Pretorius, MD, Six-year Member of SDCMS-CMA and Professor of Radiology at UC San Diego
This poem was written for the Ultrasound Team at UC San Diego to remind us of how we work together to provide optimal patient care. I think sometimes we forget that each one of us, from administrator, to doctor, to sonographer, to researcher, to secretary, has a job that is very special and that, when we work together, we can really make a difference.
We must stop and pause. We need to ask ourselves: “Why are we here?” And when we have landed on an answer, We must keep our eye on the ball. As I see it, we are here to care for patients. Some of us focus on caring for patients today While others work for dreams of future advances. Many work to educate the providers of tomorrow. We come from varied backgrounds, With a colorful array of aspirations for our lives. We each see the world a little differently; That is what makes us robust as a team. We all work hard, sometimes harder than other times. Our pathways have twists and turns. For life is not fair; it will never be so. But that’s okay. Through opposition, We learn to ponder, We are forced to grow, And great insight often follows. We can still come together as a team. We can help each other through the thick and the thin. For likely, we will all have thick and thin. And along the way we can change and be more. We study from books, from journals, from computers. We learn from mentors, from peers, from staff. We do research, we create lectures, we teach. We set the foundation for the running of clinics, of hospitals.
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Some come initially to make a living for their families, Some yearn for knowledge, Some find purpose in touching patients or team members. Some find the excitement of helping others intoxicating. We make friends along the way, We grow, mature and find our way. We learn to respect each other, As well as ourselves.
Endorsed by
And so, as we pause and reflect, And ask ourselves, “Why are we here?” We must answer, “To care for those who need us.” Yes, sometimes we must pause to keep our eye on the ball. SAN DIEGO PHYSICIAN.org
5
/////////Briefly /////////////////Noted //////////////////////////////////////////////////////////////////////// featured member
RICHARD O. BUTCHER, MD The National Medical Association (www. nmanet.org) has awarded longtime SDCMS-CMA member physician Dr. Richard O. Butcher its prestigious Practitioner of the Year Award. Dr. Butcher, who joined SDCMS in 1969, is an institution in San Diego’s medical, philanthropic, and sports communities. He’s been in private practice in southeastern San Diego for decades. He is president of the Care View Medical Group and past chief of staff at Alvarado Hospital. He is as well past president of the San Diego County Medical Society and has served on many boards. Dr. Butcher has been a local champion on a variety of fronts combating chronic disease in low-income neighborhoods. African Americans have the highest rates of these diseases locally and across the country. For example, African Americans who live in southeastern San Diego are nearly 80% more likely to die from diabetes compared to all county residents. He co-led the effort to create the Multicultural Health Foundation (mhfwellness. org), which is dedicated to finding community-based, innovative solutions to health disparities in the San Diego region. “We believe that when the history of this dynamic period of struggle is written, your name will be deeply etched in its fabric as having inspired and challenged physicians and medical professionals nationwide to address critical issues of healthcare and medicine,” said Dr. Lawrence Sanders Jr., president of the National Medical Association, in a statement announcing the award. Dr. Butcher and his wife are community leaders for local and international causes. The couple co-founded the nonprofit organization Water for Children Africa (www. waterforchildrenafrica.org), which provides safe, sustainable water to rural villages in Africa, in addition to educating people about hygiene. He has volunteered as the team doctor for Granite Hills High School for more than
6
august 2015
Right, L–R: Dr. Lawrence Sanders Jr., Immediate Past President, NMA, Dr. Richard Butcher, and Dr. Garfield Clunie, Board Chairman, NMA
L–R: Dr. Richard Butcher, Ms. Crystal Butcher, Mrs. Vickie Butcher, and Mr. Richard Butcher II
35 years and as the general physician for the Amateur Boxing Association of San Diego. Dr. Butcher received his award on Aug. 1 in Detroit, where the National Medical Association held its national convention. Representing 30,000 African American physicians, the 120-year association is the nation’s oldest and largest organization representing African American doctors and health professionals in the country. Congratulations, Dr. Butcher!
Above, L–R: Dr. Richard Butcher and Dr. Rodney Hood
///////////////////////////////////////////////////////////////////////////////////////////////////
SAVE THE DATE!
2015
San Diego County Medical Society Physician Networking Opportunity and Mixer The San Diego County Medical Society will be hosting a Physician Networking Opportunity and Mixer on Wednesday, Nov. 18 from 5 to 8 p.m. The reception will take place at the Handlery Hotel, centrally located in Mission Valley. This event will provide an opportunity for physicians to learn about companies that offer practice management resources. Physicians (both SDCMS members and nonmembers) are encouraged to attend. Complimentary beer, wine, and light hors d’oeuvres will be served. There will be raffle prizes offered by the participating vendors.
Please contact Dari Pebdani if you are interested in being an event sponsor at (858) 231-1231.
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7
C o m p l i a n c e P r o g r a m s — 4th i n a s e r i e s
Exclusions by Heidi Kocher, Esq.
Last month we reviewed the importance of certain basic written policies and procedures, and their importance to a compliance program. One of those important policies is the one regarding exclusions and sanction screening. Accordingly, this month we will review what exclusions are and why physicians should be concerned about them. Next month we will discuss how to perform exclusions/sanctions screenings. In basic terms, the federal government has the ability to “exclude” individuals and entities from participating in federally funded healthcare programs [42 USC 1320a-7]. Federally funded healthcare programs include not only Medicare and Medicaid, but also TRICARE/CHAMPUS, CHIP, Indian Health Program, Railroad Retirement Program, Black Lung Program,
8
august 2015
and a few other smaller programs. Note that many states have virtually identical laws that allow states to exclude an individual or entity from participating in state-funded healthcare programs, such as Medicaid and CHIP. Exclusion is an administrative action taken by the Office of Inspector General of the U.S. Department of Health and Human Services. If a person or entity is excluded, no payment from a federally funded healthcare program (or state healthcare program) may be made to reimburse the individual or entity for services provided [OIG Special Advisory Bulletin, The Effect of Exclusion From Participation in Federal Health Care Programs, September 1999, updated on May 8, 2013 (both bulletins available at http://oig.hhs.gov/exclusions/advisories.
asp)]. This applies whether the payment is made directly to the individual or entity or to a separate person or entity, such as a person’s employer or another entity under assignment. Furthermore, the rule applies whether the federal or state payer is primary or secondary. Therefore, exclusion is what I call the “death penalty” punishment. An excluded physician may also not write prescriptions or make referrals for items or services that may be reimbursed by a federal or state healthcare program. This places an additional burden on entities such as hospitals, pharmacies, medical device and durable medical equipment companies, and home health agencies, in particular, to ensure that none of their referring or prescribing physicians is excluded. Exclusion can occur for a number of reasons as listed in the law and depending on the underlying reason for the exclusion. They are divided into “mandatory exclusions” and “permissive exclusions” [42 USC 1320a-7(a), (b) and (c)]. Mandatory exclusions are those where the OIG has no discretion. The law states the OIG must exclude the individual. In contrast, permissive exclusions permit the OIG to exercise some discretion determining whether to exclude. Under both mandatory and permissive exclusions, the law specifies minimum exclusion time periods. On page 9 is a table of the types of exclusions (mandatory or permissive), the underlying reason for the exclusion, and the minimum exclusion period. Note that all exclusions are effective prior to a hearing, except for exclusions imposed for fraud, kickbacks, and other prohibited activities and those imposed on rural physicians in relation to failure to meet statutory obligations to provide medically necessary services meeting professionally recognized standards of healthcare. There are three types of exclusions that are most common to physicians. The first is exclusion relating to license revocation or suspension. Also included in this category is surrender of a license. What often happens is a physician is facing a matter in a state where the physician no longer normally practices (perhaps a state where the physician went to medical school or residency). The physician decides to avoid the cost and effort of fighting the licensure action in the other state and surrenders that license. The collateral effect of such licensure surrender is invariably an OIG exclusion and usually a domino effect on the physician’s licensure status in all other states where he or she is licensed. The second is a misdemeanor conviction relating to a controlled substance or alcohol, such as driving under the influence. Here
Type of Exclusion
Underlying Reason for Exclusion
Minimum Exclusion Period
Mandatory
Conviction of program-related crimes
5 Years
Mandatory
Conviction relating to patient abuse or neglect
5 Years
Mandatory
Felony conviction relating to healthcare fraud
5 Years
Mandatory
Felony conviction relating to controlled substances
5 Years
Mandatory
Conviction of 2 mandatory exclusion offenses
10 Years
Mandatory
Conviction of 3 mandatory exclusion offenses
Permanent
Permissive
Misdemeanor conviction relating to healthcare fraud
3 Years
Permissive
Conviction relating to fraud in non-healthcare programs
3 Years
Permissive
Conviction relating to obstruction of an investigation
3 Years
Permissive
Misdemeanor conviction relating to a controlled substance
3 Years
Permissive
License revocation or suspension
At least the length of time imposed by the state licensing authority
Permissive
Exclusion or suspension under federal or state healthcare program
At least the length of time imposed by federal or state healthcare program
Permissive
Claims for excessive charges, unnecessary services, or services that fail to meet professionally recognized standards of healthcare, or failure of an hmo to furnish medically necessary services
1 Year
Permissive
Fraud, kickbacks, and other prohibited activities
No minimum
Permissive
Entities controlled by a sanctioned individual
Minimum length same as length of individual’s exclusion
Permissive
Entities controlled by family or household member of an excluded individual and where there has been a transfer of ownership or control
Minimum length same as length of individual’s exclusion
Permissive
Failure to disclose required information, supply requested information on subcontractor or supplier, or supply payment information
None
Permissive
Failure to grant immediate access to records
None
Permissive
Failure to take corrective action
None
Permissive
Default on health education loan or scholarship obligations
Until default has been cured or obligations have been resolved to public health service’s satisfaction
Permissive
Individuals controlling a sanctioned entity
Same length as entity
Permissive
Making false statements or misrepresentations of material fact
None
Permissive
Failure to meet statutory obligations of practitioners and providers to provide medically necessary services meeting professionally recognized standards of health care (peer review organization findings)
1 Year
Once an individual’s period of exclusion has run, reinstatement to federally funded healthcare programs is not automatic.
the physician usually agrees to a plea deal to avoid trial on more serious charges. Unfortunately, the physician is often represented by a criminal defense attorney who is not knowledgeable about the collateral effects of a plea deal. And just because exclusion relating to a misdemeanor controlledsubstance conviction is listed in the law as “permissive” does not mean that the OIG will forgo exclusion. I personally have never seen the OIG forgo exclusion of an individual who was convicted of a misdemeanor controlled-substances or alcohol offense. The final, most common reason for exclusion of a physician is default on a Health Education Assistance Loan (HEAL) program. These were federally insured loans for students in various health programs. The last loans were issued in 1998. The problem with the defaults under the HEAL program is that a borrower is considered to remain in default until the entire loan is paid off or the individual negotiates a settlement with the Department of Justice. (As a collateral effect, default on a HEAL loan often also triggers a state licensure action, which, as noted above, is an independent reason for OIG exclusion.) Once an individual’s period of exclusion has run, reinstatement to federally funded healthcare programs is not automatic. The individual must send a written request to the OIG, which will send the required forms. Once the completed notarized forms are returned to the OIG, the agency will evaluate the information and issue a decision. The process normally takes approximately 120 days. If the reinstatement request is denied, the individual may apply again in a year. Note that obtaining a provider number from Medicare or another federal agency does not constitute reinstatement of the individual’s ability to participate in federally funded healthcare programs. As you can see, exclusion is a very serious issue and is not to be taken lightly. Therefore, physician practices and all other healthcare providers should routinely screen for excluded individuals. How to conduct sanctions screening will be next month’s topic. Ms. Kocher is counsel with the law firm of Liles Parker. In addition to serving as a chief compliance officer and chief privacy officer, she has almost 20 years of experience advising and defending clients on legal and regulatory matters affecting providers of all sizes. Ms. Kocher can be reached at hkocher@lilesparker.com or (214) 952-5169. SAN DIEGO PHYSICIAN.org
9
R i s k M a n ag e m e n t
Boost Patient Safety How Doctors Can Reduce Risks With Vaccinations
by Debbie Hill, RN, MBA, CPHRM, and Lisa McCorkle, MSN, CPHRM, Patient Safety Risk Managers, SDCMS-endorsed The Doctors Company For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.
10
august 2015
August is National Immunization Awareness Month, and with the recent outbreak of measles leading to proposed changes in vaccination laws across the country, including passage of new legislation in California, vaccinations remain a hot topic. Physicians should always be attentive to the importance of timely vaccines against infectious diseases for patients of all ages. Whether you’re seeing children for back-toschool immunizations or adults for travel abroad or general disease prevention, take time to assess the vaccine administration protocol in your practice to reduce risks and enhance patient safety. Vaccine administration is usually regarded as a simple office procedure, often performed without the direct supervision of the physician or a licensed professional. Although vaccinations are a routine procedure, physicians and staff should remain vigilant about patient safety considerations. As with any medical intervention, the risks, benefits, and alternatives of the vaccination must be discussed and documented in the medical record, as well as ensuring that safety protocols are followed. The Doctors Company performed a closed claims analysis of vaccine-related events in the medical office setting. Could similar situations occur in your office?
Parents should be reminded to alert medical personnel of their child’s immunization status each time the child seeks healthcare in case distinctive care is needed. • Missed Vaccination: A 4.5-month-old male infant received the pneumococcal conjugate vaccine (PCV) Prevnar 7, which provided protection against seven serotypes of pneumococcus. The following year, the FDA approved the use of Prevnar 13, which provided protection against an additional six serotypes of the disease. The American Academy of Pediatrics recommended that those vaccinated with Prevnar 7 also receive Prevnar 13. The physician did not update recommended immunization protocols in her office, and even though the child returned for three additional well visits, the child never received Prevnar 13. At age 39 months, the child developed serotype 6A pneumococcal meningitis, which resulted in left hemiparesis, seizures, and vision and hearing impairment. This disease could have been prevented if the child had received Prevnar 13. • Dental Injury: A 13-year-old female received a Gardisil vaccine. Even though her mother was monitoring her in the exam room, the patient fainted and fell off the exam table, resulting in a tooth avulsion, another tooth luxation, a fractured wrist, and a laceration to her hand. • Injection Site Reaction: A 35-year-old female complained of redness and swelling at the injection site for a flu vaccine, interfering with her ability to perform her job over the course of several months and resulting in several weeks of physical therapy. No informed consent was obtained. She stated she would never have had the injection had she known of the potential complications. • Vaccination Overdose: A 41-year-old female with a history of ankylosing spondylitis requested a pneumovax vaccination. No informed consent was obtained. The patient was queried regarding whether she had previously received pneumovax, which the patient denied. Actual vaccination status was never verified by the physician; however, the patient had actually received the vaccine two years earlier. The patient developed inflammatory response syndrome, including the amputation of a toe, which was alleged to have resulted from administering the vaccine without checking her
immunization history and because the vaccine was not indicated for patients younger than 65 years old. Take these steps to reduce liability risks and promote patient safety in your practice: • Ensure that immunization tracking is up to date and well documented in the medical record so that patients remain on schedule. Obtain copies of vaccination records from previous providers or state registries. Create easy-to-read office forms for documenting administration. • Educate patients and parents regarding vaccination schedules. • Designate a staff member to monitor for revisions/new recommendations of FDA/ CDC vaccination schedules. Ensure that new vaccination schedules are incorporated with office procedures and are included on office vaccination forms. • Provide accurate information to patients. Conduct and document a thorough informed consent discussion; use Vaccine Information Statements prior to vaccine administration. • Obtain patient or parent signatures on an informed consent form that includes potential side effects and complications. • Document the discussion in the progress notes when the immunization is refused. Consider using an informed refusal form, which includes the patient or parent signature. • Check state laws regarding exemptions, and educate patients. Be aware that religious and philosophical exemptions vary by state. • Monitor patients closely post-administration for anaphylaxis, vasovagal response, and reaction at the injection site. Document any reactions, suspected side effects, and complications in the medical record. • Educate staff and conduct skills verification on accepted procedures, new standards, and risk prevention methods. Document these efforts in administrative training files. • Store and handle vaccinations in accordance with Vaccines for Children/CDC guidelines. Monitor these practices with staff — don’t just assume they are being
followed correctly. • Follow basic medication administration safety protocols for vaccine administration. Be aware of the most common vaccine-related errors by reviewing “Confusion Abounds! 2-Year Summary of the ISMP National Vaccine Errors Reporting Program” Part I and Part II. • Be responsive to patients who express concerns about reactions from their vaccines. Document these discussions in the medical record. • Report errors or hazards (anonymously) to the ISMP National Vaccine Errors Reporting Program. It is a physician’s obligation to talk with all patients (or their guardians) about what could happen if they decline vaccination. This discussion should include these points: • Not vaccinating can result in disease or even death. • Unvaccinated children and adults pose a threat to the population of people unable to receive vaccinations due to weakened immune systems, such as those with leukemia, who rely on the general public being vaccinated to reduce their risk of exposure. • Social implications may include exclusion and quarantine. If there is an outbreak in a community, parents may be asked to remove their unvaccinated child from organized events and activities due to the threat of transmission. • Females of childbearing age who are unvaccinated and who become pregnant are vulnerable to diseases such as rubella, which can cause congenital rubella syndrome with congenital fetal anomalies. Parents should be reminded to alert medical personnel of their child’s immunization status each time the child seeks healthcare in case distinctive care is needed. Healthcare providers can help raise awareness of the benefits of immunizations. Use CDC materials to: • Encourage parents of young children to get immunizations by age two. • Help parents make sure older children have received vaccinations by the time they return to school. • Remind college students to get vaccinations before moving into dormitories. • Educate adults, including healthcare workers, about vaccines and boosters they may need. • Inform pregnant women about getting vaccinated to protect newborns from disease such as whooping cough. SAN DIEGO PHYSICIAN.org
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She Said, He Said, He Said M
“Death is not the greatest of evils; it is worse to want to die and not be able to.” — Sophocles
who decides?
by Paula Goodman-Crews, MSW, LC SW
rs. F is an 84-year-old female with end-stage renal disease (ESRD) who decides to stop dialysis after 18 months. She tells her son Fred — with whom she has lived for the past year — that she’s “done,” is depressed, and refuses to go to any more dialysis treatments. She opts for hospice. Mrs. F has no advance directive and never spoke about her preferences despite numerous attempts to do so by her healthcare providers and sons. Although Fred recognizes his mother is depressed because her quality of life has greatly diminished, he believes her decision to stop dialysis is rational and that the decision belongs to her. Fred, a self-described realist who loves his mother, facilitates a referral to hospice without consulting his brother, Barney. Mrs. F lived with her son Barney during the prior year. When Barney learns about his mother’s referral to hospice, he is aghast. He believes she is impressionable and too depressed to make decisions. Furthermore, Barney believes if his brother provided a better home environment, his mother would find good reason to live and continue dialysis. He accuses Fred of coercing his mother to stop dialysis and of not trying hard enough to convince her of life’s worth. Barney, a self-described optimist who loves his mother, “kidnaps” her from Fred’s home out of desperation and has her admitted to hospital in a different town. He asks that dialysis be reinstituted. When Mrs. F arrives at the hospital, she is not fully capacitated, as it has been five days since she received dialysis. Fred learns about his mother’s admission to the hospital and arrives at her bedside. He asks that the patient be released to his care under hospice. Fred confronts Barney about his interference, and a verbal confrontation ensues. Fred and Barney stop talking to each other and vie for control of their mother’s healthcare decisions. Both
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The attending physician, hardpressed to ignore what appears as a legitimate, informed refusal of dialysis, also believes she has a duty in the setting of conflict to explore the divergent opinions.
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brothers contact the physician. Fred is angry, disgruntled, difficult to engage, and believes we are violating his mother because dialysis is now being reconsidered. Barney is amiable, easily engaged, and believes we are violating his mother by not reconsidering dialysis. Now what?
Assess the Following: Is There Value Conflict? Uncertainty Regarding the Right Action? The case at hand represents a value conflict related to what is good for this patient. There are significant ethical questions, and a bioethics consultation will help to frame the case through an ethical lens in order to determine ethically reasonable and justifiable options. This is accomplished through an “ethics facilitation” approach that elucidates issues and ethical principles, aids in effective communication, integrates perspectives, and creates a plan that respects needs and values of those involved, all within the bounds of ethical and legal standards. Also consider that the goal of an ethics consultation is to help those involved reach a moral understanding that promotes the good of the patient. How should “patient good” be defined? Consider Pellegrino’s conception of the four realms of the patient’s good that are involved in healing. They include the patient’s biomedical good; the patient’s own conception of the good for him/her as an individual; his/her good as a member of the human species (i.e., the good for humans); and his/her good as a spiritual being (i.e., the good for the soul).
//////////////////////////////////////////////// Back to the Case — What Is “Good” for Mrs. F and How to Decide? The sons’ divergent opinions about what actions will promote the good of this patient are based upon differing values and beliefs about autonomy, non-maleficence, and beneficence, filtered by their individual relationships with her. The patient, albeit depressed, believes continued treatment is burdensome. Fred believes we have a duty to respect his mother’s dignity and autonomy by not burdening her with treatment she stated she does not want. Barney believes we have a duty to respect his mother’s dignity and autonomy by protecting her from a decision she made when she was too depressed to appreciate her life. The treatment team experiences collective moral uncertainty regarding the right action. The attending physician, hardpressed to ignore what appears as a legitimate, informed refusal of dialysis, also believes she has a duty in the setting of conflict to explore the divergent opinions. She believes also that the probability is of Mrs. F benefitting from dialysis to the extent she would recover consciousness after not having been dialyzed for five days. Two very opposing treatment goals are considered: 1. Maintain comfort-oriented goals of treatment; or 2. Reinstitute dialysis, if medically feasible, in an attempt for the patient to regain consciousness in order for her to participate in a conversation to readdress goals of treatment. She asks for an ethics consultation.
Frame the Ethical Questions Consider the following ethical questions that represent value perspectives as a starting point for our case: 1. Given disagreement among the patient’s sons regarding Mrs. F’s emotional state when she consented to hospice and stopped dialysis, is it ethically justifiable for son Barney to override patient’s putative informed consent? 2. Given that the patient declined dialysis, are providers ethically prohibited from reinstituting it? 3. Given that the patient was depressed, did this negate her capacity to participate in informed refusal of dialysis, to the extent that providers are ethically obligated to reinstate it? 4. If the patient was depressed to the extent she did not possess decisional capacity at the time she stopped dialysis, which of her sons should serve as the surrogate decisionmaker at this point in time?
What Do We Need to Know and How Do We Act on This? The following plan is devised: 1. Schedule an ethics consultation meeting with the patient’s sons, the attending physician, and the social worker to attempt to prevent further polarization and reach consensus regarding ethical duties to Mrs. F. 2. Contact the hospice RN who assessed Mrs. F and obtained her consent to accept hospice service. 3. Contact the patient’s nephrologist to learn if her nephrologist engaged in conversations with the patient that revealed values and beliefs that shaped her medical decisions, and his assessment of the patient’s mood.
The Ethics Consultation Meeting While the treatment team is inclined to honor the patient’s refusal of dialysis, as well as Fred’s substituted judgment, there are concerns that the negative bias that results from depression may have skewed the patient’s judgment about the worthiness of her life. Separate conversations with Fred and Barney occur, and each brother agrees to participate in an ethics consultation. However, within 20 minutes, with interests and positions becoming further polarized, Fred explodes and exits the room. Fred rejoins the meeting after recognizing that this process was about his mother and not his anger. While consensus regarding neither goals nor moral understanding between the brothers occurs, they share their distinct and rich narratives about their mother. We learn that mother placated both sons. She told Fred that her quality of life was poor and she was ready to let go. She told Barney that she was ambivalent. She “didn’t like when her boys fought.” We learn that Mrs. F never wanted to discuss advance care planning with her family and healthcare providers. We learn that Mrs. F married young, was highly dependent upon her husband until his death two years prior, and missed him deeply. She kept her emotions and inner thoughts to herself and was not easily read. There is no evidence the patient had a history of depression or other mental health issues. Over the past four months, Mrs. F was tired and achy, and had insomnia and overall malaise. Despite seeing her nephrologist to address her symptoms, nothing changed. Over a period of four months, she lacked the energy to engage in activities that gave her meaning. She became unable to leave the house to take walks or have her hair coifed at her hair salon. She stopped reading and was barely interested in watching television. She did not have a support network other than Fred and her adult grandchildren.
Conversations With the Nephrologist and Hospice RN A phone call to the patient’s nephrologist yielded little information. The patient was never interested in engaging in any advance care planning. The ethicist spoke with the RN who admitted the patient to hospice, on referral of her nephrologist. The RN believed the patient possessed the needed decisional capacity to withdraw from dialysis and to accept hospice. While the patient appeared somewhat depressed, the RN believed the depression was not sufficient to prevent the patient from making a rational decision about the risks and benefits of stopping dialysis. The RN believed a more complete assessment of the depression was not necessary.
Ethical Analysis Given disagreement among the patient’s sons regarding Mrs. F’s emotional state when she consented to hospice and stopped dialysis, is it ethically justifiable for son Barney to override the patient’s putative informed consent? Informed consent/refusal is the legal and ethical vehicle that upholds obligations to respect persons. Elements include the patient freely and voluntarily consenting or refusing consent; the adequate disclosure of information based upon the reasonable patient standard; patient freedom of choice; patient comprehension of information; patient capacity for decision-making. It is the obligation of the physician to determine if the patient has the requisite decisional capacity to participate in informed consent/refusal. Decisional capacity includes the ability of the patient to understand the information; to deliberate and appreciate benefits and harms based
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upon values and beliefs; and the ability to communicate response. Patients who do not have requisite capacity are, by definition, vulnerable and require protection. After learning more about Mrs. F’s life story and personality, and balancing it against her current condition, prognosis, and degree of suffering, the treatment team agree that the patient’s refusal of dialysis and acceptance of hospice is authentic, did not occur under coercion, and met the criteria for informed refusal. The patient expressed her voice and that voice was deemed legitimate. The only moral justification for overriding the patient’s consent was if the physician believed the informed consent process lacked integrity. Given that the patient declined dialysis, are providers ethically prohibited from reinstituting it? Patients possess negative rights to refuse treatment, as the desire to die, itself, is not considered evidence of a mental disorder, rather as an expression of self-governance. In medical settings, legal competence to refuse life-sustaining treatment is presumed, and the burden rests with the physician to prove otherwise. A capacitated patient, after balancing benefits, burdens of treatment, based upon one’s values, attitudes, and beliefs, can decide that treatment is burdensome even if death will result. It is the medical disease and not the decision that is causing death. The treatment team, while concerned that the patient’s depression was not fully evaluated, ultimately believe the patient had requisite decisional capacity to make an informed decision to decline dialysis. Under these circumstances, it would appear ethically indefensible to reinstitute it. Given patient was depressed, did this negate her capacity to participate in informed refusal of dialysis, to the extent that providers are ethically obligated to reinstate it? Decisional capacity is decision-specific, can be intermittent, and should not be conflated with legal incompetence. Patients with cognitive impairment may have capacity for some medical decisions but not others. Depressed patients do not, by definition, lack capacity. While depression can result in a gross distortion of cognition, negative bias, depressive helplessness, the undervaluing of life and survival and overvaluing of cessation of life, the obligation is to discern the extent of any impairment of decision-making in this particular patient. The determination of what is reasonable and rational is subject to wide variability of values and beliefs regarding the proper balance of the sanctity of life and conditions of futile suffering. The divergent opinions of her sons represented differences in the proper balance. In the case of Mrs. F, the treatment team was seeking evidence that her desire to stop dialysis was rooted in her longstanding values and was not the result of the disease of depression. A thorough evaluation did not occur. What was unknown to a large extent was how Mrs. F experienced her disease and the distinct values that shaped her beliefs about what was good for her. Was her decision to stop dialysis understandable in context? What was the meaning she assigned to her medical condition? Was she having unresolved pain? Spiritual pain? Did she recognize she was depressed, and might she have chosen psychotropic medication? What, really, was her experience of Fred’s home environment? Was she isolated? Did she believe she was a burden to Fred? Was she feeling dependent to the extent where she felt tremendous loss of control? How long did she ponder this decision? Ultimately, the
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treatment team needed to rely on the substituted judgment of one of the sons. The treatment team decides to rely upon the hospice RN’s assessment of patient’s capacity and the substituted judgment of Fred. There is not enough evidence to suggest Mrs. F’s depression was interfering with her capacity to appreciate the consequences of her decisions. While Barney’s narrative is credible, Fred had the most contact with the patient over the past year and experienced her suffering and her day-to-day experience. Moreover, the likelihood of the patient benefitting from dialysis is poor. Barney’s goal of his mother waking up to guide the team was felt to be highly unrealistic from a medical perspective. If the patient was depressed to the extent she did not possess decisional capacity at the time she stopped dialysis, which of her sons should serve as the surrogate decision-maker at this point in time? The autonomy of patients who cannot participate in informed consent is effectuated through surrogate decision-making. Cal. Prob. Code §4714: California Code — Section 4714 articulates, “A surrogate … shall make a healthcare decision in accordance with the patient’s individual healthcare instructions, if any, and other wishes to the extent known to the surrogate. Otherwise, the surrogate shall make the decision in accordance with the surrogate’s determination of the patient’s best interest. In determining the patient’s best interest, the surrogate shall consider the patient’s personal values to the extent known to the surrogate.” This is known as substituted judgment. California law does not provide a hierarchy of decision-makers. Next of kin is understood as family and can also include friends or neighbors. It is the responsibility of the treating physician to identify the best surrogate decision-maker. The treatment team, after evaluating the medical issues and the narratives of the sons, believe ultimately it is Fred who should serve as the surrogate decision-maker. Their decision is subjective, as both brothers fulfill the criteria as articulated in the Surrogate Selection Policy. It ultimately comes down to a leap of faith.
The Final Outcome A meeting was held the second day of the patient’s hospitalization, at which point the physician believes there was enough evidence to suggest that comfort care is the approach that best honors the patient’s precedent autonomy and what is “good” for her. The patient is transitioned to comfort care. Barney reluctantly agrees. The patient dies in the hospital two days later. In closing, the “doing” of ethics reflects law and ethical norms, some of which are subject to interpretation. Laws and ethical norms are not self-executing, and situations need to be interpreted and acted upon within the unique context of each case. Each case requires humility, curiosity, and recognition that there may not always be one right answer. Email Editor@SDCMS.org for the bibliography accompanying this article. Ms. Goodman-Crews is co-founder and co-chair of the SDCMS Bioethics Commission. She serves as the co-director of the Kaiser Permanente Southern California Bioethics Program and is the bioethics director at Kaiser Permanente in San Diego. Ms. GoodmanCrews has practiced clinical ethics for the past 17 years, having facilitated more than 1,200 bioethics consultations.
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The Role of the Hospital-based Physician in Organ Donation by Robert W. Steiner, Jr., MD, and Donald B. Stouder, DMin, PC S
W
ith almost 124,000 people in the United States on the waiting list for an organ transplant, the need for donors is great. Moreover, nearly 12.2 million Californians have registered to become organ donors in the event of their death. The hospital-based attending physician plays an important role in bringing potential donors and recipients together and in caring for potential donors, according to Jeanne Lee, MD, SDCMS-CMA member, UC San Diego trauma surgeon, and associate medical director of Lifesharing, San Diego’s organ procurement organization. “ED and ICU physicians can make or break the potential for organ donation in three crucial areas: calling Lifesharing at the appropriate time, preserving the option of donation with good medical management (including declaring death by whole brain criteria when appropriate), and collaborating with Lifesharing when approaching the family about donation.” According to Seth Krosner, MD, eight-year SDCMS-CMA member and trauma surgeon at Scripps Mercy Hospital, Life-
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Kyle Jackson
Just weeks before his 28th birthday, well-liked SDSU grad Kyle Jackson appeared to be sleeping. Friends called paramedics when they realized he had no pulse. He was anoxic and died a short time later at Scripps Memorial Hospital in La Jolla, as 60 family members, friends, and fraternity brothers gathered, hoping against hope he would survive. Like many of Lifesharing’s donors, Kyle’s death was sudden and unexpected. Like the majority of Lifesharing donors now, Kyle had registered in advance to be a donor at the DMV. “He never said anything to me about donating his organs,” recalls Gramma Betty Jean Moore. “And when I first heard about it, it just made my heart swell because that was the kind of individual Kyle was.” “He valued everybody,” says Cheri Pope, a friend. “To think he actually stopped to think, ‘Is this something I want to do?’ and then to check that box. For him I’m sure it was a very simple thing. He now has the ability to save lives, which is just amazing.” Another friend, Wes Merrit, added, “For those recipients, I really want them to know that they’re getting a part of somebody that they’re going to become more special. I don’t even think they know it yet. I think it is amazing he’s saving lives.” Kyle Jackson saved the lives of three people as an organ donor, gave sight to two, and will help heal up to 50 people as a tissue donor. He was honored in the Heroes Collage at the Padres Donate Life game in July. His mom and friends were there to honor him and the precious gift he gave others. In a touching tribute, friends also honored Kyle in a video played at his Celebration of Life, posted online at www.lifesharing.org/kyle.
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sharing is called rapidly (Medicare participation guidelines require notification within one hour) whenever a patient meets certain clinical triggers. “Our cues to call Lifesharing include ventilated patients with a neurological injury (including trauma, bleeds, or anoxia), any patient with return of pulse after CPR who remains unresponsive, and anytime a discussion of DNAR or compassionate extubation is taking place,” says Dr. Krosner. “Sometimes our staff will initiate the call right from the trauma bay,” he adds. “Most often, the call takes place after admission to the ICU.” Following the initial call, Lifesharing staff come onsite to evaluate for donation and, in most cases, will follow from a distance for hours or days until the prognosis becomes clear. Timely referral to organ procurement organizations is considered a national best practice, and improves both overall consent rates while increasing the organs transplanted per donor (OTPD). If a family begins to consider compassionate extubation, or if the patient appears dead by whole brain criteria, optimal medical management becomes critical in preserving organs for potential transplant. Additionally, if a family desires donation but has chosen DNAR, there can be a bit of a balancing act between honoring the DNAR decision and preserving the organs of a potential donor for transplant. “Optimal ICU care also means preserving the option of donation,” says Mathias Kill, MD, trauma surgeon at Sharp Memorial Hospital. “We do that by maintaining as normal a blood pressure as possible, normalizing electrolytes and body temperature, managing oxygenation and organ perfusion, and balancing intake and output,” he adds. Dr. Kill also believes that initiating brain death testing when appropriate not only opens a door to donation,
//////////////////////////////////////////////// How the ED or ICU Physician Can Help Use the acronym NURSE to remember the different steps:
N U R S
ORMALIZE Patient: Normalize the vital signs as best as possible. NDERSTAND Policy and Process: Hospital P&P and best practices.
EFER Rapidly: Refer any patients meeting the clinical cues for a consult.
UPPORT Family: Maintain good communication and support of the family. Refer for social services and spiritual care support as needed.
E
NSURE Donor Management: Initiate BD testing as appropriate, and do everything possible to optimize organ function.
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but brings comfort to many families. “It means that they do not have to take on the burden of making withdraw decisions, since the patient has already died or has no meaningful prognosis,” says Dr. Kill. “We follow hospital policy and state law when declaring death by whole brain criteria, affirm consent from the family, and only then rapidly initiate Lifesharing’s hormonal resuscitation protocols in
For Additional Information Lifesharing: A Donate Life Organization www.lifesharing.org
Organ Donation and Transplantation Alliance Hospital Clinician Toolbox www.organdonationalliance.org/ educational-resources/toolbox
Diagnosis of Brain Death Training Course: Free CME www.cchs.net/onlinelearning/ cometvs10/dncPortal/default.htm
Donate Life California: Donor Registry https://register donateLIFEcalifornia.org/register
order to preserve organs for transplant.” When families understand the good that can come from organ donation, they rarely say no to the opportunity. “Families hold on to Project4:Layout 1
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Dr. Steiner, 21-year member of SDCMS-CMA, has been full time at UC San Diego since 1978. He was the consulting nephrologist for 10 years for the Rees Stealy Medical group at Mercy and Sharp hospitals. Since 1990 he has specialized in transplant nephrology, and has been the medical director of Lifesharing since 1996. The Rev. Dr. Donald Stouder is a chaplain, crisis counselor, and educator working with organ donor families and healthcare professionals as a part of Lifesharing: A Donate Life Organization, in San Diego.
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any evidence of hope during traumatic times,” according to Susan Duthie, MD, 18-year member of SDCMS-CMA and medical director of the PICU at Rady Children’s Hospital. “They need to be sure that all interventions have been tried and not worked — that there is nothing else that can be done — before we have the donation conversation. When we do, we collaborate with Lifesharing to make a plan to approach the family.” Adds John Steele, MD, trauma program director at Palomar Hospital, “Even as an experienced and caring physician, I know that Lifesharing personnel have a better chance of being well received and increasing the chances of organ recovery if I defer to them to initiate the donation conversation.” In study after study, families say that having something good come out of their tragedy has assisted in their grieving process. Working in collaboration with Lifesharing, hospital-based physicians have a unique opportunity to help save lives through organ transplantation and help families work through some of the most difficult moments of their lives.
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august 2015
ORKS
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HEALTH HERO
SATURDAY, NOVEMBER 14 FLETCHER COVE, SOLANA BEACH
Physicians: You are a Health Role Model Model healthy living to patients and staff by inviting them to JOIN YOU at San Diego County Medical Society Foundation’s Solana Beach Sunset 5K Run/Walk November 14 at 3 PM! Lead a team of 20 or more patients and staff and receive FREE your own team t-shirts with your practice/team identification. For more information please contact Carlos Medina at carlos.medina@sdcms.org or 858.565.7930 Benefiting
Improving Health…Changing Lives
In Partnership With
Presented By
Special thanks to John Han, PharmD, Regents Pharmacy in La Jolla for his help to assure patients are able to comply with physician orders. Project Access recently partnered with Alison Gordon Cohn, MD, and Elizabeth Viriya, MD, of Gordon-Weiss-Schanzlin Vision Institute; ASMG; and Outpatient Surgery Center of La Jolla, to assure that eight patients regained their sight with cataract surgeries. But the necessary prescriptions would have cost Project Access a prohibitive $600 per patient! John Han was able to facilitate reduced cost prescriptions down to $175 per patient, a 70% savings! John and his wife also provide ongoing support for Project Access through their Charity Support Program; for each prescription filled by Regents Pharmacy for any of a provider’s patients, Regents will donate a small portion to help support prescriptions for Project Access’ uninsured patients. Since Regents both delivers and mails prescriptions, they are able to serve the entire county. For more information, contact SDCMS Foundation, or Regents Pharmacy at regentsrx.com, 858-281-5200. It takes the partnership of the entire medical community to reach our vision of improving health and changing lives. Thank you to all our Project Access San Diego physician volunteers, hospitals and surgery centers, and ancillary partners! With your help, we facilitated care for 821 uninsured patients in 2014, getting folks back to health, back to work and caring for their families, and improving their quality of life!
SAN DIEGO COUNTY MEDICAL SOCIETY FOUNDATION 5575 Ruffin Rd., Ste 250, San Diego, CA 92123 www.sdcmsf.org 858.300.2777
SAN DIEGO PHYSICIAN.org
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classifieds PHYSICIAN POSITIONS WANTED SHORT-TERM LOCUMS AVAILABLE! D. (Doyle) Eugene Johnson, family physician with a wealth of experience, looking for short-term locums, preferably in North County. Have been a full-time practicing certified family physician for 50+ years and would like to continue seeing patients on a part-time basis. Had one of the largest solo family practices in San Diego for 25+ years. Excellent references! Continually certified in family practice, ACLS, BLS, regularly use computerized records. Please email d.eugenejohnsonMD@gmail.com with particulars. [301] PHYSICIAN POSITIONS AVAILABLE SEEKING BOARD-CERTIFIED PEDIATRICIANS: UC San Diego, Dept. of Pediatrics, and Rady Children’s Hospital, San Diego, is seeking clinicians to provide patient care at the urgent care clinics of the Division of Emergency Medicine. Clinicians should be boardcertified pediatricians with a minimum of two years experience in general pediatrics/urgent care. RCHSD, a level-1 trauma center, is the major regional primary and tertiary pediatric hospital, and is the clinical home of UCSD Department of Pediatrics. The Division has a strong commitment to clinical care, teaching, and research. Interested persons should contact Dr. Katherine Konzen, Director, Pediatric Urgent Care, at kkonzen@rchsd.org. [398] SEEKING PART-TIME INTERNIST: If you’re tired of the bureaucracy of working for a large organization with no voice in how you do things, this is a great opportunity to try private practice. You will have a guaranteed salary with production-based bonuses and the potential for future growth. You will work on the campus of Scripps La Jolla with a respected internist who has been on campus >10 years and will help run the business side of the practice. Email resume to XimedMD@gmail.com. [399] Work part-time or full-time for great pay! I am looking for a few Primary/Urgent Care physicians to work an urgent care setting for $120 an hour, starting September 1, 2015. That’s almost 1 quarter million per year! I am looking for sub-contracting physicians to receive an hourly rate of $120/hr. with no withholding taken out. Work is 20-40 hours a week, very flexible. No nights, no on call. For any questions call 858-232-5369 or email dr_johnc@ hotmail.com. Please send CV. Residents in training welcome. Must be licensed in State of California. Clinics throughout San Diego County. John C. Gill, MD [400] SEEKING PER DIEM DERMATOLOGIST: Well-established dermatology practice in La Jolla is seeking a part-time or full-time per diem dermatologist for immediate hire. Prefer at least two years of experience outside of residency. This practice has thrived for over 30 years and is situated just blocks from some of San Diego’s most beautiful beaches. Very friendly staff, and access to an in-house Mohs surgeon and dermatopathologist. We have two locations and offer flexibility in schedule and encourage a healthy work-life balance. Required experience: Prefer a candidate with two years of experience outside of residency, but will consider all applicants; board certification and California medical license required. Email CV to Sasha Lepes at sasha@compassdermpath.com. [397] IMMEDIATE OPENING FOR MEDICAL DIRECTOR AT GROWING COMMUNITY HEALTH CENTER IN LINDA VISTA: Seeking a highly motivated medical director with innovative ideas and a vision for the future in community medicine. Outstanding leadership and clinical opportunity for an MD who will clinically see adults, while also leading clinical management. Reports to CEO. Experienced internal medicine providers preferred. Competitive salary and benefits, with retirement match. May be eligible for loan repayment. No hospital call required. Please email CV to awalton@lvhcc.com. [396] SEEKING PSYCHIATRISTS: Senior Medical Associates, Inc., seeks board-eligible / board-certified adult and child psychiatrists to join a cohesive team committed to clinical excellence for work at a well-run, supportive, comfortably paced, nonprofit, outpatient clinic serving a persistently mentally ill population in North San Diego County. $240,000 in compensation and bonus, or $160/hour. An additional $15,000 or $9.50/hour if child psychiatry fellowship trained. Full-time benefits include health, life, long-term disability, vision, matching 401K retirement plan, CME reimbursement. Five weeks vacation / sick / CME paid time off. Compensation prorated for part-time employment. Additional pay for optional daytime call responsibility. Position contingent on contract award. Please send your CV to Pardeep at office@seniormedicalassociates.com or call (619) 299-1419. [392] EMERGENCY MEDICINE: BC emergency medicine or family medicine trained physicians needed to join Sharp Rees-Stealy Medical Group’s Urgent Care Department. Competitive compensation and benefits package. Unique opportunity for professional and personal fulfillment. Please send CV to SRSMG, Physician Services, 300 Fir Street, San Diego, CA 92101. Fax: (619) 233-4730. Email: lori.miller@ sharp.com. [391] INTERNAL MEDICINE: Sharp Rees-Stealy Medical Group is seeking full-time or half-time (job share) BC/BE internal medicine physicians to join our staff. We offer a first year competitive compensa-
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tion guarantee and an excellent benefits package. Please send CV to SRSMG, Physician Services, 300 Fir Street, San Diego, CA 92101. Fax: (619) 233-4730. Email: lori.miller@sharp.com. [390] PRIMARY CARE POSITION: San Diego area. Outpatient only. No calls. No hospital and no weekends. Email sandiegoprimarycare@ yahoo.com. [388] BOARD-CERTIFIED FAMILY PRACTICE PHYSICIAN MD/DO WANTED IN BEAUTIFUL LA COSTA: Various shifts available at urgent care / family practice office. Nights, weekends, and day hours available. Please fax or email CV to (760) 603-7719 or gcwakeman@sbcglobal.net. [387] FAMILY OR INTERNAL MEDICINE PHYSICIAN: Graybill Medical is one of the region’s largest independent, multi-specialty groups. We are currently looking for a general family medicine physician (Escondido or Temecula) and an internal medicine physician (Temecula) to provide quality patient care to all ages of patients in a full-time, traditional practice. Conduct medical diagnosis and treatment of patients, including surgical assist, flexible sigmoidoscopy, and basic dermatology. The incumbent must hold a current California license and be board-eligible; bilingual Spanish/English preferred. Check out a full list of our benefits at www.graybill.org. Send CVs to humanresources@graybill.org, apply online, or fax to (760) 738-7101. [385/386] SPANISH-SPEAKING FAMILY PRACTICE OR INTERNAL MEDICINE: Spanish-speaking family medicine or internal medicine physician for Borrero Medical Group located in south San Diego next to Chula Vista. The practice is growing and needs to hire a new physician. Borrero Medical Group is a well-established practice, 22 years in the community, exceptional office staff. Every member of our team plays an important role in improving the health of our patients. We offer an excellent comprehensive benefits package that includes malpractice coverage, health insurance, competitive and attractive salaries and bonus. If interested, please submit inquiry and CV to rosa10borrero@att.net. [384] SEEKING HOSPICE AND PALLIATIVE MEDICINE PHYSICIAN: The Elizabeth Hospice has a full-time position for a physician whose duties will include performing home visits, attending IDTs (interdisciplinary meetings), and assisting with certification of terminal illness. Hospice and Palliative Care Certification preferred. If interested, please contact Dr. Glenn Panzer at glenn.panzer@ehospice. org. [382] KAISER PERMANENTE — SOUTHERN CALIFORNIA PERMANENTE MEDICAL GROUP IS CURRENTLY LOOKING TO HIRE EXCEPTIONAL PHYSICIANS FOR FAMILY MEDICINE, GENERAL INTERNAL MEDICINE, AND URGENT CARE OPPORTUNITIES IN SAN DIEGO: As part of our practice, you’ll be working in a progressive environment that encourages cross-specialty collaboration, professional autonomy, and work-life balance. We offer a competitive salary and one of the most comprehensive benefits packages. If you would like to work with an organization that gives you the tools, resources, and freedom you need to get the best outcomes possible for your patients, come to Kaiser Permanente. For consideration or to apply, please visit our website at http://physiciancareers.kp.org/scal. For questions or additional information, please contact the recruiter Bettina Virtusio at (877) 608-0044. [372] FAMILY PRACTICE AND INTERNAL MEDICINE NEEDED: Parttime or full-time physicians needed to work at correctional facilities. Work as an independent contractor with very competitive pay. Contact Steve at steve@cpmedgroup.com or at (619) 885-3907. [371] FAMILY PRACTICE PHYSICIAN — FT / URGENT CARE PHYSICIAN — PER DIEM: Arch Health Partners is an award-winning medical foundation in North San Diego County. Family Practice hours 8:00am–5:00pm. Urgent Care hours 9:00am–9:00pm. Send CV to catherine.jones@archhealth.org or fax to (858) 618-5820. [366] SEEKING EXPERIENCED HOSPITALISTS: Prestigious, 400-physician, multispecialty group seeks experienced hospitalists to be part of an established hospitalists program at Scripps Memorial Hospital, La Jolla. Board-certified internal medicine physicians with superior clinical skills and willing to work in a team environment. Excellent communication skills a must. Outstanding salary, bonus, and benefits. Please send CV to Yvonne Montelius/XiMED Hospitalists at ymontelius@ximedinc.com or fax to (858) 587-1642. [363] PEDIATRIC NEUROLOGY: Sharp Rees-Stealy Medical Group is looking for a part-time BC/BE pediatric neurologist. This position requires the ability to read EEGs and participation in after-hours on-call coverage. Unique opportunity for professional and personal fulfillment. Please send CV to Physician Services, 300 Fir Street, San Diego, CA 92101. Fax: (619) 233-4730. Email: lori.miller@sharp. com. [359] OPHTHALMOLOGY: BC/BE fellowship-trained glaucoma specialist needed to join collegial and well established ophthalmology division with all major sub-specialties, general ophthalmology, and optometry represented. Fluency in Spanish is a plus. Competitive compensation and benefits package, commensurate with training. Unique opportunity for professional and personal fulfillment. Please send CV to SRSMG, Physician Services, 300 Fir Street, San Diego,
CA 92101. Fax: (619) 233-4730. Email: lori.miller@sharp.com. [360] FAMILY MEDICINE: Sharp Rees-Stealy Medical Group, a 450+ physician multi-specialty group in San Diego, is seeking full-time or half-time (job share) BC/BE family medicine physicians to join our staff. We offer a first year competitive compensation guarantee and an excellent benefits package. Please send CV to SRSMG, Physician Services, 300 Fir Street, San Diego, CA 92101. Fax: (619) 233-4730. Email: lori.miller@sharp.com. [361] FULL-TIME PEDIATRIC POSITION AVAILABLE: Mountain Health & Community Services (MHCS) is seeking an energetic and enthusiastic pediatrician to help us start our new Pediatric Clinic in Alpine, near beautiful San Diego beaches, mountains, hiking trails, fishing, and great schools. Rare opportunity to start and grow your own practice in an exciting, growing community health organization. We offer excellent benefits, NHCS loan repayment eligibility, and competitive salary. Qualifications: License from the State of California (MD or DO); current CPR; board certified or board eligible. Salary negotiable. If interested, please submit your CV to Tabitha Findahl at tabitha.findahl@mtnhealth.org, or call CMO, Dr. Blain, at cell (858) 248-1509 for more information. [357] FULL-TIME FAMILY MEDICINE POSITION AVAILABLE: Mountain Health & Community Services (MHCS) is seeking energetic and enthusiastic family medicine providers at several of our clinics, near beautiful San Diego beaches, mountains, hiking trails, fishing, and great schools. We offer excellent benefits, NHCS loan repayment eligibility, and competitive salary. Qualifications: License from the State of California (MD or DO); current CPR; board certified or board eligible. Salary negotiable. If interested, please submit your CV to Tabitha Findahl at tabitha.findahl@mtnhealth.org, or call CMO, Dr. Blain, at cell (858) 248-1509 for more information. [356] PART–TIME CARDIOLOGIST NEEDED for outpatient cardiac consults and follow-ups in an established cardiology practice in East County. Call Debbie at (619) 668-0039. [354] PSYCHIATRISTS NEEDED: Part-time or full-time psychiatrists needed to work at San Diego County jails. Work as an independent contractor with very competitive pay. Contact Steve at steve@ cpmedgroup.com or at (619) 885-3907. [353] PHYSICIAN WANTED: Semi-retired or working part time elsewhere to fill in for vacations, long weekends for active family practice, urgent care, occupational medicine practice in Mission Valley area. No weekends or nights. Salary negotiable. Call cell phone at (619) 846-8156 or email at drpohl@missionvalleymedical.com. [351] PHYSICIAN FAMILY MEDICINE: North County Health Services (NCHS); Job Title: Physician Family Medicine; Location: Riverside, CA. An established, award-winning organization. Our employees work smarter, and we are looking to hire the best talent. We look for people who embrace diversity, love challenges, and welcome big changes. We have a need for a lead physician to provide comprehensive medical services for patients of NCHS. Qualifications: License from the state of California (MD or DO); CPR; Minimum two years of experience; Board certified or board eligible. NCHS is proud to be an equal opportunity workplace and is an affirmative action employer. Contact: Araceli Mercado, araceli.mercado@nchshealth.org. [349] 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. 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. [348] PHYSICIAN POSITIONS AVAILABLE AS WE CONTINUE TO GROW: 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. 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. [046a] SEEKING A FOOT/ANKLE SPECIALIST: Well-established, highly respected, four-physician group, private practice in San Diego seeking a foot/ankle specialist. Our group is expanding to meet high volume of cases and planned expansion. Potential opportunity for any established subspecialist looking for a permanent practice location. We have a broad-based primary care referral base, mature EHR, digital X-ray, ultrasound, and DME program. Interested parties, please email your CV in confidence to lisas@sdsm.net. [326] SEEKING URGENT CARE PHYSICIAN: Busy practice in El Cajon, established in 1982, seeks a part-time physician. Good pay and working conditions along with the potential to become a full-time position. Please send CV to jeff@eastcountyurgentcare.com. [306]
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]
HILLCREST OFFICE SPACE: Office space available in beautiful, updated Hillcrest medical office that also houses a fully accredited ambulatory surgery center. Great opportunity for a plastic surgeon, facial plastic surgeon, oculoplastic surgeon or dermatological surgeon. Office is conveniently located minutes from freeway access and downtown San Diego. Please contact via email at info@drhilinski.com. [355]
PA or NP at $78/hour, negotiable! I am looking for one NP and one PA to work 28 hours a week downtown San Diego for about $78 an hour starting September 1, 2015. I am looking for sub-contracting physician extenders to receive this rate with no withholding taken out. For any questions, call me at (858) 2325369 or email dr_johnc@hotmail.com. Please send CV. Must be licensed in state of California. John C. Gill, MD [401]
PHYSICIANS NEEDED: Internal medicine and family medicine physician positions currently open. Vista Community Clinic is a private, nonprofit, outpatient clinic serving the communities of North San Diego County with openings for full-time, part-time, and per-diem positions. Current CA and DEA licenses required. 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]
OFFICE SUITE — APROXIMATELY 1,650FT2 IN OFFICE BUILDING ADJACENT TO SHARP CORONADO HOSPITAL: Large, newly refurbished waiting area, a business office and six exam /consultation rooms. The space is ideal for primary care physicians or a specialty group wishing to expand to Coronado. Pharmacy and parking are available on premises. The suite is largely furnished, and tenant improvements are available depending on the length of the lease. Part-time tenants are available to share lease expenses. Base rent $2.38 / ft2 / mo, $1.28 / ft2 / mo operating expenses. Email John Kerley, MD, at kerjo100@gmail. com or call (619) 435-2060. [344]
ADMINISTRATIVE ASSISTANT FOR TWO-SURGEON OFFICE IN EAST COUNTY / GROSSMONT AREA: Previous experience and general knowledge of medical office procedures and the responsibilities of various positions, assisting office manager in employee management and HR. Business office assistance with HIPPA, meaningful use, physician meetings/schedules, credentialing, contracting etc. Possibility of becoming office manager. Part time to start going to full time. Email resume to LMop202@ gmail.com. [395]
OFFICE SPACE AVAILABLE LA JOLLA (NEAR UTC) MEDICAL OFFICE FOR SUBLEASE OR SHARE: Scripps Memorial medical office building. Great location, steps to main hospital entrance. 9834 Genesee Ave. between I-5 and I-805. Up to four exam rooms and private or shared consult office available. Please call (858) 622-9076 and ask for Jennifer. [394]
MEDICAL SPACE IN UTC
Medical Office with two exam rooms at 4130 La Jolla Village Dr, close to Scripps Memorial & UCSD.
For more information please call 858.775.7314 VISTA MEDICAL OFFICE SPACE FOR LEASE: Offered at $1.40/ ft2. 1.1 miles from Tri-City Hospital. Ideal place for solo practitioner. Ground floor, 1,424ft2, has break room, which is leaded for radiology if needed, two bathrooms, two exam rooms, spacious waiting room, ample room for support staff, physicians private office, excellent parking with seven spaces per 1,000ft2. Also available in same building, office space to share with pediatrician. Ideal for solo practitioner, either family practice or pediatrics. Space portioned off with separate wing and includes three exam rooms, two offices, shared reception area and lobby with access to two bathrooms. Area under city renovation, and lots of new business starts surround. Contact Jill at (760) 630-4715. [393] MEDICAL FACILITY AVAILABLE FOR SUBLEASE: Orthopedic group in central San Diego looking to sublet space to an orthopedic surgeon with an expertise in hand, spine, general, or non-operative orthopedic care, or rheumatologist; primary care physician. Medical office is located in Sorrento Valley at a class A medical building with a surgery center as the anchor tenant, onsite large conference room and learning center with cadaver wet lab, physical therapist next door, and easy freeway access. Opportunities for investment, ER call, and patient referrals. For more information, please contact Jeff Craven at jeff@sdmiortho. com or at (858) 245-9109. [383] 1,220FT2 OFFICE AVAILABLE IN BEAUTIFUL LA JOLLA VILLAGE AREA: Spacious waiting room with 2–3 exam rooms and 2 offices. Fully built out and furnished. Two entrances. Parttime (2 days per week) occupancy available. Wi-fi and utilities included. For more information, email at mail@ncdermatology. com. [381] DEL MAR MEDICAL OFFICE AVAILABLE: Turnkey office available in Class A medical office building in prime location in Carmel Valley, San Diego. Full- or part-time occupancy for medical professional. Dedicated parking garage for patients / clients. 1,000ft2suite with two large treatment rooms, breakroom, photography, and reception area. Rates dependent on use. Contact Margaret O’Byrne, MD, at mobyrne61@gmail.com, (619) 218-8980 (mobile), (858) 481-4888 (office). [369] $3,147 / 1,701FT2 — 1,701FT2 MEDICAL OR BUSINESS USE FLEX SPACE (5330 CARROLL CANYON RD.): 1,701ft2 office space available approved for medical or business use. Fully built out. First floor with extensive window line. Two entrances. Excellent highway access. Short- or long-term lease available. Easy patient / client parking. Contact Margaret O’Byrne, MD, at mobyrne61@gmail.com, (619) 218-8980 (mobile), (858) 481-4888 (office). [368] MEDICAL OFFICE SPACE AVAILABLE IMMEDIATELY at 9339 Genessee, San Diego, CA. 1,800ft2 at $3.60/sf. Build-out required, TI available. Please contact Synergy Specialist Medical Group at (858) 412-6080. [362] SHARED SUBLET AVAILABLE: Large, nicely furnished office space available for shared sublet 1–2 days per week, on Scripps Encinitas campus. Contact Frank at (858) 361-9377. [358]
NEW MEDICAL OFFICE SPACE AVAILABLE FOR SUBLEASE IN KEARNY MESA: Brand new office suite located at 3750 Convoy Street with nine exam rooms and digital X-ray, hi-speed wireless, free parking for patients and staff, conference room in building. Several minutes from Sharp Memorial Hospital and Children’s Hospital. Convenient freeway access to 163 and 805. Multiple half-day clinics available days, evenings, and weekends. Please contact Lisa Vaughn at (858) 278-8300, ext. 210, for more information. [343] 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] 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, 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] BUILD TO SUIT: 950SF 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 six gated parking spaces, two entryways, restrooms, lighted tower sign space. Build-out allowance to $10,000 for 4–5 year lease, rent $1,800 per month gross (no extras). 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 EXPERIENCED NP NEEDED! Experienced nurse practitioner needed for busy interventional pain management practice. We are looking for an individual with excellent clinical skills who is interested in associating with our already well-established practice in San Diego. Job duties include, but are not limited to: performing routine follow-up visits with established patients, assist in the management of intrathecal drug delivery patient population, and must be comfortable prescribing schedule II and schedule III narcotics while observing regulatory requirements and following community standards of care in regards to the prescribing of controlled substances. Please forward resume and contact information along with references and licensing certificates of training in the above-noted clinical areas. Please send a current resume with phone and/or email contact and list of references to mirjam.phillips@alcalamanagement.com. [402]
PHYSICIAN ASSISTANT POSITION IN PAIN MANAGEMENT UNDER THE DIRECTION OF THE PHYSICIAN: Apply and modify the principles, methods, and techniques of medicine to provide comprehensive pain management, medical services, and procedures. Diagnose and treat a variety of injuries, chronic and acute pain symptoms. Full-time position. Competitive salary, signon bonus, and vacation package bonus after one year. Education: Physician assistant applicants must have certification and degree from an accredited college organization. Experience: Previous experience in pain management preferred. License / Certification: Certification of physician’s assistants; current / valid CA state PA license, DEA, and NPI. Current CPR, BLS, and ACLS certifications. EOE / Minorities / Females / Vet / Disability. Email hillycarr1@yahoo.com. [379] SAN DIEGO MEDICAL GROUP SEEKS A NURSE PRACTITIONER: San Diego Medical Group (SDMG) is a well established and thriving internal medicine private practice located in Hillcrest directly across the street from Scripps Mercy Hospital in the prestigious Mercy Medical Building. The office is staffed by two internists, one nurse practitioner, and seven staff. SDMG seeks another experienced, full-time nurse practitioner to manage patients in our growing practice. This is a unique opportunity to work in a small private practice with seasoned, excellent providers and staff in an efficient, cohesive work environment providing medical care to a wide variety of patients. SDMG envisions an incoming nurse practitioner who has direct experience with the practice of internal medicine, is capable of immediate management of patients, can quickly learn and use SDMG’s EMR (eClinicalWorks), is positive, outgoing, compassionate, and a hard worker. The position is Monday through Friday, 8am–5pm (some flexibility) with a competitive six-figure salary, health benefits, retirement benefits, life insurance, paid continuing education, and paid vacation. There is no call. Interested applicants, please send your resume to sdmg@sdmedgroup.com. [365] PSYCHIATRIC NURSE PRACTITIONER: Part- or full-time psychiatric nurse practitioner needed to work at San Diego County jails. Work as an independent contractor with very competitive pay. Contact Steve at steve@cpmedgroup.com or at (619) 8853907. [352] FNP AND PA POSITIONS AVAILABLE AS WE CONTINUE TO GROW: 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. 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. [046b] NURSE PRACTITIONER: Needed for house-call physician in San Diego. Full-time, competitive benefits package and salary. Call (619) 992-5330 or email drhunt@thehousecalldocs.com. Visit www.thehousecalldocs.com. [152] PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Needed for house-call physician San Diego. Part-time, flexible days / hours. Competitive compensation. Call (619) 992-5330 or email drhunt@thehousecalldocs.com. Visit www.thehousecalldocs. com. [038] MEDICAL EQUIPMENT / OFFICE FURNITURE FREE EQUIPMENT FOR DONATION: Defibrillator — Zoll AED Plus and Inovo Oxygen tank. Interested parties please email lisas@sdsm.net. [389] INTERNAL MEDICINE OFFICE CLOSING: Small private practice closing on 8/29/15, and all items for sale, including medical equipment, office furniture, office equipment, office supplies, and medical supplies. Includes: Marquette GE EKG, Welch Allyn spirometer, ophthalmoscopes, Baumonometers, exam tables, scales, computers, waiting room furniture, bookshelves, desks, chart racks, etc. Please call Cathy for more information at (619) 829-5583. [367]
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P e r s o n a l & P r o f e s s i o n a l D e v e lo p m e n t
But how do we hold these delicate conversations without alienating our colleagues — and in a way that allows truth, kindness, and benefit to emerge?
The Ethics and Heart of Accountability by Helane Fronek, MD, FACP, FACPh
Ask most medical students what attracted them to our profession and they say, “I want to help people.” In fact, one of the tenets of the practice of medicine is Primum Non Nocere — above all, do no harm. So what do we do when we see that a colleague has forgotten that adage? Perhaps the person’s judgment has become clouded by substance abuse, financial considerations, or factors other than what’s best for the patient. Or maybe they simply see treatment options in a way different than we do. These types of ethical dilemmas are challenging because they pit one of our values against another. We physicians value service to our patients, but we also value autonomy. Which value should supersede the other? What is our responsibility to our colleagues, our patients, and our profession? The word “profession” was coined in the
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12th century to describe individuals taking vows upon entering a religious order. Today, the word connotes an esteemed occupation requiring special training. If we want medicine to remain a respected profession, our vows must have meaning and be upheld by each of us. This implies we have a duty to review our actions — individually and collectively. If we fail to effectively monitor our actions and guide individuals among us who have strayed from helping patients first and foremost, we may find ourselves being evaluated and judged by others who have less knowledge of the complexities of medical care and perhaps less compassion for the errors in judgment that all of us occasionally make. But how do we hold these delicate conversations without alienating our colleagues — and in a way that allows truth,
kindness, and benefit to emerge? Decades of research into communication and its effect on productivity have led the people at Vital Smarts to suggest that we start difficult conversations “with heart.” Before we sit down with our colleague, we can ask ourselves, what do I want — for me, for my colleague, and for our relationship? And if I want those things, how should I act? It’s important to set the stage properly by giving our colleague an idea that we have something serious to discuss, and finding a time and setting that is acceptable and comfortable. Acknowledging our discomfort as well as our intention — to share our feelings and beliefs, arrive at an understanding of the truth, and to offer assistance if that is what’s appropriate — helps to diminish defensiveness or hurt. If we find that the situation wasn’t what we believed it was, our relationship may become stronger as we emerge united on this issue. If our colleague’s behavior does need adjustment, it may be our concern and support that will provide the courage, strength, and incentive to change. There is no doubt these are difficult discussions. But if we want our profession to thrive, and we want to live our lives with integrity, we can lead with compassion for our colleagues so we skillfully hold these important conversations. We just need to summon our courage — our heart — and begin from there. 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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