October 2015 by San Diego Physician

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October

Contents

Volume 102, Number 10

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 (CMA Trustee) 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

bola Preparedness Comes to E San Diego: Five Lessons Learned BY FRANK MYERS AND KIM DELAHANTY

hikungunya: A New C Mosquito-borne Virus BY ROBERT E. PETERS, MD, PHD

Puentes de Esperanza (Bridges of Hope): Treating Tuberculosis Across Borders BY RAMON MONCADA, MD

Vector-borne Diseases in San Diego: “Where Have You Been?”

BY ERIC MCDONALD, MD, MPH

28 departments 4

Briefly Noted: Calendar • Volunteer Opportunities • Nature at Work • Directory Errata • San Diego Medical Office Snapshot • And More …

8 “How to Discourage a Doctor” BY RICHARD GUNDERMAN, MD, PHD

Auditing in a Compliance Program

BY HEIDI KOCHER, ESQ.

Navigating Risks in Breast Cancer Diagnosis and Treatment

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 (At-large AMA Delegate) CMA Speaker: Theodore M. Mazer, MD (At-large AMA Alternate Delegate) CMA Past Presidents: James T. Hay, MD (AMA Delegate) • Robert E. Hertzka, MD (Legislative Committee Chair, At-large AMA Delegate) • Ralph R. Ocampo, MD, FACS CMA Trustee: Bob E. Wailes, MD AMA Alternate Delegate: Lisa S. Miller, MD

Y PENNY GREENBERG, RN, DARRELL B RANUM, JD, AND DANA SIEGAL, RN

26 Physician Marketplace: Classifieds 28

We Can Each Contribute to Healthcare Equity

BY HELANE FRONEK, MD, FACP, FACPH

8 2

October 2015

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.]

Rents are rising. See how some of our clients are taking back control. Fourth Avenue Medical Plaza

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Venture 41 Sorrento 5 2Office Park 3

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Take a look at how we help our clients by visiting www.sdmedicalrealestate.com

Paul Braun 71 +1 858 410 6388 paul.braun@am.jll.com 76

Chris Ross +172 858 410736377 7471 chris.ross@am.jll.com 76 77 78

Sales ▪ Leases ▪ Renewals ▪ Investments

Kelly Moriarty 736359 74 7572858 410 71 75 72 +1 kelly.moriarty@am.jll.com 77 78 76 77

57 62 67 72 77

/////////Briefly /////////////////Noted //////////////////////////////////////////////////////////////////////// giving back

VOLUNTEER OPPORTUNITIES Email Your Physician Volunteer Opportunities to Editor@SDCMS.org

calendar SDCMS Events SDCMS.org

For further information or to register for any SDCMS events, visit SDCMS.org or email Seminars@SDCMS.org.

Preparing to Launch: Making Your Way After Residency/Fellowship (workshop) NOV 7: 8:00am– 3:00pm

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. 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

LUNGevity Breathe Deep San Diego 5K NOV 7 at Crown Point, Mission Bay Park San Diego Pulmonary, Critical Care, and Sleep Medicine Case Conference & Clinical Updates (critical care content) NOV 9 at the VA San Diego (sjamil@ucsd. edu)

October 2015

Surgical Stabilization and Rehabilitation of the Unstable Shoulder NOV 18 at Scripps Green Hospital Evaluations of Healthcare Professionals: From Screening to Full Assessment and Fitness for Duty Reports NOV 21 in Oakland at the Alameda Contra-Costa Medical Association Evaluations of Healthcare Professionals: From Screening to Full Assessment and Fitness for Duty Reports DEC 5 in Los Angeles at the Los Angeles County/USC Medical Center Update in Rheumatology: Highlights From the ACR and EULAR Meetings DEC 5 at the UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences San Diego Pulmonary, Critical Care, and Sleep Medicine Case Conference & Clinical Updates (sleep medicine content) DEC 7 at the VA San Diego (sjamil@ucsd. edu) Musculoskeletal Ultrasound in Hemophilia DEC 16–18 at the UC San Diego Hemophilia & Thrombosis Treatment Center

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. Interested in Becoming a Preceptor for Osteopathic Medical Students? Midwestern/AZCOM osteopathic medical school in Phoenix has third- and fourth-year medical students in San Diego looking for clinical rotations, particularly in pediatrics, psychiatry, general surgery, and OB/GYN. Requirements: Either MD or DO; physicians interested must commit to minimum one four-week rotation per year / or more as desired

(2–3 preferable) and to FT hands-on training for each student as is reasonable for the duration of the rotation. Compensation and CME provided. If interested, please contact Dr. Kevin Considine at kconsidine@sbcglobal. net for more information. Humanitarian Teams Need Medical Volunteers for Haiti: We are looking for physicians and mid-level providers for one-week primary care medical clinics in rural Haiti in February and June 2016. This is a rewarding opportunity to work with the people of Haiti and provide care in a very austere environment in a medically underserved area. Seattle-King County Disaster Team — a U.S.-based nonprofit — has been operating these clinics since 1998. We coordinate all in-country travel and logistics. Please contact Bob Downey at (619) 905-7157 or at labboy@earthlink.net if you are interested in applying. Visit www. skcdteam.org for further information. Physician Volunteer Opportunity: Established in 2011, Flying Samaritans of SDSU provides free healthcare to the underserved community of Ejido Matamoros, Mexico (15 minutes away from the border), through monthly medical and dental clinics (every second Saturday of the month), seeing 60–80 patients/medical clinic and 10/ dental clinic. Email FlyingSamaritansSDSU@gmail.com.

quote of the month

“

Courage is resistance to fear, mastery of fear — not absence of fear. — Mark Twain (1835–1910)

”

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TrusT

NATURE AT WORK

A Common sense ApproACh To InformATIon TeChnology Photo titled “Nature at Work” taken by Said M. Hashemi, MD, 34-year member of SDCMS-CMA. Members: Email your original photos/artwork to Editor@SDCMS.org for possible publication in San Diego Physician.

directory ERRATA Please update the following physician listings in your copy of SDCMS’s 2016 San Diego County All Physician Directory, aka, The Little Purple Book. Delete Listing for the Following Physician: • Mia Hosaka, DO Update Listings for the Following Physicians: • Corrections for Leo J. Murphy, MD »» Address Suite = 102 »» Telephone = (619) 800-7942 »» Fax = (619) 800-7385 • Correct photo for Steven George Pratt, MD

• Corrections for Erin J. Vance, MD »» Address = 4405 Vandever Ave., San Diego 92130 »» Telephone = (800) 290-5000 • Corrections for Cameron W. Wilson, MD »» Address = 8851 Center Drive, Suite 208, La Mesa 91942 »» Telephone = (619) 828-1000 »» Fax = (619) 828-1001

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/////////Briefly /////////////////Noted //////////////////////////////////////////////////////////////////////// commercial real estate

San Diego Medical Office Snapshot | Q2 2015 By Chris Ross

Interesting Facts

8.7%

Market Conditions and Trends: The San Diego medical office market is steadily chugging along. Many providers are seeking opportunities to upgrade their space, building, or location since, in most areas, rents and prices are still reasonable, and favorable tenant improvement allowances and concessions are still available. Vacancy continues its gradual decline and now sits at 8.7% — down from 10.3% from a year ago — with only two submarkets (Oceanside/Vista and Escondido/ San Marcos) over 10%. Class A medical space is extremely tight, down to 6.4% vacancy, which is leading to more tenant activity among Class B properties. The Class B buildings having the most success in landing those tenants are those that are enhancing their exterior and common areas to bridge the gap in quality between B and A, resulting in good value for providers with new practices or for whom it does not make economic sense to pay up for Class A space. By next year, Class B properties will

October 2015

Countywide Direct Vacancy

111,055

YTD Net Absorption (s.f.) // 65,984 s.f. (Q2 2015)

1.7%

12-month Rent Growth // $2.66 SF Average Asking

189,750 Total Under Construction (s.f.)

likely show a stronger push in rents like we have seen from Class A buildings over the past 24–36 months. With the outlook for healthcare providers and dentists more stable today than it was during the recession and the Medicare and Obamacare turmoil, many tenants who are unwilling to move are now committing to longer renewal terms in order to achieve attractive allowances and other favorable terms that justify remodeling or refurbishing their space. With the exception of a small handful of build-to-suits and expansions, there has been a limited amount of transaction and construction activity over 30,000 square feet in 2015. Six months is a pretty small sample size, but it does seem that most of the health systems in our region are currently focusing on very specific geographical areas, services, or facilities as opposed to aggressively expanding into new territory. Forecast As much as the ACA and threats of Medicare reimbursement cuts have been a cause for concern among health practitioners in recent years, it is seemingly resulting in a much more entrepreneurial spirit among many business-minded providers as they reevaluate if they are appropriately positioned for this new era of healthcare. As a result, the most improved leasing and sale activity is coming from tenants in the 3,000 to 10,000 SF range — i.e., multiprovider groups and sole practitioners with larger or growing practices. We also anticipate increased M&A activity among specialty groups — a newer trend in Southern California that has started to take place — which would lead to an uptick in activity among mid to large blocks of space. Mr. Ross is vice president of healthcare solutions for Jones Lang LaSalle. He is a commercial real estate broker specializing exclusively in medical office and healthcare properties in San Diego County. To receive the complete Q2 2015 report, call Mr. Ross at (858) 410-6377 or email him at chris.ross@ am.jll.com.

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h o s p i ta l m e d i c a l s ta f f s

Note: Reprinted with permission from the author

“How to Discourage a Doctor” by Richard Gunderman, MD, PhD

October 2015

Not accustomed to visiting hospital executive suites, I took my seat in the waiting room somewhat warily. Seated across from me was a handsome man in a well-tailored, three-piece suit, whose thoroughly professional appearance made me — in my rumpled white coat, sheaves of dog-eared paper bulging from both pockets — feel out of place. Within a minute, an administrative secretary came out and escorted him into one of the offices. Exhausted from a long call shift and lulled by the quiet, I started to doze off. Soon roused by the sound of my own snoring, I started and looked about. That was when I spotted the document on an adjacent chair. Its title immediately caught my eye: “How to Discourage a Doctor.” No one else was about, so I reached over, picked it up, and began to leaf through its pages. It became apparent immediately that it was one of the most remarkable things I had ever read, clearly not meant for my eyes. It seemed to be the product of a healthcare consulting company, presumably the well-dressed man’s employer. Fearing that he would return any moment to retrieve it, I perused it as quickly as possible. My

enough. To truly seize the reins of medicine, it is necessary to do more, to get into the heads and hearts of physicians. And the way to do this is to show physicians that they are not nearly as important as they think they are. Physicians have long seen the patient-physician relationship as the very center of the healthcare solar system. As we go forward, they must be made to feel that this relationship is not the sun around which everything else orbits, but rather one of the dimmer peripheral planets, a Uranus, or perhaps Neptune. How can this goal be achieved? A complete list of proven tactics and strategies is available to our clients, but some of the more notable include the following: Make healthcare incomprehensible to physicians. It is no easy task to baffle the most intelligent people in the organization, but it can be done. For example, make physicians increasingly dependent on complex systems outside their domain of expertise, such as information technology, and coding and billing software. Ensure that such systems are very costly so that solo practitioners and small groups, who naturally cannot afford them, must turn to the hospital. And augment their sense of incompetence by making such systems user-unfriendly and unreliable. Where possible, change vendors frequently. Promote a sense of insecurity among the medical staff. A comfortable physician is a confident physician, and a confident physician usually proves difficult to control. To undermine confidence, let it be known that physicians’ jobs are in jeopardy and their compensation is likely to decline. Fire one or more physicians, ensuring that the entire medical staff knows about it. Hire replacements with a minimum of fanfare. Place a significant percentage of compensation ‘at risk,’ so that physicians begin to feel beholden to hospital administration for what they manage to eke out. Transform physicians from decisionmakers to decision-implementers. Convince them that their professional judgment regarding particular patients no longer constitutes a reliable compass. Refer to such decisions as anecdotal, idiosyncratic, or simply insufficiently evidencebased. Make them feel that their mission is not to balance benefits and risks against their knowledge of particular patients, but instead to apply broad practice guidelines to the care of all patients. Hiring, firing, promotion, and all rewards should be based on conformity to

“To truly seize the reins of medicine, it is necessary to do more, to get into the heads and hearts of physicians. And the way to do this is to show physicians that they are not nearly so important as they think they are.” recollection of its contents is naturally somewhat imperfect, but I can reproduce the gist of what it said: The stresses on today’s hospital executive are enormous. They include a rapidly shifting regulatory environment, downward pressures on reimbursement rates, and seismic shifts in payment mechanisms. Many leaders naturally feel as though they are building a hospital in the midst of an earthquake. With prospects for revenue enhancement highly uncertain, the best strategy for ensuring a favorable bottom line is to reduce costs. And for the foreseeable future, the most important driver of costs in virtually every hospital will be its medical staff. Though physician compensation accounts for only about 8% of healthcare spending, decisions that physicians strongly influence or make directly — such as what medication to prescribe, whether to perform surgery, and when to admit and discharge a patient from the hospital — have been estimated to account for as much as 80% of the nation’s healthcare budget. To maintain a favorable balance sheet, hospital executives need to gain control of their physicians. Most hospitals have already taken an important step in this direction by employing a growing proportion of their medical staff. Transforming previously independent physicians into employees has increased hospital influence over their decision-making, an effect that has been successfully augmented in many centers by tying physician compensation directly to the execution of hospital strategic initiatives. But physicians have invested many years in learning their craft, they hold their professional autonomy in high esteem, and they take seriously the considerable respect and trust with which many patients still regard them. As a result, the challenge of managing a hospital medical staff continues to resemble herding cats. Merely controlling the purse strings is not

hospital-mandated policies and procedures. Subject physicians to escalating productivity expectations. Borrow terminology and methods from the manufacturing industry to make them think of themselves as production-line workers, then convince them that they are not working sufficiently hard and fast. Show them industry standards and benchmarks in comparison to which their output is subpar. On the off chance that their productivity compares favorably, cite numerous reasons that such benchmarks are biased and move the bar progressively higher. Increase physicians’ responsibility while decreasing their authority. For example, hold physicians responsible for patient satisfaction scores, but ensure that such scores are influenced by a variety of factors over which physicians have little or no control, such as information technology, hospitality of staff members, and parking. The goal of such measures is to induce a state that psychologists refer to as “learned helplessness,” a growing sense among physicians that whatever they do, they cannot meaningfully influence healthcare, which is to say the operations of the hospital. Above all, introduce barriers between physicians and their patients. The more directly physicians and patients feel connected to one another, the greater the threat to the hospital’s control. When physicians think about the work they do, the first image that comes to mind should be the hospital, and when patients realize they need care, they should turn first to the hospital, not a particular physician. One effective technique is to ensure that patientphysician relationships are frequently disrupted, so that the hospital remains the one constant. Another is … The sound of a door roused me again. The man in the three-piece suit emerged from the office, he and the hospital executive to whom he had been speaking shaking hands and smiling. As he turned, I looked about. Where was “How to Discourage a Doctor”? It was not on the table, nor was it on the chair where I had first found it. “Will he think I took it?” I wondered. But instead of stopping to look for it, he simply walked out of the office. As I watched him go, one thing became clear: Having read that document, I suddenly felt a lot less discouraged. Dr. Gunderman is chancellor’s professor of radiology, pediatrics, medical education, philosophy, liberal arts, philanthropy, and medical humanities and health studies at Indiana University. SAN DIEGO PHYSICIAN.org

c o m p l i a n c e p r o g r a m s — 6 th i n a s e r i e s

Auditing in a Compliance Program by Heidi Kocher, Esq.

Last month we discussed how to perform sanctions screening, and the month previously we discussed why sanctions screening is so important. Sanctions screening is really just one form of auditing. So what is an “audit”? According to Merriam-Webster’s dictionary, it is a “careful check or review of something,” such as financial or other records. That definition is deceptively simple, yet powerful. An audit can be very simple and straightforward, or it can be more comprehensive and detailed. Yet in all cases, an audit must be performed with attention and care. There are common features to all audits, regardless of the topic or subject of the audit. First, all audits should start with a specific description or outline of what is being audited. This lends structure to the audit and helps keep it from expanding beyond the original purpose (the dreaded “scope creep”). Second, all audits should cover a specific time period. Remember that all audit results will reflect a specific point

October 2015

Another area to audit is your billing. This is probably the most important audit area, where time spent will more than pay for itself.

in time, and, as you implement improvements, the results may change — and, in fact, should change … hopefully for the better. Third, the audit should be documented, documented, documented! This can be done very simply through a memo to file that describes what was audited, by whom, the dates the audit was performed, and what checklist, tool, or other criteria were used to perform the audit. Or it can be a very thorough audit plan, with completed work papers and a report with charts and graphs. Finally, all audits should identify any opportunities for improvements and make suggestions for a corrective action program. Note that there is really no wrong way to conduct an audit, as long as you conduct the audit in good faith (1). So what should you audit in your compliance program? The first and most obvious is your patient charts. This is a key area for practices, as the patient records not only serve a medical purpose but also a financial and legal purpose. Periodically select a

number of patient charts and review them to make sure all of the proper documents are in the file, including necessary insurance and initial forms such as the signed Notice of Privacy Practices. Remember that certain specialties or services may have special documentation requirements such as laboratory results or to justify diagnostic procedures. Also, don’t forget necessary documents that your patients might need for subsequent care, such as the face-to-face visit documentation for home health patients or a Certificate of Medical Necessity for certain types of durable medical equipment. Another area to audit is your billing. This is probably one of the most important audit areas, where time spent will more than pay for itself. Unfortunately, it is also one of the easiest things to put off doing until it is too late. A good audit plan is to select the top 10 or 15 CPT codes or other relevant codes. Take a sample of claims. If you pick five or six claims in each of the top 10 CPT codes, your audit will cover 50–60 claims. While not necessarily statistically valid, it will nonetheless provide a very good assessment of issues in your practice. If even that number is too high, an audit of even three claims for each of the top 10 CPT codes (or 30 claims) may serve to identify problem areas or as an early warning of developing issues. On the other hand, if you wish to perform a more rigorous, statistically valid audit, a good tool to use is the RAT-STATS program (available at www.oig.hhs.gov/compliance/ rat-stats/index.asp). This program is a free statistical package created by the federal government. Besides its simplicity and ease of use (even a lawyer like me can use it!), its key advantage is that the OIG utilizes this program in its auditing program. Accordingly, it is also used by many entities that

have claims audit requirements under a Corporate Integrity Agreement. Once you have audited your patient charts and your claims, then you can choose virtually any other subject or topic to audit. Common areas for audits are adherence to given policies or procedures, patient copays or waivers, or previously identified problem areas uncovered by payer audits or inquiries. Don’t forget that the process of conducting an audit can also apply to topics that may not initially be thought of as audit areas, such as human resource or training records. As part of conducting the audit, remember to identify ways to remedy any deficiencies that are found. First, this will demonstrate to any third-party reviewers or investigators that you are taking a thoughtful approach to compliance. Second, this forms the basis of your corrective action plan. Once you have identified recommended improvements, you can monitor that the fixes are properly and promptly implemented. Note that repeating an audit is also a useful exercise, particularly if you have identified ways to correct any deficiencies. A second audit will either document improved results, thereby demonstrating that your compliance program is working, or, if there aren’t better results, help in a root cause analysis to refine your corrective actions. It can also help establish a trend, which again hopefully will help to demonstrate that your compliance program is working. In summary, while auditing may seem to be a time-consuming and overwhelming task, it is a worthwhile activity for all physician practices — worthwhile enough to carve out resources and staff time. Next month, since the holidays are approaching, we will discuss gifts and courtesies. References: 1. CMS published a practical guide for physicians conducting self-audits, available at www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/MedicaidIntegrity-Education/Downloads/auditselfaudit-booklet[April-2015].pdf 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.

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Navigating Risks in Breast Cancer Diagnosis and Treatment How Physicians Can Enhance Patient Safety by Penny Greenberg, RN, MS, Darrell Ranum, JD, CPHRM, and Dana Siegal, RN, CPHRM

Acknowledgments: For help in developing this article, the authors extend their thanks to Robin Diamond, JD, RN, senior vice president of patient safety and risk management at The Doctors Company. This article was originally published in Patient Safety & Quality Healthcare (www.psqh.com). Breast cancer is one of the most common cancers among American women — affecting approximately one in eight women — and is the leading cause of cancer-related death. The good news is the overall rate of newly diagnosed cases began to decrease in 2000, and the overall death rate has continued to trend downward over the past 20 years (1). Patients diagnosed with breast cancer must navigate the complex healthcare system while dealing with the emotions of their diagnosis and relying on the expertise, communication, and empathy of caregivers who practice in environments with inherent risks. To better understand these risks and improve patient safety, The Doctors Company and CRICO Strategies recently partnered to study 562 breast cancer medical malpractice claims from 2009 to 2014 in CRICO’s extensive Comparative Benchmark System (CBS). The analysis revealed two specific areas where harm occurred: during initial diagnosis, and during management and treatment. The analysis identified 342 cases where there was a delay in diagnosing breast cancer. Failure or delay in ordering diagnostic tests, consults, or referrals and failure to have a system in place for communicating the results among providers can lead to missed or delayed diagnosis. Patient allegations in these cases were decreased chance of recovery, decreased life expectancy, or increased recovery time. Inadequate patient assessment, at 71%, was the top-contributing factor identified by a panel of experts who reviewed the cases. Harm occurred during the treatment and/or management of the patient in 220 cases, with the top allegation related to performance of surgery, including the initial surgery to remove the malignancy and subsequent reconstructive surgeries. Plastic surgery and general surgery were the primary services in nearly half of the cases, with many cases involving poor communication between the patient and surgeon — especially related to informed consent. Physicians treating breast cancer patients should consider the following risk reduction strategies: • Obtaining an accurate and timely diagnosis — including interpretation of diagnostic studies, updated family history, comprehensive exam, and thorough medical record review — is critical to ensuring the best possible outcome for patients. • Use decision support tools such as a breast care management algorithm (www.rmf.harvard.edu/Clinician-Resources/Guidelines-

October 2015

Algorithms/2014/Breast-Care-Management-Algorithm) and an effective referral tracking system (www.thedoctors.com/KnowledgeCenter/PatientSafety/articles/Tracking-Referrals) to assist in diagnosis. • Implement processes, including documentation forms (www. thedoctors.com/KnowledgeCenter/PatientSafety/InformedConsent/informed-consent), to support an interactive informed consent process. • Utilize CRICO’s Safer Care modules (www.rmf.harvard.edu/ Clinician-Resources/Article/2014/Safer-Care-in-Office-SettingLanding-Page) so that all members of the care team can help prevent patient harm in the course of diagnosis and treatment. • Refer to resources such as The Doctors Company’s interactive guides (www.thedoctors.com/KnowledgeCenter/PatientSafety/Interactive-Guides-Site-Surveys-Evaluate-Your-Practice-and-Systems) to identify system weaknesses and to develop reliable processes.

Contributed by SDCMS-endorsed The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/ patientsafety. Reference: 1. A snapshot of breast cancer. National Cancer Institute. Nov. 5, 2014. www.cancer.gov/research/progress/snapshots/breast. Accessed Aug. 5, 2015.

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Infectious Disease Ebola Zaire is a virus found in Africa. While some viral hemorrhagic diseases have been carried far outside of Africa, they have always been quickly contained. Therefore, many assumed that Ebola would be no different. The experiences in Texas demonstrated that that was not the case: Transmission did occur to civilians and healthcare workers. While San Diego County has a very small West African population, many hospitals knowing this still stepped forward to be assessment hospitals, and one — UC San Diego Health — took on the role of a treatment facility. As the Ebola outbreak in Africa winds down and it seems very unlikely that any facilities in the county will ever see an Ebola case from this outbreak, much was learned.

Ebola 1 Preparedness Comes to San Diego Five Lessons Learned

by Frank Myers, MA, CIC, and Kim Delahanty, BSN, PHN, MBA/HCM, CIC

October 2015

GEOGRAPHY

What became quickly apparent throughout the United States was that many healthcare providers and patients have an abysmal knowledge of geography. This lack of knowledge of where countries are in Africa resulted in a lot of wasted resources throughout the country. San Diego County was no different. Especially confusing for some was that while San Diego has a large Ethiopian and Somali immigrant population, these countries are nowhere near the three countries that were most heavily impacted: Guinea, Liberia, and Sierra Leone. The distance between Ethiopia and Sierra Leone is roughly that between Portugal and Russia or San Diego and Nova Scotia. Yet hospitals had patients present to them concerned that having shared a drink with an Ethiopian may have exposed them to Ebola. Additionally, lack of knowledge of African countries led some to worry when patients presented from Equatorial Guinea, a country that is different from Guinea with no cases of Ebola.

ALWAYS GET A TRAVEL HISTORY

It is amazing to most people working in infectious diseases that travel histories are not routinely obtained. This year, with measles outbreaks in the Philippines, MERS CoV outbreaks in the Middle East, and endemic cases of chikungunya in Mexico and the Caribbean, a few questions on travel history seem a minimum to protect the healthcare worker and to help diagnose the patient. Even when a travel history was obtained, clinicians sometimes seemed at a loss as to what to do with the information. Rather than note that a patient’s history was not credible if he or she claimed recent travel history from Liberia but could name no cities in Liberia or claimed to have flown direct on Southwest, healthcare resources were mobilized to respond. The short lesson is we will always need to get a travel history even after the current Ebola outbreak is over as long as there are isolated outbreaks and unique endemic diseases in the world.

EBOLA IS HARDER TO CONTAIN THAN WE THOUGHT

Control of blood-borne diseases in the United States has been very good. HIV, hepatitis B, and hepatitis C transmission to healthcare workers is virtually unheard of here. Having said that, one identified Ebola case in Texas managed to infect two healthcare providers. The obvious question is, why? Why did the people he shared an apartment with not get infected? Why did the ambulance

What became quickly apparent throughout the United States was that many healthcare providers and patients have an abysmal knowledge of geography.

crew not get infected? The original emergency department care providers who failed to diagnose him also saw no cases of transmission, and yet two healthcare workers who were aware of the diagnosis become infected. The answer simply is that the stage of the disease he presented with when he was cared for by those two nurses was much more dangerous. That isn’t because the disease is airborne at this later stage — there are no data to suggest that. In fact, the attack rate for Ebola in African households with a case is around 16%, with the risk factors being sharing a bed and caring for the patient while in hospital or burial. These households generally have no ventilation other than windows, and no running water or toileting facilities. If the disease were airborne, it would only be logical that a higher attack rate would occur. Instead, the risk factor comes when the patient enters the “wet” stage of the disease, where a patient may lose 10–15 liters of fluid a day. This copious production of infectious waste combined with a lack of regulatory responsiveness for how to dispose of the waste caused the patient’s room to fill infectious waste containers, posing significant challenges in keeping the room clean and eliminating the bio-burden. In this setting, with less than optimal personal protective equipment, the opportunity for cross-transmission arose.

SOMETIMES LESS IS MORE

While San Diego hospitals began to plan for the possibility of caring for an Ebola patient, they attempted to follow a myriad of constantly changing recommendations from the CDC, the WHO, and CAL-OSHA. Most of the hospitals gathered volunteer healthcare workers and trained them on the use of the personal protective equipment (PPE) they were being directed to use. Using glow-germ (an invisible powder that can only be seen under a special black light) or chocolate pudding or oatmeal, they began to test to make sure staff would not contaminate themselves when doffing (taking off the PPE). Quickly they began to learn some basic facts. Doffing is considered by most experts to be the most dangerous time for cross-transmission to healthcare workers. So the hospitals sought out PPE that was safe and would allow their healthcare workers to work the longest without overheating or fatiguing in order to minimize the number of doffing events per shift. While some worried healthcare workers took to the press demanding to have the PPE they were using in Africa, it became apparent to those testing that PPE that it was inherently more dangerous than safer options. Why was the “African PPE” — Tychem suits and powered air purifying respirators (PAPR) — not seen by many as the best to utilize in caring for patients in U.S. hospitals?

The answer lies in the PPE itself and what it was designed for. The Tychem suits were built for protection against chemicals and gases, meaning that the suits, while great at protection against those agents, did not allow for any heat exchange from the healthcare worker (HCW). This meant the healthcare worker would quickly overheat and need to doff the equipment more frequently, thus putting them at greatest risk. Additionally, the suits were designed to be doffed outside after the wearer had been washed down in a shower or by hose. Hospitals do not provide care outside nor are they set up to hose down an employee coming out of an ICU room. Lastly, as noted by the U.S. government based on hundreds of doffing practices, the suits proved extremely difficult to doff without cross-contamination. In response, many facilities went with a Tyvex suit covered by a surgical gown used in most traumas. HCW were more familiar with this equipment; it was designed to be doffed without cross-transmission, and it had a proven track record of protecting U.S. healthcare workers from blood-borne pathogens even with arterial bleeds.

HOSPITALS ARE NOT BUILT FOR EBOLA CARE

As was stated above, Ebola patients in the wet stage produce copious quantities of infectious materials (vomitus and diarrhea predominately) daily. This meant that in an Ebola care unit, like the one UC San Diego designed, all materials in the room had to be cleanable or would be wasted after the case. Since the costs around hauling Ebola waste can be exorbitant, all noncleanable items would have to be removed. Given the large quantities of PPE needed to wear and the complexity of putting it on in

the correct order, special areas would be needed to don (put on) PPE without interruption or distraction under the direction of a trained staff member. The care area would have to be equipped so staff outside could see into the room and offer assistance. If the patient is in the early stages of disease, he or she may need to communicate with family and loved ones and be kept entertained, so iPads would be used. Simple tasks like listening to heart and breath sounds became impossible when healthcare workers wore PAPRs that covered their entire head. So stethoscopes would need to be purchased that would record the sounds that could be then sent to a professional outside the room so that they could be interpreted. Additionally, all lab tests except the Ebola and malaria tests would preferably be done in the patient’s room to minimize exposure outside the unit. Lastly, an area would need to be developed so that a doffing assistant could aid an HCW in taking off their PPE while not cross-contaminating themselves. Also, a respite area for those on a break needs to be established with showers. San Diego proved up to the task. Hopefully its response will never be tested. Mr. Myers, who sits on the SDCMS GERM Commission (Group to Eradicate Resistant Microorganisms), has worked in the field of infectious disease epidemiology and prevention for more than 25 years, 20 of those in acute care. He is currently an infectious preventionist at UC San Diego Health System. Ms. Delahanty, administrative director of the UC San Diego Health System Infection Prevention/Clinical Epidemiology Unit, also sits on the GERM Commission and has worked in the field of infectious disease epidemiology and prevention for more than 15 years. SAN DIEGO PHYSICIAN.org

Infectious Disease

Chikungunya A New Mosquitoborne Virus

by Robert E. Peters, MD, PhD

October 2015

Chikungunya is on the rise in the United States. Do you know what it is? Some might think it’s one of Ben & Jerry’s new ice cream flavors, but it is a deadly virus that causes severe, often disabling joint pain. Few U.S. doctors are prepared to recognize its signs and symptoms. Since it spread from Asia and Africa in late 2013, chikungunya has infected a million people in the Caribbean, Latin America, and parts of South America and Mexico. Thousands of travelers to the Caribbean and nearby regions are coming home with an unwanted sou-

venir: a mosquito-borne virus that recently settled there. In the United States alone, more than 2,300 travelers since last May have brought home the virus. About a dozen people have gotten it from mosquito bites in Florida. The virus can cause fever, a rash, headache, and muscle and joint pain — mostly in the arms and legs — that can last for months and in some cases even years. The symptoms come and go. Infected subjects never know when it is going to happen. Symptoms usually start three to seven days after the mosquito bite.

Infected individuals will show up to the emergency room with debilitating joint pain. Tests for common illnesses do not help identify the virus as the causative agent. This typically leads to nothing more than an unexplained mystery. Laboratory diagnosis is generally accomplished by testing serum or plasma to detect virus, viral nucleic acid, or virus-specific immunoglobulin (Ig) M and neutralizing antibodies. Viral culture may detect virus in the first three days of illness; however, chikungunya virus should be handled under biosafety level (BSL) 3 conditions. During the first eight days of illness, chikungunya viral RNA can often be identified in serum. Chikungunya virus antibodies normally develop toward the end of the first week of illness. Therefore, to definitively rule out the diagnosis, convalesProject4:Layout 1

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cent-phase samples should be obtained from patients whose acute-phase samples test negative. One of the first Americans to have caught chikungunya from local mosquitoes lived in Florida. State health officials say at least 11 people have been infected in Florida, and they worry the virus will become established there. Florida is not the only state at risk. The fear is that the disease can take hold in any environment that’s warm and humid. The mosquitoes that spread chikungunya live throughout the south, west, and eastern seaboards of the United States. Infectious disease experts are concerned about travelers. Local mosquitoes that bite a traveler infected with the virus can pass it on when they bite others. The southern hemisphere is not the only location 11:22 AM

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Since it spread from Asia and Africa in late 2013, chikungunya has infected a million people in the Caribbean, Latin America, and parts of South America and Mexico. where chikungunya has been identified. Outbreaks spread by locally infected mosquitoes have occurred in Italy and France, and one type of mosquito that can carry chikungunya recently was found in the United Kingdom. As far as we know, you can’t become reinfected. No vaccine has been developed, and there is no treatment except medicine for pain. If you’re heading to the islands or one of the two-dozen countries where chikungunya

is a risk, what should you do? You can prevent infection by using bug repellent with the active ingredient DEET. Keep arms and legs covered, and be alert for symptoms when you get home. Dr. Peters, 18-year member of SDCMS-CMA, is board-certified in family medicine, sits on SDCMS’s GERM Commission, is past president of SDCMS, and is the current chair of the District I Delegation to CMA’s House of Delegates.

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Infectious Disease

Puentes de Esperanza (Bridges of Hope) Treating Tuberculosis Across Borders

by Ramon Moncada, MD, on Behalf of the Puentes Partnership

October 2015

San Diego County has more patients diagnosed with tuberculosis (TB) per year than 43 U.S. states. Imperial County has the highest rate of TB of all 52 counties in California. Baja California has the highest number of TB patients and the highest rate of all 32 states in Mexico. At least 30% of the cases in San Diego and Imperial counties meet the CDC definition of â&#x20AC;&#x153;binationalâ&#x20AC;? by either crossing the border before TB treatment is completed or having exposed someone on the other side while infectious. Our border region is linked economically and socially, and,

At least 30% of the cases in San Diego and Imperial counties meet the CDC definition of “binational” by either crossing the border before TB treatment is completed or having exposed someone on the other side while infectious.

therefore, airborne infectious diseases like TB also link our populations. Because of this reality, virtually every jurisdiction along the U.S.Mexico border, from Texas to California, has reached across the international boundary to collaborate with its Mexican sister jurisdiction in the fight against TB.

What Is Puentes de Esperanza?

In 2006, health providers from Baja California and San Diego began a partnership, Puentes de Esperanza (Puentes) to treat multi-drug-resistant

(MDR) TB patients in Tijuana and Mexicali. At the time, medications for MDR TB were fairly unavailable in Mexico, and laboratory testing was limited to sputum smears. The partnership, funded largely by the U.S. Agency for International Development, created strategies to obtain the tools needed to diagnose and treat MDR patients, established a cross-border expert network to discuss cases, and supported promotoras, or outreach workers, to monitor patient adherence through home-based directly observed therapy (DOT). Over the next five years, 44 binational MDR patients were treated with a cure rate of over 90%. Previously, less than half of patients completed largely self-administered courses of therapy. In 2014, Puentes, aided by San Diego-based International Community Foundation and Robert Wood Johnson Foundation funding, became a Mexican nonprofit organization in an effort to broaden bilateral opportunities for support. In 2015, Puentes was a signatory to a memorandum of agreement with the Counties of San Diego and Imperial, and the State of Baja California for continued commitment to collaborate in TB prevention and treatment. Also this year, the State of California began limited funding of the partnership. Puentes continues its focus on drug- resistant patients but is also broadening

assistance to TB patients with co-morbid conditions, such as HIV infection and other challenging cross-border patients.

Who Are Our patients?

Patient 1: A child with developmental delays was diagnosed with TB in San Diego and, during treatment, returned to live with family members in Baja California. The family had challenges bringing the child into the local health center every day for DOT appointments. Puentes de Esperanza assured the child had home-based DOT. Patient 2: A TB patient in Imperial County lived, on and off, on the other side of the border and was erratic in keeping clinic appointments in Imperial. Treatment was repeatedly suspended. Puentes de Esperanza was able to provide residencebased DOT in Baja California, and the patient became fully adherent. Patient 3: A young adult was diagnosed with pleural TB in San Diego, a type of presentation that signals recent acquisition of infection. The individual spent time on both sides of the border and indicated a symptomatic associate on the Mexican side. Puentes de Esperanza was able to assist in locating the putative source case.

How Can You help?

1. If you are treating a patient for active tuberculosis and he or she is“binational” (i.e.,

they live, spend time, or may have exposed people on both sides of the border), you can call CureTB at (619) 542-4013. CureTB is a binational referral program based in San Diego working with the Puentes de Esperanza partnership. It can work to assure your patient and his or her family get the support they need. 2. The Puentes partnership provides laboratory support and expert provider oversight for drug-resistant TB patients and challenging binational cases. But home-based adherence monitoring cannot be guaranteed with existing resources in Baja California. Lack of DOT places these patients at risk for treatment failure and our binational region at risk of ongoing TB transmission and rising drug resistance. Puentes de Esperanza can provide home-based DOT in Baja California for $60–$90 per month. A donation of $1,000 can provide DOT for one year. If you are interested in supporting Puentes de Esperanza or learning more, you can reach the Puentes de Esperanza partnership by emailing rmoncada@ aol.com or hectorpuentesac@ gmail.com. Dr. Moncada, 23-year member of SDCMS-CMA (currently retired), is an infectious disease specialist and sits on SDCMS’s GERM (Group to Eradicate Resistant Microorganisms) Commission. SAN DIEGO PHYSICIAN.org

Infectious Disease Tick Bite Prevention “Where have you been?” is a routine yet critical question to ask patients, especially when working up fever and other acute complaints that may be caused by vector-borne diseases. According to the World Health Organization, vectorborne diseases account for more than one billion cases of illness and one million deaths worldwide each year. The great majority of these diseases occur in the tropics and subtropics, but when a patient reports no travel outside San Diego County, vector-borne disease is increasingly becoming a concern as local mosquitoes, ticks, and fleas can carry human pathogens.

West Nile Virus

Vector-borne Diseases in San Diego “Where have you been?”

by Eric McDonald, MD, MPH

October 2015

West Nile virus (WNV) is the most common, locally acquired vector-borne disease reported in San Diego County. WNV was first detected in the United States in 1999 in New York and is transmitted primarily by Culex species mosquitoes that feed on birds and humans, and breed in urban environments. It quickly spread westward, reaching California in 2003 in Imperial County. The following year, WNV was found in San Diego County, and the first locally acquired human case was reported here in 2006. WNV activity varies each year, with multiple factors contributing to its incidence, including weather, economics, and naïve reservoir populations. Last year, 11 cases (including two deaths) were reported in the county. The 2015 season has been more intense, with increased numbers of dead birds and mosquito pools positive for the virus and more human cases reported than in recent years. Current surveillance and case information can be found on the San Diego County Department of Environmental Health Vector Control Program (DEH VCP) website at www.sdvector.org. WNV should be considered

Ticks are generally found near the ground, in brushy or wooded areas. They can’t jump or fly. Instead, they climb tall grasses or shrubs and wait for a potential host to brush against them. When this happens, they climb onto the host and seek a site for attachment. To prevent bites: • Wear repellent containing at least 20% DEET or permethrintreated clothing. Additional repellent options are available. For more information, visit http://cfpub.epa. gov/oppref/insect. • Treat dogs and cats for ticks as recommended by a veterinarian. • Check for ticks after walking through tick habitat, especially under the arms, behind the ears, inside the belly button, behind the knees, between the legs, around the waist, and on the hairline and scalp. • Shower soon after being outdoors. • For tips on “tick-safe” landscaping, see www. cdc.gov/lyme/prev/ in_the_yard.html.

in the differential diagnosis for patients presenting with fever or rash after a mosquito bite and those with aseptic meningitis, encephalitis, and/ or acute flaccid paralysis. WNV testing is available through most commercial laboratories and through the California Department of Public Health (CDPH) Viral and Rickettsial Disease Laboratory (VRDL), via submittal to the San Diego County Public Health Laboratory. Clinical guidelines, testing algorithms, and specimen submission forms are available at www.sdepi.org and more information about WNV may also be found at the Centers for Disease Control and Prevention (CDC) WNV website at www. cdc.gov/westnile.

HEALTH HERO

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Infectious Disease Yellow Fever, and Dengue and Chikungunya Viruses

Two invasive mosquitoes capable of transmitting yellow fever, and dengue and chikungunya viruses have recently been detected in San Diego County. In 2014, Aedes aegypti (yellow fever mosquito) was found at Naval Base San Diego on 32nd Street and has subsequently been detected in several other areas of the county. In September 2015, Aedes albopictus (Asian tiger mosquito) was detected in Barrio Logan and Carlsbad. Both of these mosquitoes are aggressive daytime biters, and residents are encouraged to report them to the VCP at (858) 694-2888. Although no locally acquired cases of dengue or chikungunya have been reported, many cases occur in northern Mexican states, and imported cases of have been reported in San Diego. Many clinicians are not familiar with the presentation and evaluation of dengue fever. Symptoms begin three to 10 days after exposure and include biphasic fever, joint pain, headache, retro-orbital

pain, rash, myalgia, arthralgia, general weakness, and extreme fatigue. Recognizing early signs of shock and hemorrhagic complications and promptly initiating intensive supportive therapy can reduce the risk of death among patients with severe dengue. Dengue is typically diagnosed using serum collected during both acute (first five days post symptom onset) and convalescent phases (six or more days post symptom onset). For clinical information and laboratory guidance on dengue, go to the CDC dengue website at www. cdc.gov/dengue, where a free continuing medical education accredited (CME) online course about the disease was recently posted: www.cdc.gov/ dengue/training/cme.html. Chikungunya (CHIKV) is also an illness that most clinicians have never seen. The incubation period is typically three to seven days (range one to 12 days) after exposure. Acute onset of fever and polyarthralgia are the primary clinical findings. Joint symptoms are usually symmetric, often occur in the hands and feet, and can be severe and

Mosquito Bite Prevention Mosquitoes can spread disease when they bite humans and animals. The best way to prevent getting a disease like West Nile virus is to protect yourself from mosquitoes via the following actions: • Wear long sleeves and pants to cover up skin when outdoors. • Apply an insect repellant that contains DEET, Picadirin, oil of lemon eucalyptus, or IR3535 to your exposed skin or clothing; follow label instructions. • Install screens on doors and windows, and keep them well maintained to prevent mosquitoes from entering the home. • Use larvicides, such as mosquito dunks (Bti) or mosquito fish in backyard ponds, fountains, and unused pools to stop larvae from developing into adults. Mosquito dunks are available at most home improvement stores. • Avoid going outdoors during dawn and dusk hours, when mosquitoes are most active. • Trim and thin shrubs and bushy plants where mosquitoes may hide. • Remove standing water from around your home. • Report mosquito-breeding sources to www.sdvector.com.

October 2015

debilitating. Other symptoms may include headache, myalgia, arthritis, conjunctivitis, nausea/vomiting, or maculopapular rash. Dengue and CHIKV should be considered together in a differential diagnosis, especially in travelers with fever and polyarthralgia. CHIKV serologic testing is available through commercial laboratories, as well as from the CDPH VRDL. More information about the clinical presentation, diagnosis, and management of CHIKV infection may be found at the CDC chikungunya website at www. cdc.gov/chikungunya.

Tick-borne Diseases

The pathogens for several tick-borne diseases have been detected in ticks in San Diego County: Borrelia burgdorferi, the spirochete responsible for Lyme disease; Francisella tularensis, the cause of tularemia (also transmitted by deer flies); Rickettsia rickettsii, which causes Rocky Mountain spotted fever (RMSF); and Rickettsia phillipi, which can result in an eschar and fever. Human disease from any of these bacteria is rare in San Diego, but each can be diagnosed with specialized testing and treated with antibiotics. For more information on the symptoms, diagnosis, treatment, and prevention of tick-borne diseases, the CDC tick-borne disease website has published a newly updated booklet at www.cdc. gov/lyme/resources/TickborneDiseases.pdf.

Flea-borne Diseases

Two flea-borne diseases are endemic in San Diego County: murine typhus, caused by Rickettsia typhi and possibly Rickettsia felis; and plague, caused by Yersinia pestis. Murine typhus should be considered in patients presenting with persistent fever of three to five days’ duration without explanation, especially if there has been

possible flea contact though local exposure to opossum or cats, or if there is a travel history to tropical or semitropical environments with large rat populations. Although a San Diego woman was diagnosed with locally acquired murine typhus this year, it is uncommon. More information on this illness in Southern California may be found at http://cid. oxfordjournals.org/content/46/6/913.full. Human plague has been in the news because of recent cases contracted in Yosemite. The symptoms of plague depend on the organs infected in each person: bubonic plague in lymph nodes, septicemic plague in blood, and pneumonic plague in lungs. No human case of plague has been reported in San Diego County in decades, although squirrels on Palomar Mountain have tested positive for the bacteria this year. Detailed symptom, diagnosis, and treatment information may be found at the CDC plague website at www. cdc.gov/plague.

Conclusion

All of the vector-borne diseases in this article are reportable by California law. Clinicians should report suspected or confirmed cases to the San Diego County Epidemiology Program by calling (619) 6928499 during normal business hours, or (858) 565-5255 after hours, on weekends, or county-observed holidays. For more information on preventive measures for the public and about vector-borne disease surveillance in San Diego County, visit www. sdvector.org. Dr. McDonald, seven-year member of SDCMS-CMA, has a fiveyear tenure with the County of San Diego and currently serves as the medical director of the HHSA Epidemiology and Immunization Services Branch (EISB) in the local health department.

Where are your patients coming from? Each month, every practicing physician in San Diego County receives a copy of San Diego Physician magazine. What better way to ensure that other physicians know about your medical practice than through a referral advertisement in this highly regarded publication? Advertising packages are available at very attractive price points, and for a limited time SDCMS member physicians receive 50% off by mentioning this ad.

Physician referral marketing is on the rise — just read some of the statistics:

“…patients…get nearly 70% of specialist referrals from their primary care doctors.” “According to one national survey, four in 10 medical office managers flagged referrals from other physicians as the most effective way to attract new patients.”

“…most experts say referral marketing will only become more entrenched as health care cuts continue.” Contact Dari Pebdani today to get your campaign started. DPebdani@SDCMS.org or 858-231-1231 *New contracts only

SAN DIEGO PHYSICIAN.org

Early Bird Special! SDCMS-CMA Member Physicians: If you are paying full, non-discounted dues and are with a medical group of 150 or fewer physicians, you will receive a 5% discount on your 2016 SDCMS-CMA dues if you renew and pay in full before October 31, 2015. SDCMS-CMA Members

Save $50

Seeking Family Medical and Internal Medicine Physicians in Vista and Riverside Position: Full-time, part-time and per diem Family Medicine and Internal Medicine Physicians. Malpractice coverage is provided by clinic. Requirements: California license, DEA license, CPR certification and board certified in family medicine. Bilingual English/Spanish preferred. Send resume to: hr@vistacommunityclinic.org or fax to 760-414-3702

Pay Early â&#x20AC;Ś Save Money

Renew Online Today at SDCMS.org or Call SDCMS at (858) 565-8888

Vista Community Clinic is a private, nonprofit outpatient community serving people who experience social, cultural or economic barriers to health care in a comprehensive, high quality setting.

www.vistacommunityclinic.org EEO/AA/M/F/Vet/Disabled

October 2015

SDCMS Physician Networking Opportunity and Mixer The November 18, 2015 mixer at Handlery Hotel has been rescheduled to February 4, 2016. Save the Date!

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!

Lead a team of 20 or more patients and staff and receive FREE team t-shirts with your practice/team identification.

Visit www.SB5K.org to sign up. For more information email Carlos.Medina@sdcms.org. Benefiting

Improving Health…Changing Lives PRESENTED BY

IN PARTNERSHIP WITH

5575 Ruffin Rd., Ste 250, San Diego, CA 92123 www.SB5K.org 858.300.2777 SAN DIEGO PHYSICIAN.org

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 KAISER PERMANENTE SAN DIEGO LOOKING FOR PEDIATRIC PER DIEM MDs: As many hours per week as you want! Shifts are available during the day, evenings, and/or weekends. We have 13 different locations across the county, and three main ones for evenings and weekends: San Marcos, Vandever, Otay Mesa. Competitive hourly rates! Please contact (619) 641-4324 if interested. [430] ED PHYSICIAN WANTED: Full/part-time opportunity for BC/BE emergency physician, 20-bed ED, GlideScope, ultrasound, mid-levels. Independent group with partnership tract. Send CV to ppiememergencyphysicians@yahoo.com. Call (619) 417-6581. [428] SEEKING A PART-TIME, FAMILY PRACTICE, BOARDCERTIFIED/BOARD-ELIGIBLE PHYSICIAN: Urgent care / family practice office in upscale North Coastal San Diego County area, located two miles from the ocean, is currently seeking a part-time family practice board-certified / boardeligible physician. See a variety of urgent care and family practice patients at a well-established solo practice. No HMO patients, no call. Growth potential. Please email CV to gcwakeman@sbcglobal.net or fax to (760) 603-7719. [387] 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] FAMILY PRACTICE PHYSICIAN FOR A BUSY FEDERALLY QUALIFIED HEALTH CENTER: Mountain Health is a mission-driven organization that serves both rural and urban residents of San Diego County. We have been in business for 40 years and offer a competitive salary, medical benefits, vacation, paid holidays, sick time, CME reimbursement, and license reimbursement. Board-certified and bilingual English/Spanish preferred. Send CV to tfindahl@mtnhealth.org or (619) 478-9164. You may contact HR directly at (619) 478-5254, ext 30. Visit www.mtnhealth.org. [416] INTERESTED IN BECOMING A PRECEPTOR FOR OSTEOPATHIC MEDICAL STUDENTS? Midwestern / AZCOM osteopathic medical school in Phoenix has third- and fourthyear medical students in San Diego looking for clinical rotations, particularly in pediatrics, psychiatry, general surgery, and OB/GYN. Requirements: Either MD or DO; physicians interested must commit to minimum one four-week rotation per year / or more as desired (2–3 preferable) and to FT hands-on training for each student as is reasonable for the duration of the rotation. Compensation and CME provided. If interested, please contact Dr. Kevin Considine at kconsidine@sbcglobal.net for more information. [408] 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] 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 board-certified 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 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, longterm 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 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. [390] PRIMARY CARE POSITION: San Diego area. Outpatient only. No calls. No hospital and no weekends. Email sandiegoprimarycare@yahoo.com. [388] FAMILY OR INTERNAL MEDICINE PHYSICIAN: Graybill Medical is one of the region’s largest independent, multispecialty groups. We are currently looking for a general family medicine physician (Escondido or Temecula) and an internal medicine physician (Temecula) to provide quality

To submit a classified ad, email Kyle Lewis at KLewis@SDCMS.org. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $150 (100-word limit) per ad per month of insertion.

October 2015

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] 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) 9925330 or email CV to drhunt@thehousecalldocs.com. Visit www.thehousecalldocs.com. [037] 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 SPACE AVAILABLE OFFICE ASSOCIATE TO SHARE SPACE WITH FULLTIME PCP: Ideal for part-time PCP or full-time subspecialist who needs presence near hospital. 2700ft2 beautifully appointed setup with four exam rooms, a cardiac testing room, two consultation rooms, and balcony in classy and well-maintained, multi-use building. One block from Scripps Mercy Hospital in Hillcrest. Highly trained and service-oriented back- and front-office staff with time to spare. EHR fully set up and smoothly functioning. Friendly office dog. Costs negotiable. Most important factor for the associate is personal and professional compatibility. Interested? Send letter of inquiry with contact information to associate@personalprimarycare.com. [429] 2,000FT2 MEDICAL OFFICE SPACE AVAILABLE TO SHARE IN POWAY: Office space available as of January or February 2016 to share with orthopedic surgeon in Poway at professional medical building. Approximately 2,000ft2, separate reception, four exam rooms, part-time on Thursdays and Fridays or schedule to discuss. Utilities included, separate desk work area for one employee with separate phone line and internet. Rates will depend on usage, shortor long-time lease available. Newly remodeled, upbeat staff and environment, walking distance to Pomerado Hospital and other medical facilities nearby. For more information, email Anna at anna@pomeradoortho.com or call (858) 487-6440. [427] CLASS “A” MEDICAL OFFICE FOR SUBLEASE / SHARE: Great location — beautiful office — 700 Garden View Court, Suite 100 Encinitas. For more information, please call Annie at (760) 633-1000. [426] CENTRALLY LOCATED UTC/LA JOLLA MEDICAL OFFICE SPACE and Medicare/AAAASF-accredited surgery center available for sublease starting January 2016. Facility has three examination rooms, physician office space, full operating room, and recovery area. This is an excellent opportunity and location for a busy dermatologic, surgical, ENT, or internal medicine practice. Please contact drmofid@drmofid.com for further information. [425]

MEDICAL OFFICE FOR SUBLEASE / SHARE: Scripps Encinitas Campus, 332 Santa Fe Dr. — great location on the hospital campus directly off the I-5. Sublease Office Space: 2,745ft2 available January 1, 2016. Available Immediately to Share: MD and nurse station, 2–3 exam rooms, ADA restroom, ample waiting. High-speed wireless, and conference room onsite. Large parking garage for patient convenience. Please call (760) 943 -6700, ext. 676, for further information. [421]

LAST CLASS “A” MEDICAL OFFICE AVAILABLE, VISTA Upgrade to Class “A” medical office in TriCity’s leading outpatient health center. 1,250 RSF office for lease. 3 large exam rooms, MD office, nurse station, ADA restroom, and ample waiting. Will be completely rebuilt. Reserved physician parking & ample surface patient parking. One blockfrom TriCity Medical Center. More than 40 physicians and strong primary care referral base. Contact Greg Petree at (858) 792-0696 x112 or visit www.vistamedicalplaza.com/ suite-265

OFFICE BUILDING FOR SALE: Approximately 11,000ft2 building for sale. Established tenants producing income in 2,190ft2 and 3,010ft2 suites. Remaining suite approximately 5,800ft2 with large waiting room, six exam rooms, minor procedure room, PT area, digital X-ray suite, ample storage, and administrative offices. Free parking. Located near Sharp Memorial and Rady Children’s Hospital. Email lvista55@yahoo.com. [420] FOR LEASE — SORRENTO MEDICAL PLAZA: 9200 Scranton Road, San Diego, CA 92121. New construction. This one-story Class ‘A’ medical office building is designed and constructed to meet the demands of contemporary medical and dental practices. An open layout achieves a balance of light and offers flexibility for designing a fully customized office. Great location with easy access for patients and excellent parking. Sorrento Medical Plaza is a strategic location that provides immediate access to visibility to Interstate 805 with easy connection to Interstate 5 and the 56 & 52 freeways and close proximity to San Diego’s leading hospitals. Accessibility extends to the expanding patient base of UTC / La Jolla, Carmel Valley, Central San Diego, and Coastal North County. Please call Paul Braun at (858) 410-6388 or email him at paul.braun@am.jll.com. [419] ESCONDIDO OFFICE AVAILABLE FOR SUBLEASE: Four exam rooms with reception and waiting area, located near downtown. Available full and half days. Please email staff@palmedinc.com for info. [417] LAST CLASS ‘A’ MEDICAL OFFICE AVAILABLE, VISTA: Upgrade to Class ‘A’ medical office in Tri-City’s leading outpatient health center. 1,250 RSF office for lease. Three large exam rooms, MD office, nurse station, ADA restroom, and ample waiting. Will be completely rebuilt. Reserved physician parking and ample surface patient parking. One block from Tri-City Medical Center. More than 40 physicians and strong primary care referral base. Contact Greg Petree at (858) 792-0696, ext. 112, or visit www.vistamedicalplaza.com/suite-265. [415]

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] 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] 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 Xray, 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: Welldesigned 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]

OLD DEL MAR MEDICAL OFFICE SPACE FOR LEASE: 317 14th St., Del Mar, CA. 1,400 square feet / $3 square foot gross rent — located in the heart of Del Mar in an established medical complex. 3–5 year terms with TI allowances available. Email inquiries to richcardow@yahoo.com or call (970) 3907026. [406]

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]

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]

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]

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

NONPHYSICIAN POSITIONS AVAILABLE NURSE PRACTITIONER OR PHYSICIAN ASSISTANT: Looking for full-time nurse practitioner or physician assistant to see patients in various nursing homes. It can be salaried position (1099) or percentage of production depending on experience. Average $100–$120 per hour. Flexible hours, choose your own days and time. Lots of upward potential for the right candidate. Please email guharoysd@gmail.com or call (858) 430-6656. [424] 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] EXPERT MA FOR SPORTS/ARTHRITIS REGENERATIVE MEDICINE PRACTICE: Seeking experienced MA (3 years +) to bridge our front and back offices. We are a female-led, seven-year-old solo practice in Encinitas. Duties include processing patient paperwork, taking vitals and histories, entering data into EHR system, drawing blood, drawing up medications, processing orders, and ensuring a friendly, caring patient experience of excellence. BA/BS preferred; MA certification required. Attention to detail, sterile technique, and a sense of humor a must! Great compensation package, including pro growth stipend. Send your resume, salary history/requirements, and letter of interest (text pasted into the body of the email) to admin@feelboundless.com. [418] 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] NURSE PRACTITIONER: Needed for housecall physician in San Diego. Full-time, competitive benefits package and salary. Call (619) 992-5330 or email drhunt@thehousecalldocs.com. Visit www.thehousecalldocs.com. [152] PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Needed for house-call physician San Diego. Part-time, flexible days / hours. Competitive compensation. Call (619) 9925330 or email drhunt@thehousecalldocs.com. Visit www. thehousecalldocs.com. [038] MEDICAL EQUIPMENT / OFFICE FURNITURE FREE EQUIPMENT FOR DONATION: Defibrillator — Zoll AED Plus and Inovo Oxygen tank. Interested parties please email lisas@sdsm.net. [389] CLINICAL TRIAL VOLUNTEERS NEEDED BIPOLAR DISORDER CLINICAL TRIAL VOLUNTEERS NEEDED: UCSD is conducting a longitudinal study on how inflammatory biomarkers and mood fluctuations among those diagnosed with bipolar disorder may be predicting factors to decline in their cognitive functioning over time. We are recruiting people between ages 35–60 who are diagnosed with Bipolar I Disorder. They must consent to three blood draws a year, clinical assessments, neurocognitive batteries, and use of smartphone. There is monetary compensation for their participation. No medication is involved in this study. If you have any referrals or would like more information, please contact the study recruiter, Nana Kori, at nkori@ucsd.edu or at (858) 534-9439. [405]

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] SAN DIEGO PHYSICIAN.org

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

What did surprise me was that I strongly associated women with home and family, and men with career.

We Can Each Contribute to Healthcare Equity by Helane Fronek, MD, FACP, FACPh

That healthcare disparities exist — in access, treatment, and outcomes — is a fact. Historical mistreatment of certain groups, like the Tuskegee experiments on African Americans, engendered mistrust of the healthcare system by minorities. In response, medical education now attempts to illuminate the effect of culture on patient-physician interactions by teaching cultural competence and humility. Lack of medical insurance limits access for the poor or unemployed. Our government has improved access by expanding the availability of medical insurance. Yet the most crucial factor in maintaining disparities is our own unconscious bias. We each walk into work with a set of biases. If athletic, we may relate better to and prefer thin, athletic patients. Millennials may want patients to be quick and

October 2015

technology-savvy. Whites may have a tendency to distrust people of color and vice versa. As healthcare professionals, we must care for many types of individuals. How can we overcome our preferences and provide the best for each of them? The first step is to recognize our biases and acknowledge they may be affecting the care of our patients. Harvard’s Project Implicit — https://implicit.harvard.edu — can help us discover our unconscious preferences through quick tests that demonstrate our associations with different types of people: young vs. old, dark-skinned vs. light-skinned, fat vs. thin, etc. I found my results interesting, although most weren’t surprising — our society sends strong messages that it’s better to be young, beautiful, and thin, and I clearly picked these up. What did

surprise me was that I strongly associated women with home and family, and men with career. At my earliest opportunity, I enthusiastically jumped into the workforce and have enjoyed many stimulating and fulfilling jobs. My mother, the highest-ranking woman in a large company, managed the credit operations for a chain of department stores. I am a strong advocate for women in the workplace. However, in my early years, my mom stayed at home, cooking dinner, doing the laundry, keeping the house clean, and serving in many volunteer roles in women’s organizations. It seems that in spite of my mother’s activities and my 30-year medical career, my unconscious expectations for women have not changed since early childhood. This was both distressing and very informative. It may explain why I always acknowledge stay-at-home moms’ contributions to their family and the hard work they do; in this regard, my bias may help to form strong connections to this group of patients. But does a bias against fat people cause me to discount patients’ abilities and offer less treatment or encouragement? Does a preference for young vs. old make me tune out rambling histories told by elderly patients? As the adage goes, the only person we have control over is ourself. We are wise to observe our unconscious biases and how they affect the care we provide. Once aware of our behavior, we can intentionally take steps to correct it. In this way, we have the power to create an enormous shift toward equalizing healthcare outcomes for all of our patients. 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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