November 2016 by San Diego Physician

November 2016 official publication of SDCMS

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Thank you for helping us create a safety net for uninsured patients in San Diego.

Donating your time, talent, and treasure makes a tremendous difference. At Champions for Health, our work is only possible through support from physicians who volunteer their time and expertise to heal uninsured patients in our community. To date, this extraordinary team has performed more than 13,000 procedures to enhance the health and quality of life of patients who otherwise couldn’t afford these services. Yet, countless others are still in need of our help. By joining our team of volunteer physicians or by making a donation today, you can help ensure Champions for Health reaches the patients who desperately need specialty medical care. To help us heal neighbors in need, please visit: ChampionsForHealth.org/donate Or contact: Barbara.Mandel@ChampionsFH.org I 858-300-2777 SAN DIEGO PHYSICIAN.org

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Contents

Volume 103, Number 11

EDITOR: James Santiago Grisolía, MD MANAGING EDITOR: Kyle Lewis EDITORIAL BOARD: James Santiago Grisolía, MD • Mihir Parikh, MD • Robert E. Peters, MD, PhD • J. Steven Poceta, MD MARKETING & PRODUCTION MANAGER: Jennifer Rohr SALES DIRECTOR: Dari Pebdani ART DIRECTOR: Lisa Williams COPY EDITOR: Adam Elder OFFICERS President: Mihir Y. Parikh, MD President-elect: Mark W. Sornson, MD Secretary: David E. J. Bazzo, MD Treasurer: James H. Schultz Jr., MD Immediate Past President: William T-C Tseng, MD, MPH (CMA Trustee)

6 features

AT-LARGE and AT-LARGE ALTERNATE DIRECTORS Lase A. Ajayi, MD • Karrar H. Ali, DO, MPH • Steven L-W Chen, MD, MBA (Alt) • Stephen R. Hayden, MD • Vimal I. Nanavati, MD (Alt) • Alexexandra E. Page, MD • Robert E. Peters, MD, PhD (Alt) • Carl A. Powell, DO (Alt) • Peter O. Raudaskoski, MD • Albert Ray, MD (Alt) • Thomas J. Savides, MD • Karl E. Steinberg, MD (Alt) • Erin L. Whitaker, MD (Alt) • Marcella (Marci) M. Wilson, MD (Alt) • Holly B. Yang, MD (Board Rep) • Nicholas J. Yphantides, MD

Antibiotic-resistant Microbial Pathogens: Update on Efforts to Combat This Public Health Threat

BY MICHAEL BUTERA, MD, FIDSA

OTHER VOTING MEMBERS Communications Chair: J. Steven Poceta, MD Delegation Chair: Robert E. Peters, MD, PhD Young Physician Director: Edwin S. Chen, MD Resident Physician Director: Michael C. Hann, MD Retired Physician Director: Rosemarie M. Johnson, MD Medical Student Director: David Li

18 Zika Virus: An Unprecedented Public Health Epidemic ROBERT E. PETERS, PHD, MD

Sexually Transmitted Diseases in San Diego County BY WINSTON TILGHMAN, MD

epatitis C: The Need to Expand H Screening Now Y ROBERT G. GISH, MD, AND B CATHERINE T. FRENETTE, MD

departments 4

riefly Noted: Calendar • CMA HOD • B Patient Rights and Dementia • Featured Members • In Memoriam • And More …

Four Ways San Diego’s Physician Leaders Will Help Our Community Thrive in the Years Ahead

OTHER NONVOTING MEMBERS Young Physician Alternate Director: Heidi M. Meyer, MD Resident Physician Alternate Director: Zachary T. Berman, MD Retired Physician Alternate Director: Mitsuo Tomita, MD SDCMS Foundation President: Albert Ray, MD (Delegation Vice Chair) (At-large AMA Delegate, Appointed by CMA) Delegation Chair: Robert E. Peters, MD, PhD CMA President-elect: Theodore M. Mazer, MD (At-large AMA Delegate, Appointed by CMA) CMA Past Presidents: James T. Hay, MD (AMA Delegate) • Robert E. Hertzka, MD (Legislative Committee Chair, At-large AMA Delegate, Appointed by CMA) • Ralph R. Ocampo, MD CMA Trustee: Bob E. Wailes, MD AMA Alternate Delegate: Lisa S. Miller, MD

BY SHERRY NOORAVI, PSYD

Physician Marketplace: Classifieds

8 Money Talks: Discussing Cost With Patients Before Treatment Is a Win-Win

BY RALPH A. GAMBARDELLA, MD

BY CHRISTINA LEWIS, MPA

November 2016

GEOGRAPHIC and GEOGRAPHIC ALTERNATE DIRECTORS East County: Susan Kaweski, MD (Alt) • Jay P. Mongiardo, MD • Venu Prabaker, MD • Kosala Samarasinghe, MD Hillcrest: Gregory M. Balourdas, MD • Kyle P. Edmonds, MD (Alt) • Thomas C. Lian, MD Kearny Mesa: Sergio R. Flores, MD (Board Rep) • 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 • Wayne C. Sun, MD (Alt) North County: Neelima V. Chu, MD (Alt) • Michael A. Lobatz, MD • Patrick A. Tellez, MD South Bay: Maria Carriedo, MD (Alt) • Reno D. Tiangco, MD • Michael H. Verdolin, MD

unning and Walking to Prevent R Diabetes

Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org. All advertising inquiries can be sent to DPebdani@SDCMS.org. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

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/////////Briefly /////////////////Noted //////////////////////////////////////////////////////////////////////// calendar SDCMS-CMA CALENDAR

For further information or to register for the following, contact Jen at (858) 300-2781 or at JOhmstede@ SDCMS.org. Medicare: Managing Change and Facing the Future (seminar/ webinar) DEC 1: 11:30AM–1:00PM

HEALTHCARE CONFERENCES

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. Biomarker Summit 2017 MAR 20–22 at the Hilton San Diego Resort & Spa

CMA

145th Annual House of Delegates More than 500 physicians from across California convened in Sacramento Oct. 14–16 for CMA’s 145th annual House of Delegates (HOD) meeting, marking the end of the first year of CMA’s new governance reforms. The HOD now meets to establish broad policy on current major issues affecting physician members, the association, and the practice of medicine, with the major issues discussed this year being MACRA, maintenance of certification, opioids, physician burnout, ACA changes, and public health. We will share with you the final reports detailing the actions taken by the delegates as soon as they become available.

Dr. Ruth Haskins Becomes CMA’s 149th President

PATIENT SUPPORT

San Diego Spondylitis Support Group

Ruth Haskins, MD, was installed as the 149th president of CMA during its annual House of Delegates meeting in October. Dr. Haskins, an OB-GYN practicing out of Folsom, has been a CMA and Sierra Sacramento Valley Medical Association member for 23 years. She served on the CMA board of trustees from 2013 to 2015 and as chair of the CMA Council on Legislation from 2010 to 2013. Congratulations, Dr. Haskins!

By Michael Supancich, MD, Group Co-leader

Our support group is affiliated with the Spondylitis Association of America. We meet on the third Saturday of alternate months. The meetings are held in “The Hastings Room” within the cafeteria at Scripps Green Hospital in La Jolla. There is no charge to attend the meetings. The goal of our group is to inform individuals with A.S. on treatment options along with how to best communicate with their physicians. For further information, visit www. spondylitis.org/San-Diego-Support-Group.

November 2016

“

I have been impressed with the urgency of doing. Knowing is not enough; we must apply. Being willing is not enough; we must do.

”

— Leonardo da Vinci, Italian Polymath (1452–1519)

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BIOETHICS

Patient Rights and Dementia SDCMS’s Bioethics Commission met again on Oct. 26 to discuss “Patient Rights and Dementia,” with presentations on rights vs. capacity by Dr. Glenn Panzer, chief medical officer at the Elizabeth Hospice, board chair of the San Diego Dementia Consortium, and chair of the Palomar Health Bioethics Committee, and Kimberly McGhee, Esq., elder law attorney, board member of the Southern Caregiver Resource Center, and vice president of Southern California National Academy of Elder Law Attorneys. Dr. Panzer’s presentation was titled, “Treatment Decisions in Residents With Dementia: Understanding Capacity and Resident Rights,” and Ms. McGhee’s was titled, “Legal Aspects of Incapacity.” If you would like to receive copies of Dr. Panzer’s and Ms. McGhee’s presentations, please email Editor@SDCMS.org. SDCMS’s Bioethics Commission will meet in 2017 on Jan. 25, April 26, July 26, and Oct. 25. Our Bioethics Commission comprises physicians, nurses, pastors, social workers, professors, attorneys, students, and others from across the county who meet quarterly to promote best and innovative practices in bioethics, including clinical, organizational, systems issues, and bioethics committee

functions. Meetings begin at 6 p.m. and end at 8 p.m., and are held at SDCMS’s offices — with dinner available. If you would like more information on how you can get involved, email Kyle Lewis at KLewis@SDCMS.org. As well in October, SDCMS hosted an all-day workshop on the End of Life Option Act, conducted by the San Diego Coalition for Compassionate Care, with the following objectives: discuss key aspects of the End of Life Option Act, including patient eligibility and required provider actions; describe how ethical considerations impact personal and organizational participation; list three important things to consider when patients ask about their dying process; implement conversation skills to help patients discuss end of life; apply cultural congruency theory to care conversations in the setting of serious illness. SDCMS has a number of committees and commissions and various other opportunities for member physicians to become involved and get engaged. To learn more about how you can support your physician colleagues, fight for your patients, and be a part of the solution, email SDCMS@SDCMS.org. Thank you for your membership!

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In the October issue, Jen Devries should have been listed with Evelyn Ross as co-author of “White Coats for Black Lives” — our apologies to Ms. Devries. SAN DIEGO PHYSICIAN.org

/////////Briefly /////////////////Noted //////////////////////////////////////////////////////////////////////// featured members Several SDCMS member physicians received CMA honors in October, including Dr. Ted Mazer, who was elected president-elect of CMA; Dr. Al Ray, who was awarded the Gary F. Krieger Speaker’s Recognition Award for distinguishing himself with his contributions to patients, to the profession, to CMA, and to the House of Delegates; Dr. Bob Wailes, who received the Joseph Boyle, MD, Young at Heart Award, given by CMA’s Young Physician Section (YPS) to a CMA member who supports and mentors California’s young physicians; Dr. Lase Ajayi, who was inducted as this year’s CMA YPS chair; and Dr. Susan Kaweski, who was elected vice chair of CALPAC, CMA’s political action committee. Congratulations, Drs. Mazer, Ray, Wailes, Ajayi, and Kaweski.

Vector-Borne Disease Survey

Please Take 15 Minutes to Complete This County Survey The County of San Diego HHSA has asked SDCMS to promote a survey it’s conducting to gauge the current knowledge, attitudes, and practices among clinicians and other healthcare providers about endemic and emerging mosquito-borne diseases. The survey should take no longer than 15 minutes to complete, and all responses will be anonymous. Results will be used to improve communication and guidance to healthcare providers about mosquito-borne viruses in our border region. If you would like more information on how this survey will be used, please contact Dr. Eric McDonald at eric.mcdonald@sdcounty.ca.gov. If you would like to be entered into a drawing for either an iPad or a $400 donation to a charity of your choice, provide your email address at the end of the survey. Your email address is collected only as means for notifying a winner of the drawing, and will not be used for any other purpose. Visit www.surveymonkey.com/r/Vectorborne to take the survey. Your participation is greatly appreciated and is completely voluntary!

Dr. Mazer

Dr. Ray

Dr. Ajayi

Jerry E. Fein, MD, 47-year member of SDCMS-CMA, was discovered to have passed on Jan. 27, 2016. Our deepest sympathies to Dr. Fein’s family and friends.

For the first time in CMA’s 160-year history, membership has surpassed 43,000. Your California Medical Association is bigger and stronger than it has ever been — thank you for your support! November 2016

Dr. Kaweski

IN MEMORIAM

CMA MEMBERSHIP

Dr. Wailes

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R i s k M a n ag e m e n t

Money Talks Discussing Cost With Patients Before Treatment Is a Win-Win by Ralph A. Gambardella, MD

“My knee still hurts after surgery, and I’m getting all these bills to pay that I didn’t know about.” I thought it was going to be another typical day at my practice, but I found myself comforting an upset and frustrated patient who was still having a hard time returning to golf three months after having an arthroscopic medial menisectomy. “What had I done wrong?” I asked myself. “Mr. Jones” had made an appointment to see me after twisting his knee trying to kick a soccer ball around with his grandson. He was 62 years old and already had been treated by his primary care physician with medicine and therapy but had remained symptomatic with a torn medial meniscus on MRI. He was miserable because he had not been able to play golf and couldn’t even keep up with his wife on their evening walks. He was overweight, with a varus knee and early osteoarthritis on weightbearing X-rays and MRI. Of course, his internist and friends had told him that he needed an arthroscopic surgery, and, after that, he would be all better. Despite counseling him that he might still have knee pain after a meniscectomy

November 2016

due to the underlying arthritis, we agreed that an arthroscopic surgery was in his best interest to try to improve his lifestyle. We discussed all the medical and surgical risks and postoperative rehabilitation program. I connected him to my surgery scheduling team after carefully and clearly explaining his medical diagnosis and treatment. I thought I had done a good job — but I was wrong. I had neglected to make sure he had been advised of all the growing financial obligations that our patients face today. When the pain didn’t resolve completely after surgery — and Mr. Jones was receiving bills he hadn’t expected — I had an unhappy patient.

Miscommunication Can Lead to Claims Patient-physician miscommunication issues such as this one play a large role in contributing to malpractice claims. The Doctors Company, the nation’s largest physician-owned medical malpractice insurer, has studied thousands of closed claims in various specialties and found that poor communication between the provider and the patient or the patient’s

family is one of the key factors behind lawsuits. This issue contributes to 12% of cases for hospitalists and orthopedists and 14% of cases for obstetricians and emergency medicine providers. A key component of good communication with patients is a discussion about financial obligations for the medical services provided. Good communication up front can help, especially if a surgical outcome or treatment does not lead to a perfect outcome. Increasing numbers of physicians are joining large medical groups with a business manager or becoming hospital employees, which typically decreases their involvement with the business portion of healthcare. Most major medical insurance companies continue to sell policies with varying deductibles, co-payments, and complex rules. Unfortunately, these factors have led to an increasing disconnect between the patient and the physician when it comes to discussing financial obligations. The physician needs to be involved in making sure that the patient is informed and educated about the financial burden of surgical and medical treatments. Doing this before proceeding with treatment can help lower the risk of a malpractice claim even when the medical outcome doesn’t meet the patient’s expectations. Understanding the financial commitment up front allows patients to make a more informed decision for care.

How to Ensure Financial Disclosure In our office, we have established a series of steps for our patients once the patient has decided to proceed with elective surgery. These steps can be adjusted for non-surgical specialties: • At the time of the office visit, the office staff provides the patient with a surgical information packet that includes a direct telephone number to the physician’s care coordinator (PCC). The staff tells the patient to contact the PCC once he or she has decided to proceed with surgery. • The patient and physician also complete three forms with information that a staff member then enters into our electronic medical record: 1. Surgery procedure form, completed by the physician with the appropriate CPT and ICD-10 codes. 2. Anesthesia medical questionnaire form, completed by the patient. 3. Durable medical equipment (DME) form, completed by the physician. • If the patient then contacts the PCC to proceed with surgery: 1. The PCC contacts the insurance provider. If precertification is required,

the office notes this and sends other data (MRIs, etc.) to the provider to authorize. 2. The PCC then confirms the provider authorization. Once the insurance provider has certified surgery, the PCC will contact the patient to schedule a surgery date and ensure that, if needed, the patient will obtain an appropriate medical clearance by their primary care physician (or a local physician to whom the patient is referred if the patient does not have a primary care physician). The physician must complete the clearance by the time of the preoperative office visit. The type of medical clearance required, if any, is determined by the criteria set by the anesthesia medical questionnaire form. The PCC then sends the correct surgical date, CPT codes, and ICD-10 codes to: • Office financial adviser: This adviser will discuss the patient’s insurance plan, deductible, and co-pay; establish the surgeon’s fee based on the expected procedure; and require a patient deposit at the time of the preoperative office visit. The deposit amount is designed to minimize the need for patient refunds due to overpayment post-surgery. • Surgery center: The surgery date will be set and the surgery center financial adviser will contact the patient and discuss the patient’s insurance plan, deductible, and co-pay; establish the facility and anesthesia fees based on the expected procedure; and require another patient deposit prior to the date of surgery. • DME company: A private DME company will contact the patient and discuss payment costs and options for the DME requested by the physician. It is incumbent upon the physician to work with his or her entire office and, where applicable, the surgery center team to provide patients with both the medical and financial information they need to make an informed decision prior to an elective surgery or other medical treatment. By paying attention to both the medical and financial details, we are more likely to have happier patients, physicians, and surgery centers. Realistic medical and financial expectations discussed prior to elective surgery or other medical treatment can result in better efficiency, better outcomes, and less litigation. Dr. Gambarella, chairman and president of Kerlan-Jobe Orthopaedic Clinic, is a member of SDCMS-endorsed The Doctors Company’s Orthopedic Advisory Board. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

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Leadership — Last in a Series

Four Ways San Diego’s Physician Leaders Will Help Our Community Thrive in the Years Ahead by Sherry Nooravi, PsyD

Change is the new normal in healthcare. From the Affordable Care Act, to how Medicare pays physicians and hospitals, to exciting technological developments like telemedicine that will allow us to receive care by logging in online or visiting a kiosk. The seven physician leaders interviewed for this series have a vision of success and are taking key steps to get their teams and our community there. Four key themes emerged for how they keep up with and thrive during this time of change and evolution: 1. They are intentional about how they shape their organizational cultures and engage their staff, consulting physicians and patients; 2. They are patient-focused; 3. They manage the way change is introduced and implemented; and 4. They seek to learn, grow, and stay updated. Leaders of other industries should heed their advice as it is applicable in more than just the complex world of healthcare. Organizational culture, also known as “How things are done around here,” consists of group norms of behavior and the underlying shared values that help keep those norms in place. According to Edgar Schein, leaders shape and drive culture by what they pay attention to, how they react to crises, what they role model, how they reward staff, how they bring people into the organization, and how they exit them. Every company has its own way of doing things, from how they make decisions, treat customers, develop (or not develop) their staff and so forth that influences culture. What the physician leaders in this study shared clearly indicates that they are crystal clear on what it takes to drive an engaging culture.

November 2016

They Are Intentional About How They Engage Their Teams

They drive the behaviors and culture they want, and a key phrase that came up was the importance of “walking the talk.” Dr. Paul Bernstein, Medical Director and Chief of Staff at Kaiser Permanente, has a hands-on, open-door policy and shares that one should lead by example from your clinical practice, to your work ethic, to how engaged you are for your physicians. “Influence is communicating well and focusing on patients. Engaging physicians happens by driving patient-focused care, creating a ‘yes’ culture and ‘yes’ philosophy.” Dr. Tom Moore, CEO of UCSD Family Practice, believes in “walking the talk” and having a willingness to speak up if something is not right, even if it means calling out colleagues’ errors or oversights, especially among those who refer to them. “We need to have the courage to identify shortcomings in outcomes in a respectful but honest way, and that includes our own performance.” When these types of behaviors are role-modeled from the leaders, it helps increase the engagement of staff. According to Kevin Kruse, author of Employee Engagement 2.0, employee engagement is defined as the emotional commitment the employee has to the organization and its goals. Engaged employees work on behalf of the organization’s goals and they use discretionary effort, also known as “going the extra mile” and the “secret sauce.” Ways to engage staff include initiating activities to boost the mood and interac-

tions of the environment. Dr. Wendy Buchi, CEO of IGO Medical Group, stays up to date with what companies like Google, Pirch, and Apple do and applies it to engaging her staff from employee appreciation days, to paying for education, to team spirit Fridays when staff can wear Padres or Chargers shirts to show their San Diego spirit. Another way the leaders of Kaiser Permanente and Sharp HealthCare drive their culture is through events and frequent communication. Dr. Bernstein shared that he reinforces the culture at different levels from weekly physician summary emails, to three-minute podcasts, to attending big group meetings, events, and new physician orientations. Dr. Steven Green, CMO of Sharp Rees-Stealy Medical Group, shared that hosting annual educational retreats and dinner events is useful for helping people feel like they are a part of something. He shared that Sharp HealthCare has an all-physician assembly with videos of patient stories, speakers, and discussion of what’s up and coming. “It reminds people why they are here when we share stories of successes that have changed people’s lives.” The intentional ways these physicians drive culture starts with their mindset and consistency in their actions. Successful companies we know, such as Southwest Airlines 1, Starbucks 2, Container Store 3, and Whole Foods 4, attribute much of their success to their company culture. These companies consistently engage employees through clear communication on their strategy and values, invest in employee development, and create positive work environments. This focus on culture is not only good for employees and customers, it impacts the bottom line. A Kenexa 2008 study of 64 organizations found that companies with highly engaged employees achieve twice the annual net income of companies whose employees are less than highly engaged 5.

The Patient Is the Center of Their Worlds

A large part of driving the culture for these leaders is to be patient-focused, a mindset and way of leading that drives excellent patient care. “The superpower of the physician is the relationship and connection to the patient. We are the most intensely connected to the patient, and that is the physician leader’s superpower and how we’ll make changes to the system.” This statement by Dr. James LaBelle, CMO of Scripps Health, captured the sentiment of the physician leaders. Dr. Green recommended setting one’s schedule around what will be easiest for

the patient. “Does the patient need to see me versus email or call me? Over 100,000 of our patients are using our email portal, and this can be a great way to provide care. With email, you see what is going on in the patient’s own words.” This view was reflected in Dr. Bernstein’s view on patients, and he advised other physicians to “focus on medicine as a profession and not as a job. It’s about a calling — caring and how you make patients feel. When someone leaves your office, it’s how you make them feel that they’ll remember, your compassion.”

They Drive Change With Care

Dr. Mihir Parikh, medical director of NVISION Laser Eye Centers in La Jolla and president of the San Diego County Medical Society, believes in the importance of driving change by sharing a common goal. “First, I learn who my audience is, and I take the time to listen to their concerns and ideas, both individually and as a group. Second, I’ll learn what their strengths and weaknesses are and how I can help them work toward their goals and the organization’s goals.” Dr. John Jenrette, CEO of Sharp Community Medical Group, shared that he drives change by helping others understand the journey and how decisions were made. “If you start at the end and people have not been part of the journey, you lose them.” During times when melding two practices and cultures, he recommends referring back to the common vision, the greater good, and giving the team permission to think and speak differently. “It definitely takes time, effort, relationship building, and a healthy dose of collaboration to change a culture. If you try to change culture by issuing marching orders, you may feel successful in the short term, but I guarantee when you revisit it, this perceived cultural change will be undermined and not a reality.”

Change Is Coming and We Need to Prepare

The theme of embracing change can easily be applied in different industries. In the words of Dr. Parikh, “In the next 10 years, there will be many new layers of technology, and, as physicians, you don’t want to be the ‘Barnes and Noble’ practice.” He advised that rather than commiserating and complaining with one’s colleagues, one can take a proactive approach and talk to the leaders of innovative healthcare solutions, band with colleagues in

your mode of practice, join CMA and AMA, and participate in the political process. Dr. Jenrette also encourages getting involved and educated to broaden your horizon and scope of knowledge outside of your clinical practice. “In doing so, one usually will be more open and react more favorably to change or challenges.” Kaiser Permanente serves patients in innovative ways from having a futuristic kiosk in the lobby of the County of San Diego campus in addition to two Target stores with nurse practitioners, and a virtual exam room with biometric equipment to virtually consult with a physician when needed. Dr. Bernstein shared that we must embrace change, as the only thing certain is uncertainty. Abraham Lincoln’s belief that “the only way to predict the future is to create it” is a mindset that can drive success in the evolving healthcare industry or any other business. Dr. Nooravi is an organizational psychologist and CEO of Strategy Meets Performance, a leadership consulting firm that focuses on helping CEOs of fastgrowth companies shape engaging, innovative, and customer-driven cultures through executive coaching and senior team facilitation. She has been named “Trailblazer of the Year” for her research on the best practices of CEOs of high performing organizations. She can be reached at sherry@ strategymeetsperformance.com or at (312) 286-0325. References: 1. Makovsky, K. (2013). Behind the Southwest Airlines Culture. Forbes. Nov. 21, 2013. Retrieved on Aug. 6, 2015 from: www.forbes.com/sites/ kenmakovsky/2013/11/21/behind-the-southwestairlines-culture 2. Hanna, J. 2014. Starbucks, Reinvented: A SevenYear Study on Schultz, Strategy and Reinventing a Brilliant Brand. Forbes. Aug. 25, 2014. Retrieved on Aug. 6, 2015 from: www.forbes.com/sites/ hbsworkingknowledge/2014/08/25/starbucksreinvented 3. Schawbel, D. 2014. Kip Tindell: How He Created an Employee-First Culture at the Container Store. Forbes. Oct. 7, 2015. Retrieved on Aug. 6, 2015 from: www.forbes.com/sites/danschawbel/2014/10/07/kip-tindell-how-he-created-anemployee-first-culture-at-the-container-store 4. Rossi, H.L. 2015. 7 Core Values Statements that Inspire. Fortune. March 13, 2015. Retrieved on Aug. 6, 2015 from: www.forbes.com/sites/hbsworkingknowledge/2014/08/25/starbucks-reinvented 5. Edmonds, C. 2014. The Culture Engine: A Framework for Driving Results, Inspiring Your Employees, and Transforming Your Workplace. Wiley.

Physician Leaders Interviewed t Dr. Paul Bernstein, Medical Director and Chief of Staff, Kaiser Permanente

t Dr. Wendy Buchi, CEO, IGO Medical Group

t Dr. Steven Green, CMO, Sharp Rees-Stealy Medical Group

t Dr. John Jenrette, CEO, Sharp Community Medical Group

t Dr. James LaBelle, CMO, Scripps Health

t Dr. Tom Moore, CEO, UCSD Family Practice

t Dr. Mihir Parikh, Medical Director of NVISION Laser Eye Centers, La Jolla, and President of the San Diego County Medical Society.

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INFECTIOUS DISEASE

AntibioticResistant Microbial Pathogens Update on Efforts to Combat This Public Health Threat by Michael Butera, MD, FIDSA

November 2016

San Diego County’s medical community was proactive in recognizing the public health threat of emerging antibiotic-resistant pathogens. Within the San Diego County Medical Society, the Group to Eradicate Resistant Microbes (GERM Commission) was founded in 1996 and generated the GERM Commission Report. Authored by Dr. Ramon Moncada and other GERM founders, and endorsed by the membership of SDCMS, this visionary document defined the problem and called for urgent action to respond to the threat with substantive recommendations that form the framework of what we now call “antimicrobial stewardship.” ¶ The basic premises have been proven true over the past 20 years, but the scope of the problem has continued to evolve, with emerging new mechanisms of ever more resistant pathogens and the spread of the organisms in both the initial hospital and nursing home settings to outpatient settings and the community at large.

I contend that it is incumbent upon us all as healthcare professionals dedicated to promoting the health and welfare of our patients and our community, regardless of specialty, to maintain proficiency and knowledge regarding appropriate antibiotic use so as to help prevent emergence of resistance and not contribute to the problem.

3. Antimicrobial agents are unique therapeutics that have an impact on the individual patient being treated, but also on the microbial ecology and public health of the community at large. I contend that it is incumbent upon us all as healthcare professionals dedicated to promoting the health and welfare of our patients and our community, regardless of specialty, to maintain proficiency and knowledge regarding appropriate antibiotic use so as to help prevent emergence of resistance and not contribute to the problem.

Some fundamental principles are as follows: 1. Microbes have been confounding us with their adaptive abilities since the introduction of antibiotics. For every class of antibiotics introduced, there exists intrinsic mechanisms of resistance, and the use of these agents will result in the evolution and spread of acquired resistance. 2. The judicious use of antimicrobial drugs will decrease selective pressure for the evolution, emergence, and spread of antimicrobial-resistant bacteria, and this is the premise upon which stewardship efforts have been pursued. There is an increasing body of data supporting this contention.

More than 2 million illnesses and 23,000 deaths are attributed to infections with antimicrobial-resistant organisms in the United States each year, which translates to approximately 260,000 illnesses and nearly 3,000 deaths among Californians. Infections with resistant organisms are more difficult to treat and are associated with prolonged hospital stays and greater disability and death compared with infections caused by susceptible organisms. There are currently few antibiotics left in the treatment arsenal against resistant infections and even fewer new drugs in the development pipeline (CDPH, www.cdph.ca.gov/programs/hai/Pages/ AntimicrobialResistanceLandingPage.aspx). The CDC published “Antibiotic Resistance Threats in the United States, 2013,” defining public health threats of emerging resistant pathogens and defining three threat levels (www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf). Initiatives to address resistance emergence initially focused on acute care facilities and particularly the ICU setting, where there is a concentration of ill patients often requiring invasive devices, life support, and antibiotic therapy for initial and subsequent healthcare-acquired infections, and an environment that fosters spread of resistance by healthcare workers from patient to patient. Recent data suggests that post-acute healthcare environments, including longterm acute care facilities, sub-acute and chronic care facilities, serve as a major

breeding ground for the acquisition and spread of MDRO organisms (VRE, CDI, ESBL GNRs, and CRE) that are then reintroduced into the acute care hospital setting when these most ill patients get readmitted to acute care facilities. Reasons include: • inadequate communication and documentation between facilities at patient transfer/transition of care; • inappropriate antibiotic use promoted by nurse-driven cultures of asymptomatic colonized wounds, urine, sputum, feeding tube sites, etc., asymptomatic bacteriuria, and lack of adoption of best practice measures to address transient febrile episodes in these patients, many of which do not represent invasive infection. Antibiotics are not antipyretics, and not all fevers require cultures and antibiotic R x. [See “Surveillance Definitions of Infections in Long-Term Care Facilities: Revisiting the McGeer Criteria,” Nimalie D. Stone et.al. Infect Control Hosp Epidemiol 2012;33(10):965-977)]; and • less robust resources for optimizing infection control best practice. Interventions to address the emergence and spread of MDROs in the acute and chronic care setting include: • immunization to prevent vaccine-preventable infections among patients/ residents; • maintaining a robust infection prevention program, and understanding the principles of infection prevention; • avoidance of device- and procedurerelated, healthcare-associated infections such as catheter-associated UTIs, central line-associated bloodstream infections, ventilatorassociated pneumonias, pressure ulcer prevention, and prevention of surgical site infections by adhering to principles of best practice; • adherence to the principles of infection control with prompt identification, treatment, isolation of patients infectSAN DIEGO PHYSICIAN.org

INFECTIOUS DISEASE ed with MDROs, including availability of rapid diagnostic testing and robust microbiology lab support to rapidly and reliably provide susceptibility data and antibiograms to allow pathogendirected specific therapy. The latest compendium of best practice guidelines for prevention of HAIs and infection control principles can be found on the SHEA website at www.shea-online.org/ guidelines-resources. The Infectious Diseases Society of America (IDSA) publishes clinical practice guidelines regarding pathogen-specific and syndrome-specific treatment guidelines, including community- and hospitalacquired pneumonia, sepsis, neutropenia, intra-abdominal, skin and soft tissue, CNS, vascular and cardiac, bone and joint, and device-related infections (www.idsociety. org/Guidelines_Patient_Care). The single most important action needed to greatly slow down the development and spread of antibiotic-resistant infections is to change the way antibiotics are used. Half of antibiotic use in humans and much of antibiotic use in animals is unnecessary and inappropriate. Stewardship is a commitment to always use antibiotics only when they are necessary to treat, and in some cases prevent, disease; to choose the

antibiotic use, to optimize patient outcomes, and to reduce overall costs for a healthcare facility. Successful antibiotic stewardship programs monitor and direct antimicrobial use, providing a standard, evidence-based approach to judicious antibiotic use. In September 2014, California Senate Bill 1311 was signed into law, further requiring hospitals to adopt and implement an antimicrobial stewardship policy in accordance with guidelines established by the federal government and professional organizations, and to establish a physician-supervised multidisciplinary antimicrobial stewardship committee with at least one physician or pharmacist who has undergone specific training related to stewardship (www.cdph. ca.gov/certlic/facilities/Documents/LNCAFL-14-36.pdf). The Healthcare-Associated Infections (HAI) Program of CDPH has published a toolkit to assist California hospitals in establishing and improving ASPs (www.cdph. ca.gov/programs/hai/Documents/ASPToolkitReviewedLC042815FINAL.pdf). References regarding nationwide ASP recommendations and mandates include: • Barlam TF, Cosgrove SE, Abbo LM, et al., “Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of

The single most important action needed to greatly slow down the development and spread of antibioticresistant infections is to change the way antibiotics are used. right antibiotics; and to administer them in the right way in every case. Effective stewardship ensures that every patient gets the maximum benefit from the antibiotics, avoids unnecessary harm from allergic reactions and side effects, and helps preserve the life-saving potential of these drugs for the future. Efforts to improve the responsible use of antibiotics have not only demonstrated these benefits but have also been shown to improve outcomes and save healthcare facilities money in pharmacy costs. In 2009, the American Medical Association passed policy, promulgated by a resolution from the IDSA, to support antimicrobial stewardship programs — overseen by qualified physicians — as an effective way to ensure appropriate

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America and the Society for Healthcare Epidemiology of America.” Clinical Infectious Diseases; 2016 May 15;62(10):e51-77. • Dellinger RD. Guidelines for management of severe sepsis and septic shock: 2012 [PDF — 3.30 MB]. Critical Care Medicine 2013;41:580. [Accessed Sept. 6, 2016] • Dellit, TH, Owens, RC, McGowan, JE, et al,; Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship”; Clinical Infectious Diseases; 2007; 44:159-77.

• National Quality Forum “National Action Plan for Combating Antibiotic Resistant Bacteria” September 2014. [Accessed Feb. 22, 2016] • Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society; “Policy Statement on Antimicrobial Stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS).” Infection Control and Hospital Epidemiology; 33(4 - Special Topic Issue: Antimicrobial Stewardship (April 2012): 322-327. • Society for Hospital Medicine “Fight the Resistance” 2015. [Accessed Feb. 22, 2016] • Spellberg B, Srinivasn A, Chambers HF, “New Societal Approaches to Empowering Antibiotic Stewardship”; JAMA. 2016 Feb 25; E1-E2. [Epub ahead of print] • The Joint Commission; “Antimicrobial Stewardship Toolkit.” [Accessed Feb. 22, 2016] • The Joint Commission; “New Antimicrobial Stewardship Standard; Standard MM.09.01.01 [PDF — 254 KB]” Issued June 22, 2016. [Last Accessed July 14, 2016] • The National Institute for Health and Care and Excellence (NICE); “Antimicrobial Stewardship Quality Standard; NICE quality standard [QS121 published April 2016.]” [Accessed August 22, 2016] • CMS will soon publish ASP requirement mandate criteria as condition of participation in CMS programs and will affect all acute and long-term care facilities. With regard to long-term care facilities, California SB 361 (Chapter 764, Statutes of 2015) requires that each SNF adopt and implement an antimicrobial stewardship policy by Jan. 1, 2017. The policy must be consistent with antimicrobial stewardship guidelines developed by the federal Centers for Disease Control and Prevention (CDC), the Centers for Medicare and Medicaid Services, the Society for Healthcare Epidemiology of America, or similar recognized professional organizations (www.cdph.ca.gov/certlic/ facilities/Documents/LNC-AFL-15-30.pdf). The CDC has defined seven core elements of antibiotic stewardship for nursing homes; the CDC recommendations are available at www.cdc.gov/longtermcare/prevention/ antibiotic-stewardship.html).

According to the CDC, more than 260 million antibiotic courses are prescribed in the outpatient setting annually, which equates to more than five prescriptions for every six people in the United States. Primary care physicians account for 45% of all outpatient antibiotic prescriptions, followed by nurse practitioners and physician assistants at 18%, dentists at 9%, surgical specialists at 8%, and emergency medicine physicians at 5%. It is estimated that 50% of all outpatient antibiotic prescriptions are unnecessary (www.cdc.gov/getsmart/community/programs-measurement/measuring-antibiotic-prescribing.html). The next major challenge is how to best address and influence outpatient prescribing habits and educate our physicians and other healthcare providers on outpatient antibiotic use best practice. In California, State Senator Hill introduced a bill to address the outpatient setting stewardship arena in 2015, and, among other suggestions, would have required mandatory CMEs on antibiotic best practice as a condition of license renewal, but it was withdrawn.

CMA has passed policy opposing any specific topic CME mandate for California physicians. The antimicrobial stewardship subcommittee of the Healthcare Associated Infection Advisory Committee to CDPH has made recommendations to integrate antibiotic stewardship education into the curriculum of HCW professional school and residency programs, and further calls for the requirement that all licensed practitioners get CMEs regarding antibiotic appropriate use, so this issue will remain a consideration for future voluntary action or legislated regulated mandate. State Senator Dr. Richard Pan’s bill promoting statewide immunization by making it harder to decline school-agechildren-mandated vaccination on the basis of personal belief exemptions was strongly supported by IDAC and CMA. Outpatient resources focus on giving physicians tools to use for their patients to promote acceptance of ACIP-recommended vaccines and to avoid antibiotic use in those illnesses that are usually caused by viral pathogens or for which there is no estab-

lished benefit from routine antibiotic use. These include serous otitis media, chronic sinusitis, and many cases of pharyngitis, bronchitis, acute exacerbations of asthma and COPD, asymptomatic bacteriuria, among others. Many of these are available through specialty society websites, including ACP, ACOG, family practice and pediatric specialty societies. The CDC manages the Get Smart Programs (www.cdc.gov/getsmart), a national effort to improve antibiotic prescribing and use in both outpatient and inpatient settings (www.cdc.gov/getsmart/community/index. htm). Various outpatient practice interventions applicable to clinic and integrated healthcare settings are presented. Additional resources can be found through the CMA Foundation’s AWARE Project website (www.thecmafoundation.org/ Programs/AWARE). For a print copy of the AWARE Toolkit, contact Veronica Mijic at (916) 779-6624 or at vmijic@thecmafoundation.org. Dr. Butera, 24-year member of SDCMS-CMA, sits on SDCMS’s GERM Commission.

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INFECTIOUS DISEASE

Zika Virus An Unprecedented Public Health Epidemic by Robert E. Peters, PhD, MD

Dr. Peters would like to thank Dr. Eric McDonald, Medical Director, Epidemiology and Immunization Services Branch, San Diego County Health and Human Services Agency, for his review and comments in preparation of this article.

obody knows where Zika virus first came from. The Zika virus was first discovered by scientists at the Yellow Fever Research Institute in 1947, during a routine surveillance for yellow fever from a rhesus macaque monkey that had been placed in a cage in the Zika forest in Uganda. Zika has been found in many forests for ages, from West Africa to East Africa and in Asia. Only occasional cases of Zika infection in humans were reported until 2007, when an outbreak occurred on Yap Island in Micronesia in the Pacific Ocean. This was the first time the virus had been reported outside its usual geographical range. Zika virus is spread by the Aedes species of mosquitoes, which include the Aedes aegypti “yellow fever mosquitoes” and Aedes albopictus “Asian tiger mosquitoes.” Since Aedes mosquitoes can’t fly more than 400 meters, it was contemplated that the virus spread through the transportation of infected mosquito eggs. In 2013, another outbreak was reported in Polynesia. Experts believe that boat races facilitated the spread of Zika from Micronesia to Polynesia. The Asian strain of the Zika virus behind the current outbreak, which began in Brazil, has spread to more than 60 countries and territories. A genetic analysis in March revealed that Zika may have been circulating in Brazil since 2013. More than 60 countries and territories have reported new local transmission of Zika

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virus. An up-to-date list can be found at www.nc.cdc.gov/travel/page/zika-travelinformation. There are now dozens of countries and territories in the Western Hemisphere (the Americas) that have reported locally transmitted Zika virus infections. In the U.S. territories (American Samoa, Puerto Rico, U.S. Virgin Islands), 28,723 cases of Zika infections have been reported, of which 28,627 were locally acquired and 96 travel associated. There were also 2,027 pregnant women who were infected. In the United States, as of Nov. 2, 2016, there have been 4,128 cases of Zika infections reported, 3,988 were travel associated, 139 locally acquired mosquito-borne cases, and 1 lab-acquired case. Thirty-four cases were associated with sexual transmission. There have been 1,005 pregnant women with laboratory evidence of possible Zika virus infection. Mosquitoes that can carry the virus have been found in 12 California counties. 353 cases of Zika virus have been reported in California. They have involved people who contracted the virus while traveling outside of the United States or through sexual contact with someone who had. On the other hand, Florida has documented 186 nontravel-related Zika infections in three areas of Miami-Dade County. The first case of Zika virus infection in San Diego County was reported in July 2014 in a resident returning from a trip to the Cook Islands. The second case of Zika was reported in July 2015 in a resident returning from a trip to Kiribati. Since 2016 there have been 63 cases, and that number is expected to increase. Two of those cases were sexually transmitted, and the rest contracted Zika after travel to another country. No cases of local mosquito transmission have been reported.

The Aedes mosquito species is not native to California. Aedes aegypti first appeared in San Diego in October 2014 and can transmit viruses that cause dengue, chikungunya, and yellow fever. The only known animal reservoirs for the Zika virus are jungle primates, in contrast to West Nile virus, which causes infections in birds. Aedes albopictus appeared in San Diego in September 2015. Both mosquitoes are aggressive biters both indoors and outdoors, especially during the day. On Jan. 1, 2016, the Centers for Disease Control and Prevention issued an advisory for pregnant women not to travel to areas where Zika was spreading. One of the most devastating consequences of Zika virus has been reported in pregnant women associated with the serious birth defect microcephaly (1). The risk after infec-

The first case of Zika virus infection in San Diego County was reported in July 2014 in a resident returning from a trip to the Cook Islands.

tion early in pregnancy is 1–13%. The full spectrum of congenital defects is not known. It is also unknown whether infants exposed during pregnancy who appear healthy at birth will develop neurological problems. Two babies with Zika-related microcephaly have been born in California. In both cases, the women spent time during their pregnancies in countries where the virus is endemic. There have been no reports of infants getting Zika virus through breastfeeding. Northwestern Brazil has reported >1,700 cases of microcephaly attributed to Zika (2). Other Latin American areas are just starting to deliver infants with evidence of Zikarelated complications. Puerto Rico is in the midst of a large epidemic. Experience with chikungunya, a newly introduced virus (3) spread by Aedes aegypti, blood screening, case reports, and testing of pregnant women

suggest 25% of Puerto Rican individuals, including an estimated 6,000–11,000 pregnant women, may be infected this year.

exual transmission of Zika virus from both male and female partners can occur. This can occur before symptoms start, while they have symptoms, and after their symptoms have ended. Studies are underway to find out how long Zika virus stays in semen and vaginal fluids of people who have Zika and how long it can be passed to sex partners. It is thought the virus remains viable for months in semen. Zika virus is unprecedented. This is the first time in history we have a mosquitoborne virus associated with human birth defects and capable of sexual transmission. The consequences are tragic, lifelong, and expensive. Zika is rarely associated with

other complications such as Guillain-Barré syndrome and severe thrombocytopenia. The causality is uncertain. During the French Polynesian outbreak, 2.8% of blood donors tested positive for Zika. Transfusion-associated Zika virus has been reported in Brazil. This has prompted blood donation screening in selected areas of the United States, including San Diego. To date, there have not been any confirmed blood transfusion cases in the United States. Most people infected with Zika have no symptoms. This presents a challenge for the clinician to make a preliminary diagnosis based on patients’ clinical features, places and dates of travel. Fever, rash, joint pain, and conjunctivitis are the most common symptoms of Zika. Other symptoms may include muscle pain and headache. The illness is usually mild, with symptoms lasting from several days to a week. Zika virus usually remains in the blood of an infected person for about a week. Because of similar geographic distribution and symptoms, other vector-borne pathogens like dengue virus and chikungunya virus should be evaluated. Dengue virus and chikungunya virus cause painful symptoms and are easily recognized by affected communities. In April the FDA approved the first U.S. commercial test to diagnose the Zika virus. A blood or urine test can confirm Zika infection diagnosis. Lab diagnosis is generally accomplished by testing serum or plasma to detect virus, viral nucleic acid, or virusspecific immunoglobulin M and neutralizing antibodies (4). To detect local transmission of Zika, clinicians in areas at risk need to test patients without travel to Zika-affected areas with fever, rash, joint pain, or conjunctivitis. Symptomatic persons with Zika virus infection can be detected early in the course of illness. Real time reverse transcriptionpolymerase chain reaction (rRT-PCR) testing should be performed on serum collected during first two weeks after symptom onset. It is also conducted on urine samples collected less than 14 days after symptom onset. SAN DIEGO PHYSICIAN.org

INFECTIOUS DISEASE A positive rRT-PCR confirms Zika virus infection. If the result is negative, the sample should be analyzed by serological testing for IgM antibody. For asymptomatic pregnant women who have traveled to areas with active Zika virus transmission, rRT-PCR testing is recommended on serum and urine within two weeks of potential exposure. Also rRT-PCR testing is indicated for those who present for care greater than two weeks after exposure and have been found to be IgM positive. In areas with active Zika transmission, asymptomatic women should undergo IgM testing as part of routine obstetrical care in the first and second trimesters with reflex testing by rRT-PCR for IgM positive results. Zika virus-specific IgM and neutralizing antibodies develop toward the end of the first week of illness and start four days post-onset of symptoms and continue for 12 weeks. If rRT-PCR result is negative or equivocal, serum IgM should be done for Zika, dengue, and chikungunya. Zika IgM antibody capture ELISA is used for qualitative detection of Zika virus IgM antibodies in cerebrospinal fluid; however, due to the cross-reaction with other flaviviruses and nonspecific reactivity confirmation by plaque-reduction neutralization, testing (PRNT) must be done for positive or equivocal tests. This testing is done by the CDC or designated labs. There is no vaccine or medicine for the treatment of Zika. Treatment is supportive with rest, fluids, use of analgesics and antipyretics. Aspirin and nonsteroidal anti-inflammatories should be avoided until dengue can be ruled out to reduce the risk of hemorrhage. Once a person has been infected with Zika virus, he or she is likely to be protected from future infections. Comprehensive mosquito control involves integrated vector management, which includes a) effective mosquito surveillance, b) reduction in mosquito larval habitats, and c) application of products that control mosquito larvae and adults. While monitoring birds provides early warning for West Nile outbreaks, human infections are the best early indicator of Zika virus circulation in a community. Homeowners, neighbors, and municipalities should remove standing water where mosquitoes can breed. Using U.S. Environmental Protection Agency registered insect repellants, such as those containing diethyltoluamide (DEET), is effective against mosquitoes that carry

November 2016

Zika. These products are safe for pregnant women and infants as young as two months. Backpack sprayers and trucks have also been used to eliminate larval forms of mosquitoes with pyrethroid insecticides and larvicides. In August 2016, San Diego County sprayed a two-block area in South Park after discovering the larvae from a mosquito known to be a carrier of Zika virus. When Aedes aegypti mosquitoes are found, aerial spraying with Naled and larvicide is initiated within days of documented ongoing risk of Zika transmission. There are other personal and community levels of protection that can be initiated. The blood supply is screened for Zika virus in areas of active transmission. Pregnant women should avoid travel to areas with Zika transmission. Anyone planning a trip should check the CDC travel alert website at www.nc.cdc.gov/travel. Women who want to avoid pregnancy should be offered voluntary effective contraception. Because Zika virus is found in semen, men who live in or have traveled to Zika-affected areas should use a condom every time they have sex with a woman who is or may become pregnant. The mechanical barrier of long sleeves and pants will reduce the risk of mosquito bites during travel and after return, as will staying and sleeping in screened-in or airconditioned rooms. Although we have learned much about the science of Zika virus and have mobilized considerable resources to control Zika transmission, experience with other flaviviruses, such as dengue, suggest large populations

will be vulnerable for years. More funding and other resources will be needed to increase preparedness for outbreaks. Pregnant women must be protected through reduction in exposure and increased screening. Babies with Zika-related congenital defects will need lifelong care. Because Zika virus antibodies cross-react with other flaviviruses, more specific diagnostic assays need to be created that are less expensive and yield more rapid results. New classes of insecticides and repellants and novel approaches to vector control will also need to be found. The best prevention, a safe and effective vaccine against Zika, is years away. Dr. Peters, a 19-year member of SDCMS-CMA and past SDCMS president, sits on SDCMS’s GERM Commission. References: 1. Rasmussen, S.A., et.al. Zika virus and birth defects — reviewing the evidence for causality. N Engl. J. Med. 2016;374(20):1981-1987. 2. Franca, GVA et.al. Congenital Zika virus syndrome in Brazil: a case series of the first 1501 live births with complete investigation (published online June 29, 2016) Lancet doi:10. 1016/so140-6736 (16)30902-3. 3. Peters, R.E. Chikungunya A New Mosquito Borne Virus. San Diego Physician 2015 October, pp 16–17. 4. Centers for Disease Control and Prevention. Zika virus. www.cdc.gov/ Zika , updated July 31, 2016. Accessed Aug. 1, 2016.

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INFECTIOUS DISEASE

Sexually Transmitted Diseases in San Diego County by Winston Tilghman, MD

he burden of reportable, bacterial sexually transmitted diseases (STDs) is increasing in San Diego County, with a disproportionate impact on young people; African Americans; and gay, bisexual, and other men who have sex with men (MSM). Chlamydia is the most common reportable STD in San Diego County and nationwide. Despite declines in reported chlamydia cases in 2013 and 2014, cases and rates of chlamydia were the highest in 2015 that they have been in the past two decades, based on data released by the County of San Diego Health and Human Services Agency (1). A total of 17,418 cases were reported in 2015, representing an 11.5% increase from 2014, and the overall rate of chlamydia was 539.7 cases per 100,000 population. Rates were higher among women than among men (693.3 versus 384.2 cases per 100,000 population), and the highest rate was observed among women aged 15 to 24 years (1). Untreated, both chlamydia and gonorrhea can lead to pelvic inflammatory disease, ectopic pregnancy, tubal scarring, and infertility. However, given the much higher rate of chlamydia among young women, chlamydia poses the highest threat of long-term reproductive health complications in San Diego. Due to the asymptomatic nature of many infections, the potential for long-term complications, and high disease burden among women under the age of 25, annual screening for chlamydia and gonorrhea is recommended for sexually active women in this age group (2). Providers can prevent complications of these infections by adhering to STD screening guidelines and

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normalizing discussions about sexual health with patients. While less common than chlamydia, cases of gonorrhea increased by 9% in 2015, compared to 2014, and by 100% since 2009. A total of 3,695 cases were reported in San Diego County in 2015, and the overall rate of infection was 114.5 cases per 100,000 population. The overall rate of infection has increased by 90.5% since 2009. Unlike chlamydia, gonorrhea is more common in men in San Diego County. The rate of infection in men was 2.6 times that of women (165.9 versus 62.7 cases per 100,000 population) and increased by 13% between 2014 and 2015, while the rate among women decreased slightly. Rates were significantly higher among African-American men and women compared to other racial and ethnic groups (1). Providers can help to control the spread of gonorrhea by screening at all potential sites of infection in MSM patients. Extragenital (i.e., pharyngeal and/or rectal) gonorrhea is common in this population, and is usually asymptomatic (3), which facilitates onward transmission. Although commercially available Neisseria gonorrhoeae nucleic acid amplification tests are not approved by the U.S. Food and Drug Administration (FDA) for use on extragenital specimens, these tests are widely available in laboratories that have performed necessary Clinical Laboratory Improvement Amendments (CLIA) validation procedures. The ability of N. gonorrhoeae to develop resistance to antibiotics has been elevated as an urgent public health threat by the Centers for Disease Control and Prevention (CDC), which currently recommends two antibiotics

for all gonorrhea infections. Reports of treatment failure and resistance to cephalosporins in other countries; decreasing susceptibility to commonly used antibiotics, such as azithromycin (4); a recent cluster of N. gonorrhoeae cases in Hawaii, with decreased susceptibility to ceftriaxone and high-level resistance to azithromycin (5); and the paucity of new antibiotics effective against this organism in the pipeline highlight the public health threat posed by gonorrhea. Recommended and alternative dual antibiotic regimens for gonorrhea are available in the 2015 CDC STD treatment guidelines (6). The most significant increase, from 2014 to 2015, was observed for primary and secondary syphilis (i.e., the most infectious stages of syphilis), with 490 cases reported in 2015 (a 33% increase from 2014) and an overall rate of 15.2 cases per 100,000 population. Syphilis has a disproportionate impact on MSM, who accounted for 87% of primary and secondary syphilis cases reported in 2015. Of primary and secondary syphilis cases reported among MSM, 48% also had HIV infection. The rate of infection was higher among African-American men compared to men from other racial and ethnic groups (60.6 cases per 100,000 population versus 36.1 and 24.0 cases per 100,000 population for Hispanic and white men respectively). A total of 339 early latent and 346 late latent cases also were reported (1). Syphilis can cause multiple complications affecting the cardiovascular, musculoskeletal, and central nervous systems. Congenital syphilis, or transmission of the causative organism Treponema pallidum from mother to fetus, can result in birth defects, blind-

ness, deafness, and fetal demise. Cases of congenital syphilis in California increased by 330% from 33 cases in 2012 to 142 cases in 2015, with most cases reported from the Central Valley and Los Angeles County (7). Congenital syphilis is completely preventable, and providers can do their part by ensuring timely prenatal care for all pregnant women; syphilis screening during the first prenatal visit (and additional screening during the third trimester and at delivery for high-risk women); and timely treatment of syphilis, in pregnant women, with CDC-recommended therapy (8). The County of San Diego operates four categorical STD clinics, as well as a home testing program for gonorrhea and chlamydia for young women (www.DontThinkKnow.org). More information about STDs and resources available through the County of San Diego are available at www.stdsandiego.org.

References: 1. County of San Diego Health and Human Services Agency, Division of Public Health Services, HIV, STD, and Hepatitis Branch. Sexually Transmitted Diseases in San Diego County: 2015 STD Data Slides. Available at: www.sandiegocounty.gov/content/dam/sdc/hhsa/programs/phs/HIV%2C%20STD%20 &%20Hepatitis%20Branch/Data%20Slide%20Sets/2015%20STD%20 Slides%20Final.pdf. 2. LeFevre ML, U.S. Preventive Services Task Force. Screening for chlamydia and gonorrhea: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2014 Dec 16;161(12):902-10. 3. Kent CK, Chaw JK, Wong W, et al. Prevalence of rectal, urethral, and pharyngeal chlamydia and gonorrhea detected in 2 clinical settings among men who have sex with men: San Francisco, California, 2003. Clin Infect Dis. 2005 Jul 1;41(1):67-74. 4. Kirkcaldy RD, Harvey A, Papp JR, et al. Neisseria gonorrhoeae antimicrobial susceptibility surveillance — the Gonococcal Isolate Surveillance Project, 27 sites, United States, 2014. MMWR Surveill Summ. 2016 Jul 15;65(7):1-19. 5. Centers for Disease Control and Prevention press release, available at: www. cdc.gov/nchhstp/newsroom/2016/2016-std-prevention-conference-pressrelease.html. 6. Frieden TR, Jaffe HW, Cono J, et al. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015;64(No. RR-3):60-68. Available at: http://www.cdc.gov/std/tg2015/tg-2015-print.pdf. 7. California Department of Public Health Sexually Transmitted Disease Control Branch. Sexually Transmitted Disease Data. Available at: www.cdph.ca.gov/ data/statistics/Pages/STDData.aspx. 8. Frieden TR, Jaffe HW, Cono J, et al. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015;64(No. RR-3):34-51. Available at www.cdc.gov/std/tg2015/tg-2015-print.pdf.

Dr. Tilghman, three-year member of SDCMSCMA, is senior physician/STD controller with the HIV, STD, and Hepatitis Branch of Public Health Services, County of San Diego Health & Human Services Agency.

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SAN DIEGO PHYSICIAN.org

INFECTIOUS DISEASE

Hepatitis C The Need to Expand Screening Now by Robert G. Gish, MD, and Catherine T. Frenette, MD

Chronic infection with hepatitis C virus (HCV) is a major cause of chronic liver disease, a leading cause of liver cancer, and the leading cause of liver transplants in the United States (1). By 2007, it had superseded HIV as a cause of death in the United States (2). Despite this, far too many people at risk for HCV infection remain untested. This is of particular concern since we now have direct-acting antivirals that result in cure in almost all patients with minimal side effects.

November 2016

Failure to screen will mean that patients with chronic hepatitis C (CHC) are not diagnosed and properly linked to care, and will remain at increased risk of chronic liver disease, cirrhosis, liver transplant, cancer, and death, as well as at increased risk of the multiple extra-hepatic manifestations of CHC, which can include renal disease, diabetes, cardiovascular and cerebrovascular disease, cognitive impairment, and others (3). In addition, they will continue to be a possible source of infection transmission. It is time for primary care providers to implement testing of all those considered to be at risk. The U.S. Preventive Services Task Force recommends screening of all persons at high risk for infection, as well as one-time screening of all adults in the “birth cohort,” those born

between 1945 and 1965 (4). Risk factors include past or current injection drug use, receipt of a blood transfusion before 1992 or clotting factors before 1987 (prior to the implementation of screening programs for donated blood), long-term hemodialysis, HIV infection, being born to an HCV-infected mother, incarceration, intranasal drug use, getting an unregulated tattoo, other percutaneous exposures (such as in healthcare workers or from having surgery before the implementation of universal precautions), and high-risk sexual behaviors (unprotected sex, or sex with multiple partners or with an HCV-infected person or injection drug user). Patients with elevated liver enzymes or — using an out-of-date term — “liver function tests” should also be tested. Of note, testing solely based on elevated ALT is esti-

It is crucial that all physicians ensure that screening includes the follow-up nucleic acid test for HCV RNA for all patients identified as anti-HCV-positive.

mated to miss 50% of chronic hepatitis C infections (1). All persons in the birth cohort are considered to be at increased risk for CHC and should be tested. Approximately 75% of people with CHC in the United States were born between 1945 and 1965 (1). It has been shown that nosocomial or iatrogenic factors were the most likely causes of CHC in birth cohort members rather than past behaviors such as injection drug use or high-risk sex (5); relaying this to patients might decrease stigmatization about the need for screening. It will also be important to educate patients on the breakthroughs in antiviral therapy that now result in a cure (sustained viral response) in almost all patients taking only one pill daily of one of the highly effective combination medications for only 8 to 12 weeks. Patients who know that

a simple cure is available may be much more likely to agree to screening. Experts in the field estimate that there are likely 5 to 6 million or more people in the United States with CHC, 94–95% of whom have not yet been successfully treated (6,7). Unfortunately, according to the Centers for Disease Control and Prevention (CDC), a large proportion (45–85%) of people with CHC are unaware that they are infected (1). Thus, the need for improved approaches to screening is clear. Initial screening is with HCV antibody testing. Confirmation of the presence or absence of infection must then be done with tests for HCV RNA. Unfortunately, in an important study carried out in two major cities and six states over a seven-year period, the CDC found that 49.2% of newly reported HCV

patients had only received the first test for antibodies, with no HCV RNA follow up (8). It is crucial that all physicians ensure that screening includes the follow-up nucleic acid test for HCV RNA for all patients identified as anti-HCV-positive. The CDC estimates that one-time testing of birth cohort members will identify 800,000 infections and allow linkage to care and treatment that could prevent more than 120,000 HCV-associated deaths while saving $1.5–$7.1 billion in liverdisease-related costs (1). There should also be a substantial decrease in the costs related to the many extra-hepatic manifestations of CHC since multiple studies have shown marked improvement in such manifestations after successful treatment of CHC (3). Risk-based screening has failed to identify the majority of HCV disease, and it is time to increase implementation of birth cohort screening on a routine basis. Dr. Gish, 33-year member of SDCMS-CMA, is with the Department of Medicine, Division of Gastroenterology and Hepatology, Stanford University; the University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences; and sits on the Steering and Executive Committee, National Viral Hepatitis Roundtable, San Francisco. Dr. Frenette, six-year member of SDCMSCMA, is medical director of liver transplantation at the Scripps Center for Organ and Cell Transplantation, Scripps Green Hospital.

References: 1. Centers for Disease Control and Prevention. Viral Hepatitis-CDC Recommendations for Specific Populations and Settings, People Born 1945–1965 & Hepatitis C. Centers for Disease Control and Prevention. 2015; Available at: www.cdc.gov/hepatitis/ populations/1945-1965. htm. Accessed Sept. 30, 2016. 2. Ly KN, Xing J, Klevens RM, et al. The increasing burden of mortality from viral hepatitis in the United States between 1999 and 2007. Ann Intern Med 2012;156:271-278. 3. Gill K, Ghazinian H, Manch R, et al. Hepatitis C virus as a systemic disease: reaching beyond the liver. Hepatol Int 2016;10:415-423. 4. U.S. Preventive Services Task Force. Final Recommendation Statement: Hepatitis C: Screening. U.S. Preventive Services Task Force. 2015; Available at: www.uspreventiveservicestaskforce.org/Page/ Document/RecommendationStatementFinal/hepatitis-c-screening Accessed Sept. 22, 2016. 5. Joy JB, McCloskey RM, Nguyen T, et al. The spread of hepatitis C virus genotype 1a in North America: a retrospective phylogenetic study. Lancet Infect Dis 2016;16:698-702. 6. Edlin BR, Eckhardt BJ, Shu MA, et al. Toward a more accurate estimate of the prevalence of hepatitis C in the United States. Hepatology 2015;62:1353-1363. 7. Gish RG, Cohen CA, Block JM, et al. Data supporting updating estimates of the prevalence of chronic hepatitis B and C in the United States. Hepatology 2015;62:1339-1341. 8. Centers for Disease Control and Prevention. Vital signs: evaluation of hepatitis C virus infection testing and reporting — eight U.S. sites, 2005-2011. MMWR Morb Mortal Wkly Rep 2013;62:357-361. SAN DIEGO PHYSICIAN.org

classifieds PRACTICE FOR SALE THRIVING SAN DIEGO MED SPA GROSSING OVER ONE MILLION PER YEAR: Work part time! (760) 710-7085. [532] OFFICE OF GENERAL PRACTICE FOR SALE: Please contact Dr. Mary Raiszadeh at (858) 7508984. [522] PHYSICIAN POSITIONS AVAILABLE

Seeking Dermatologist for La Jolla practice Well established dermatology practice in La Jolla with extremely loyal patient base in need of an excellent board certified general and procedural dermatologist to round out our team. Cosmetic expertise and familiarity with lasers a plus. Our support staff is highly trained and our facilities are state of the art. Familiarity with Modernizing Medicine or EMA helpful. Requirements: . BC/BE in Dermatology . CA license Competitive compensation and benefits Please contact Stephen at 858-362-8800 stephen@torreypinesderm.com

OPPORTUNITY FOR INTERVENTIONAL PHYSIATRY / PHYSICAL MEDICINE SPECIALIST: Practice opportunity for part-time or full-time interventional physiatry / physical medicine specialist with well-established orthopaedic practice. Office located near Alvarado Hospital. Onsite digital X-ray and EMR. Interested parties, please email lisas@sdsm. net. [554] SEEKING OCCUPATIONAL MEDICINE PHYSICIAN: Full time, part time or independent contractor for busy workers’ compensation specialist practice. Located in San Diego. Competitive salary. Please email CV or direct any enquiries to Robynne McMurtrie, Manager, at rmcmurtrie@davidkupfermd.com or call (858) 560-0242, ext. 101. [553] LOOKING FOR CALIFORNIA-LICENSED MD FOR CONSULTATIVE WORK: Alternative care office in Carlsbad looking for California-licensed MD for consultative work. One or two days a week. Part time, excellent compensation. Contact James at (760) 703-3767. [552] FAMILY PRACTICE MD/DO AND PHYSICIAN ASSISTANT WANTED IN BEAUTIFUL LA COSTA: Various shifts available at urgent care / family practice office. Nights, weekends, and day hours available. Please fax or email CV to (760) 603-7719 or gcwakeman@sbcglobal.net. [551]

SEEKING PART-TIME PHYSICIAN: Anderson Medical Center is a busy primary care, sports and occupational medicine practice housed in a state-ofthe-art urgent care facility in Pacific Beach. We’re seeking a part-time physician. Experience in a busy practice, emergency department, or urgent care; with musculoskeletal medicine, X-Ray, and sutures/wound care required; and ability to provide compassionate care in a fast-paced environment necessary. We seek someone who values: integrity and quality medical care; with impeccable bedside manner, emotional/ professional maturity, ability to work well with patients/team members, easily manages multiple priorities/patients; detail-oriented and team-focused. We’re open 8am–8pm, Monday–Friday, 8am–4pm weekends. Providers share day, night, and weekend coverage. [550] PUBLIC HEALTH MEDICAL OFFICER, TUBERCULOSIS CONTROL & REFUGEE HEALTH: HHSA. Anticipated range $145,000–$155,000. Excellent benefits package. For details, go to www.sandiegocounty.gov/content/dam/sdc/hr/jobs/ HHSA_TB_Control.pdf. [548] SEEKING A FEW GOOD PSYCHIATRISTS AND PHYSICIANS: The California Department of Social Services is seeking a few good psychiatrists and physicians who are interested in working with outside treating sources and other state professionals that evaluate medical evidence to determine its adequacy for making disability decisions as defined by Social Security regulations. On-the-job training is provided. Interested applicants must have a current CA MD/DO License. Full-time salary ranges can start at $9,152.00 – $13,547.00 per month, depending on experience and credentials. If you are interested, please contact Ruby Chin at (916) 285-7593 or at ruby.chin@ssa.gov. [546] GENERAL FAMILY MEDICINE / GERIATRICS / LONG-TERM CARE PHYSICIANS / NPs wanted to join our team of professionals in beautiful North San Diego County. We are dedicated to making “housecalls” to serve chronically ill patients in their homes. No hospital call, M–F, 8–5 or part time available. Independent contractor position. We are a very relaxed, professional practice environment. We very much look forward to your call! No recruiters, please. Email your CV or résumé to mobiledoctor@sbcglobal.net. [545] PRIMARY CARE POSITION: San Diego area. Outpatient only. No calls, no hospital, and no weekends. Email sandiegoprimarycare@yahoo.com. [542] MEDICAL DIRECTOR-BEHAVIORAL HEALTH: The County of San Diego Health & Human Services Agency (HHSA), Behavioral Health Services (BHS), is seeking online applications and résumés from qualified individuals for medical director-behavioral health. As medical director-behavioral health, you will have significant responsibility for formulating policy and managing the overall activities within your assigned programs/facilities. This position will oversee the medical activities of the San Diego County Psychiatric Hospital, in addition to assigned clinical activities within Behavioral Health Administration. To apply, visit www.sandiegocounty.gov/hr. [537] IS INTERNAL MEDICINE YOUR CALLING AND NOT JUST YOUR JOB? If you’re tired of working in the bureaucracy of a large medical group and would like to be in charge of your own destiny, consider this unique opportunity. Looking for someone who wants to practice part time (with the ability to expand over time) and really take care of his or her patients. You would take over patients from the practice of a general internist that’s leaving the area, and you would be sharing an office and overhead with another internist on the campus of Scripps La Jolla, an environment that is in need of more primary care physicians. If you are at all interested in making this move, please send questions and your CV to XimedMD@gmail.com. [536]

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.

November 2016

PER DIEM PHYSICIANS NEEDED: The County of San Diego Health and Human Services Agency is seeking physicians to work in tuberculosis (TB) clinic; clinic is located in Old Town. Applicants (MD or DO) must hold a current California medical license. Board certification in internal medicine, family medicine, or preventive medicine is desired but not required. Experience in infectious diseases and/or pulmonology is a plus. Applicants must be comfortable working with diverse patient populations and willing to work a minimum of two days per week. If interested, please email CV to janette.dubski@sdcounty.ca.gov or call (619) 692 8629. [535] PART-TIME PRIVATE PRACTICE IM/FP OPPORTUNITY IN BEAUTIFUL NORTH SAN DIEGO COUNTY: Unique opportunity to enjoy outpatient medicine in a premier private practice setting. Practice is part of a well-established internal medicine group with a 30+ year history in the community, and has need for a part-time physician who enjoys providing thoughtful, personalized patient care. Exceptional office staff, flexible scheduling options, small-group environment, and very high quality patient care set this far apart from many other situations. Office is easily accessible from all parts of San Diego County, as well as Orange County. Interested in board-certified IM or FP applicants with EHR experience. Please email CV to portofino3@aol. com or call (619) 248-2324. [534] SEEKING URGENT CARE CLINICIANS: UC San Diego, Department of Pediatrics (www-pediatrics. ucsd.edu), and Rady Children’s Hospital of San Diego (www.rchsd.org) is seeking clinicians for our urgent care clinics, Division of Emergency Medicine & Urgent Care. Clinicians should be BC/BE pediatricians, with experience in general pediatrics and urgent care. Our main campus EM has a census of over 85,000 visits per year; the division also has four community pediatric urgent care centers with a combined census of about 54,000 visits per year. Salary will be commensurate with experience. Interested persons should contact Dr. Katherine Konzen, Director of Pediatric Urgent Care, at kkonzen@rchsd.org. [531] SEEKING FAMILY MEDICINE PHYSICIANS: Sharp Rees-Stealy Medical Group is seeking full-time or half-time (job share) BC/BE family medicine physicians to join our staff. Openings available in La Mesa, Downtown San Diego, Otay Ranch, and Kearny Mesa. 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, or email lori.miller@sharp.com. [529] SEEKING INTERNAL MEDICINE PHYSICIANS: SHARP Rees-Stealy Medical Group is seeking fulltime BC/BE Internal Medicine physicians to join our staff. Openings available in La Mesa, Otay Ranch, Downtown San Diego and Kearny Mesa. 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, or email lori.miller@sharp.com. [528] SEEKING OCCUPATIONAL MEDICINE PHYSICIANS: SHARP Rees-Stealy Medical Group is seeking full-time BC/BE Occupational 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, or email lori.miller@sharp.com. [527] SEEKING OB/GYN NOCTURNIST PHYSICIANS: SHARP Rees-Stealy Medical Group is seeking fulltime and part-time BC/BE ob-gyn nocturnists to join our staff working at Sharp Mary Birch Hospital. 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, or email lori.miller@sharp.com. [526] DERMATOLOGIST NEEDED: Dermatologist, with California license, needed for a well established, well

respected dermatology practice in Encinitas, CA. Part-time or full-time position available immediately. Competitive salary. Training in Mohs micrographic surgery a plus. Exceptional new graduates are considered for the position. Please email CV to dermmd10@gmail.com or call (760) 612-7171. [523] SEEKING FAMILY MEDICINE PHYSICIANS: Graybill Medical Group, an independent physician group of 80 + physicians, is seeking full-time BC/BE family medicine physicians for its offices in Escondido, San Marcos, and Ramona. We offer a competitive compensation package and shareholder opportunity. Please send CV to Jackie Craw, Director Human Resources, via fax at (760) 738-7101 or via email at humanresources@graybill.org. [499]

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] 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]

SEEKING CARDIOLOGISTS: Graybill Medical Group is seeking full-time interventional cardiologists and non-invasive cardiologists for its Escondido office. We have a significant patient base and offer competitive compensation packages. Please send CV to Jackie Craw, Director Human Resources, via fax at (760) 738-7101 or via email at humanresources@graybill.org. [498] FULL- AND PART-TIME FAMILY MEDICINE PHYSICIAN POSITIONS: North County Health Services (NCHS) • Job Title: Family Medicine Physician • Location: Multiple Locations • Job Status: Full Time and Part Time. We have several open family medicine physician positions. Must have active California state license (MD/DO), CPR, board certified or board eligible. Full benefits package, malpractice liability insurance included, CME allowance, and license reimbursement. NCHS is proud to be an equal opportunity workplace and is an affirmative action employer. Contact Araceli Mercado, www.nchs-health. org, araceli.mercado@nchs-health.org, (760) 7366780. [497] PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com) is a fastgrowing group of house-call doctors. Great pay ($140–$220+K), flexible hours, choose your own days (full or part time). No ER call or inpatient duties required. Transportation and personal assistant provided. Call Chris Hunt, MD, at (619) 992-5330 or email CV to drhunt@thehousecalldocs.com. Visit www.thehousecalldocs.com. [037] OFFICE SPACE AVAILABLE

CLASS A MEDICAL OFFICE CONDO FOR SALE OR LEASE Encinitas • 781 Garden View Court 2,809 SF (divisible to 1,000 SF)

Rare opportunity to purchase or lease a first-class 2,809 SF medical office condominium in the heart of North County near Scripps Memorial Hospital Encinitas. The space can be easily reconfigured for a variety of medical uses and sizes, and is currently OSHPD-3 certified. The building has excellent parking and is located just off of N. El Camino Real near the vast number of highly-frequented retail and restaurant attractions and other healthcare providers. For more information, please contact Chris Ross at (858) 410-6377 or chris.ross@am.jll.com.

MEDICAL OFFICE AVAILABLE FOR SUBLEASE UTC / SORRENTO VALLEY: Seeking physicians in the fields of orthopedic surgery, sports medicine, podiatry, primary care, rheumatology, and physical medicine and rehab or related fields to sublease a large medical office in Sorrento Valley. Built in 2013, the facility consists of two suites and includes eight exam rooms, two procedure rooms, onsite X-ray machine, onsite DME supplier, two waiting rooms, and a large conference room. The office is also adjacent to a physical therapist and is situated directly above an outpatient surgical center. Rates are negotiable with the terms of the lease. For more information, please contact Jeff Craven at (858) 245-9109 or at jeff@ sdmiortho.com. [539]

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]

CONSIDERING A BRANCH OFFICE IN THE SOUTH BAY? This is an opportunity to work with like-minded, independent, board-certified physicians in the same building who wish to work and grow together, providing an integrative approach to provide comprehensive patient care in one setting. Call (619) 585-0476 and ask for Vanessa. [538]

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]

ADMINISTRATIVE ASSISTANT FOR BUSY WORKERS’ COMPENSATION MULTI-SPECIALTY PRACTICE: Must know work comp, multi-task, and be detail-orientated. Bi-lingual helpful. Full-time with great benefits. Please email rmcmurtrie@davidkupfermd.com with resume. [547] GENERAL FAMILY MEDICINE / GERIATRICS / LONG-TERM CARE PHYSICIANS / NPs wanted to join our team of professionals in beautiful North San Diego County. We are dedicated to making “housecalls” to serve chronically ill patients in their homes. No hospital call, M–F, 8–5 or part time available. Independent contractor position. We are a very relaxed, professional practice environment. We very much look forward to your call! No recruiters, please. Email your CV or résumé to mobiledoctor@sbcglobal.net. [545] SEEKING PER DIEM PHYSICIAN ASSISTANTS OR NURSE PRACTITIONERS: Graybill Medical Group, an independent physician group of 80+ physicians and midlevel practitioners, is seeking a PA or NP for our Escondido location every other weekend and a float for our North Coastal locations of Carlsbad, Oceanside, and Tri-City. Provide direct patient care in an urgent care / extended family practice setting; this will include examination and treatment of patients, recommendations and supervision of health concerns, and completion of all necessary paperwork. The incumbent must hold a current California (PA or NP) license and be ACLS and CPR certified. Two years prior experience in an urgent care or ER required. Bilingual in English / Spanish preferred. Send CVs to humanresources@graybill.org, apply online at www.graybill.org, or fax (760) 738-7101. [525] PHYSICIAN ASSISTANT: Comprehensive Pain Management Specialists are seeking a physician assistant for our La Jolla, Rancho Bernardo, and Escondido locations. The physician assistant will provide direct patient care in an outpatient setting; this will include examination and treatment of patients, recommendations and supervision of health concerns, and completion of all necessary paperwork. The incumbent must hold a current California PA and DEA license and be ACLS and CPR certified. Candidates with previous experience in pain management are highly desirable, but recent graduates are welcome to apply and will be considered. We are willing to train the right candidate. Please submit resume with cover letter outlining salary history and references to Nicci Parker at nparker@sdcpms.com. [524] NURSE PRACTITIONER: Needed for house-call physician in San Diego. Full-time, competitive benefits package and salary. Call (619) 992-5330 or email drhunt@thehousecalldocs.com. Visit www.thehousecalldocs.com. [152] PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Needed for house-call physician San Diego. Part-time, flexible days / hours. Competitive compensation. Call (619) 992-5330 or email drhunt@thehousecalldocs.com. Visit www.thehousecalldocs.com. [038] OFFICE FURNITURE / MEDICAL EQUIPMENT FOR SALE

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. [530] 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

NONPHYSICIAN POSITIONS AVAILABLE FAMILY PRACTICE MD/DO AND PHYSICIAN ASSISTANT WANTED IN BEAUTIFUL LA COSTA: Various shifts available at urgent care / family practice office. Nights, weekends, and day hours available. Please fax or email CV to (760) 603-7719 or gcwakeman@sbcglobal.net. [551]

NEARLY NEW OFFICE FURNITURE AVAILABLE BELOW MARKET PRICING: Conference room table (medium to light wood) with black leather high back chairs with arm rests, physician desks with matching hutch, waiting room chairs (navy blue leather with light wood), and exam room tables and chairs (black leather with light wood). Everything is in excellent condition and looks brand new. Please call Tracy at (619) 286-9480 for information. [549] LABORATORY FOR SALE: CGM-LABDAQ: 1. Piccolo (chemistry); 2. Sysmex XP-300 (hematology); 3. Qualigen Fastpack (immunoassay); 4. Clinitek Status (urinalysis); 5. Affinition (HbA1c). Please contact Afsaneh Maghsoudy, MD, Tue.–Fri., 10:00am–3:30pm, at (760) 730-3536. [543]

SAN DIEGO PHYSICIAN.org

PUBLI C H EALT H

Running and Walking to Prevent Diabetes By Christina Lewis, MPA, Director of Communications & Philanthropy, Champions for Health

More than 700 San Diegans participated in the third-annual Champions for Health Sunset 5K Run/Walk on Oct. 1, with runners and walkers alike taking advantage of this unique, family1 friendly race to enjoy a sunny and fun-filled afternoon at Fletcher Cove in Solana Beach. Over $70,000 was raised for Jump Start for Health, the diabetes-prevention program of SDCMSâ&#x20AC;&#x2122;s charitable arm, Champions for Health. Champions for Health has matured over the past 11 years, and we have been blessed with a growing number of champions working with us to improve the health of our community. Even with the implementation of the Affordable Care Act and increased numbers of people eligible for health insurance, there are still too many adults in our community uninsured, underinsured, or with limited access to care and preventive services. If you would like to learn more about Jump Start for Health or any of the many other Champions for Health programs, please visit www.ChampionsForHealth.org.

Please consider making an end-of-year donation to help us help you improve health and change lives â&#x20AC;&#x201D; visit www.ChampionsForHealth.org. 28

November 2016

Left and Above: Energy and enthusiasm abound along the scenic 5K course at Fletcher Cove. Below: Team Fertility Specialist Medical Group, led by Dr. Sharon Kinney, poses for a photo before the start.

Success. It’s what California’s finest physicians strive for... and what CAP can help you achieve. Since 1977, the Cooperative of American Physicians (CAP) has provided superior medical professional liability coverage and valuable risk and practice management programs to California’s finest physicians through its Mutual Protection Trust (MPT). As a physician-directed organization, we understand the realities of running a medical practice, and we are committed to supporting you with a range of valuable programs and services. These include a 24-hour adverse outcomes hotline, HR support, EHR consultation, a group purchasing program, and payment and reimbursement education and support, to name a few.

The 6 Most Common HIPAA Violations Revealed in CAP’s Free Guide. CAP’s new compliance guide, The 6 Most Common HIPAA

Violations, not only explains how to avoid such mistakes, but cites the accompanying penalties for these common – yet easily avoidable – violations. With the right procedures in place, you can focus on practicing medicine and serving your patients instead of worrying about penalties.

For Your Protection. For Your Success.

Request your free copy today! 800-356-5672 | CAPphysicians.com/Compliance SAN DIEGO PHYSICIAN.org

$5.95 | www.SANDIEGOPHYSICIAN.org

San Diego County Medical Society 5575 Ruffin Road, Suite 250 San Diego, Ca 92123 [ Return Service Requested ]

Tirelessly defending the practice of

GOOD MEDICINE. We’re taking the mal out of malpractice insurance. By constantly looking ahead, we help our members anticipate issues before they can become problems. And should frivolous claims ever threaten their good name, we fight to win—both in and out of the courtroom. It’s a strategy made for your success that delivers malpractice insurance without the mal. See how at thedoctors.com

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PAID DENVER, CO PERMIT NO. 5377