January 2020

JANUARY 2020

Official Publication of SDCMS

1870 to 2020 The Founding of SDCMS

Celebrating 150 Years

Waves of Weeness CHAMPIONS SOIRÉE

March 28, 2020 6:00pm – 9:00pm Birch Aquarium PRESENTED BY:

WWW.CHAMPIONSSOIREE.ORG • Charlie.Huettner@championsfh.org • 619.381.1632 B

January 2020

Contents JANUARY

Editor: James Santiago Grisolia, MD Editorial Board: James Santiago Grisolia, MD; David E.J. Bazzo, MD; Robert E. Peters, MD, PhD; William T-C Tseng, MD Marketing & Production Manager: Jennifer Rohr Sales Director: Dari Pebdani Art Director: Lisa Williams Copy Editor: Adam Elder OFFICERS President: James H. Schultz, MD President-elect: Holly B. Yang, MD Secretary: Sergio R. Flores, MD Treasurer: Toluwalase (Lase) A. Ajayi, MD Immediate Past President: David E. J. Bazzo, MD GEOGRAPHIC DIRECTORS East County #1: Heidi M. Meyer, MD (Board Representative to the Executive Committee) East County #2: Rakesh R. Patel, MD Hillcrest #1: Kyle P. Edmonds, MD Hillcrest #2: Steve Koh, MD Kearny Mesa #1: Anthony E. Magit, MD Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Laura H. Goetz, MD La Jolla #2: Marc M. Sedwitz, MD, FACS North County #1: Patrick A. Tellez, MD North County #2: Christopher M. Bergeron, MD, FACS South Bay #2: Maria T. Carriedo, MD GEOGRAPHIC ALTERNATE DIRECTORS Kearny Mesa #2: Eileen R. Quintela, MD La Jolla: Wayne C. Sun, MD North County #1: Franklin M. Martin, MD South Bay: Karrar H. Ali, DO

VOLUME 107, NUMBER 1

feature:

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Frontier Days and the Birth of the San Diego County Medical Society

By James Santiago Grisolia, MD, and Sue Fledderjohn

AT-LARGE DIRECTORS #1: Thomas J. Savides, MD; #2: Paul J. Manos, DO; #3: Irineo “Reno” D. Tiangco, MD; #4: Nicholas J. Yphantides, MD (Board Representative to Executive Committee); #5: Stephen R. Hayden, MD (Delegation Chair); #6: Marcella (Marci) M. Wilson, MD; #7: Karl E. Steinberg, MD; #8: Alejandra Postlethwaite, MD AT-LARGE ALTERNATE DIRECTORS #1: Mark W. Sornson, MD; #2: Steven L-W Chen, MD, FACS, MBA; #3: Susan Kaweski, MD; #4: Al Ray, MD; #5: Preeti Mehta, MD; #6: Vimal I. Nanavati, MD, FACC, FSCAI; #7: Peter O. Raudaskoski, MD; #8: Kosala Samarasinghe, MD ADDITIONAL VOTING DIRECTORS Communications Chair: William T-C Tseng, MD Young Physician Director: Obiora “Obi” Chidi, MD Resident Director: Vishnu Parthasarathay, MD Retired Physician Director: David Priver, MD Medical Student Director: Grace Chen ADDITIONAL NON-VOTING MEMBERS Alternate Young Physician Director: Brian Rebolledo, MD Alternate Resident Director: Nicole Herrick, MD Alternate Retired Physician Director: Mitsuo Tomita, MD San Diego Physician Editor: James Santiago Grisolia, MD CMA Past President: James T. Hay, MD CMA Past President: Robert E. Hertzka, MD (Legislative Committee Chair) CMA Past President: Ralph R. Ocampo, MD, FACS CMA President: Theodore M. Mazer, MD CMA Trustee: William T-C Tseng, MD CMA Trustee: Robert E. Wailes, MD CMA Trustee: Sergio R. Flores, MD CMA TRUSTEES Robert E. Wailes, MD William T-C Tseng, MD, MPH Sergio R. Flores, MD AMA DELEGATES AND ALTERNATE DELEGATES District 1 AMA Delegate: James T. Hay, MD District 1 AMA Alternate Delegate: Mihir Y. Parikh, MD At-large AMA Delegate: Albert Ray, MD At-large AMA Delegate: Theodore M. Mazer, MD At-large AMA Alternate Delegate: Robert E. Hertzka, MD At-large AMA Alternate Delegate: Holly B. Yang, MD

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.]

Departments 2

Briefly Noted: Advocacy/ Physician Workforce • Prescribing/Regulations • Dr. Tseng Introduction to SDCMS’ 150th Anniversary

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Physicians Can Help Reduce the Obesity Epidemic by Changing the Way We Treat Patients with Obesity By Natalie Digate Muth, MD, MPH, RDN, FAAP, FACSM, and Cassandra Padgett, MS

Congenital Syphilis

By M. Winston Tilghman, MD, MPH

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Promoting Mothers’ Milk: The Important Role All Physicians Can Play to Improve Infant and Maternal Health By Naomi Billups, Shaila Serpas, MD, MPH, Dean E. Sidelinger, MD, MSED, Alison Sipler, MPH, CHES, Lisa Stellwagen, MD, FAAP, and Wilma J. Wooten, MD, MPH

Physician Classifieds

Let’s Make 2020 Be the Year of Creativity By Helane Fronek, MD, FACP, FACPh

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Physician Fun in the Sun … and Striking Out Health Barriers

By Adama Dyoniziak

SanDiegoPhysician.org 1

ADVOCACY/PHYSICIAN WORKFORCE

State Tobacco Tax Expanding Healthcare Workforce; CalMedForce Awards $38 Million from Prop 56 Funds Revenues Will Help Address Physician Shortage, Increase Access to Care PHYSICIANS FOR A HEALTHY CALIFORNIA

(PHC) announced more than $38 million in CalMedForce awards to support medical training and residency programs across the state and to help grow the physician workforce.

The funding, generated by the voter-approved Proposition 56 tobacco tax in 2016, will pay for 198 residency positions in 89 Graduate Medical Education (GME) programs at hospitals and clinics, with an emphasis on programs serving medically underserved groups and communities.

Medical school graduates must continue training in an accredited, specialty-specific GME residency program to care for patients independently. The lack of sufficient residency opportunities contributes to the state’s physician shortage and limits the number of new doctors entering the workforce.

The California Future Health Workforce Commission estimates California will have a 4,100-clinician shortfall by 2025. PHC established the CalMedForce grant program to create additional GME opportunities.

“CalMedForce helps grow and strengthen our physician workforce to meet the demands of California’s growing and changing patient population,” said Lupe Alonzo-Diaz, MPAff, PHC president and CEO. “Research also shows that physicians are more likely to practice where they complete residency programs, demonstrating an

By California Medical Association Staff

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January 2020

opportunity to address access to care challenges in underserved communities.”

The University of California (UC) is the designated recipient of Proposition 56 funding and has contracted with PHC to administer CalMedForce. All accredited residency programs in the state that meet guidelines are eligible to apply for funding. Of the CalMedForce awardees, approximately 25% of GME programs are sponsored by the University.

For the 2018–2019 award cycle, CalMedForce released an initial round of awards also totaling more than $38 million to 72 GME programs across California to retain and expand GME programs in primary care (family medicine, internal medicine, pediatrics, and obstetrics and gynecology) and emergency medicine.

However, even with the additional funding, the shortage of California residency programs poses an ongoing challenge to expanding the physician workforce. “CalMedForce received funding requests this grant cycle for 528 slots seeking more than $93 million, underscoring the long-standing need for additional investment to train and retain physicians,” said Cathryn Nation, MD, vice president for Health Sciences at UC Office of the President. “We continue to face a long road of needed investment to improve access to quality care across the state.”

For more information, visit PHCdocs.org/ CalMedForce.

PRESCRIBING/REGULATIONS

Legislature Clarifies Law Requiring Physicians to Offer Naloxone to Patients

By California Medical Association Staff IN JANUARY, A NEW LAW TOOK EFFECT that requires opioid

prescribers to also offer prescriptions for opioid-overdose reversal drugs such as naloxone. The California Medical Association (CMA) received numerous calls from physicians regarding the ambiguity of the new requirements.

The California Legislature recently enacted a bill that clarifies the circumstances under which physicians are required to offer opioidoverdose reversal drugs. Effective Sept. 5, 2019, AB 714 specifies that the requirement to offer naloxone applies only if the patient is receiving a prescription for an opioid or benzodiazepine medication.

If a patient is receiving such a prescription, the law requires that the prescriber offer naloxone or other similar drug if: • The prescription dosage for the patient is 90 or more morphine milligram equivalents of an opioid medication per day; • An opioid medication is prescribed within a year from the date a prescription for benzodiazepine has been dispensed to the patient; or • The patient presents with an increased risk for opioid overdose, including a patient with a history of opioid overdose, a patient with a history of opioid use disorder, or a patient at risk for returning to a high dose of opioid medication to which the patient is no longer tolerant.

In addition, the law now specifies that the education physicians must provide patients who are prescribed naloxone or other similar drug must be about opioid overdose prevention and use of the opioid reversal drug. Physicians do not need to provide the education if the patient declines or if the patient has received the education within the past 24 months.

The new law further clarifies that the requirement to offer naloxone does not apply when the opioid or benzodiazepine medication is being administered in a facility or prescribed to a patient who is terminally ill.

To learn more about prescribing controlled substances, including this new requirement, see CMA health law library document #3201, “Controlled Substances: Prescribing.”

This document, as well as the rest of CMA’s online health law library, is available free to members at cmadocs.org/health-lawlibrary. Nonmembers can purchase documents for $2 per page.

Contact: CMA Legal Information Line, (800) 786-4262 or legalinfo@ cmadocs.org.

Celebrating 150 Years

A Special Year: San Diego County Medical Society’s 150th Anniversary

By Will T. Tseng, MD,

HELLO SAN DIEGO

County Medical Society community!

Along with our current SDCMS President, Dr. Jim Schultz the board, and our CEO, Paul Hegyi plus the entire SDCMS staff, we would like to wish you and your loved ones a happy and prosperous new decade!

As we bid adios to an incredible and industrious 2019, let’s gather to raise a toast to a special anniversary year ahead of us. Can everyone say “sesquicentennial”!

2020 is the 150th birthday of our Medical Society, and we have collector editions of San Diego Physician magazine to commemorate the occasion! This year’s special articles will include: Highlights of our major milestones and accomplishments; legacies of past physician giants in the community and their contributions; dynamics that have shaped the San Diego medical community; and trends for physician practices in an evolving landscape.

We would also love to hear from you if you have any interesting historical tidbits or fascinating professional updates for the team to include in the magazine this anniversary year!

Stay tuned and stay connected with your growing fellow physician community this year.

We look forward to rededicating ourselves to our Society’s founding missions and traditions of serving our physician members and the community.

Dr. Tseng is chair of SDCMS’ Communications Committee.

SanDiegoPhysician.org 3

SDCMS’ 150TH ANNIVERSARY

FRONTIER Photographs Courtesy of San Diego History Center

S

an Diego’s first recorded physician, Frederick J. Painter, nearly smothered beneath the falling weight of a hanged man. From this inauspicious beginning, San Diego’s frontier medicine has grown to reach undreamed-of frontiers in science, clinical medicine, and policy influence at state and national levels.

Dr. Painter came to San Diego about 1848, the year that America claimed Alta California as U.S. territory from the Mexican-American War. Painter practiced in New York City for a few years before moving to San Diego. We don’t know if he studied mainly by apprenticeship to an older physician, as we cannot find record of his attendance or graduation from any formal program. He lived and worked, very possibly in the old Exchange Hotel, on the south side of the main square or old colonial plaza, at the time a one-story adobe boasting a bar with a billiard table and mirrors for décor.

Like most who came, Dr. Painter probably arrived by ship, sailing around Cape Horn from the East Coast. His first view of San Diego Bay would be breathtakingly beautiful after the slow desert trek up the coast of Baja California. Gray

Horton’s Hall c. 1890. First meeting location of the San Diego County Medical Society

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DAYS

and the Birth of the San Diego County Medical Society

By James Santiago Grisolía, MD, and Sue Fledderjohn whales still spouted their heart-shaped sea breath in the harbor, no longer calving there with increasing ships and human commotion. Ships docked below Point Loma in La Playa, a separate township. A well-built road took him the 4 miles to San Diego proper, a dusty collection of colonial adobes sprinkled with a few Yankee wooden structures.

The town huddled at the base of the old Spanish Presidio, surrounded by hills and arroyos clothed in the dull greens and browns of coastal sage and chaparral, dotted with a few scrubby live oaks. The dirt streets raised dust with every hoof, wagon rim, or footfall.

More than 500 European/Anglo people lived in San Diego proper, with many more Native Americans in rancherías throughout the county. Both the Spanish colonizers and the Mexicans who followed believed the country to be dry and worthless, unsuitable for farming, fit only for raising cattle for the hide and tallow trade. Yet San Diego boasted the finest harbor on the West Coast, after San Francisco, so great hide-houses were built in La Playa for storage prior to shipping to the East Coast, and later to Northern California.

In 1851, the first issue of the San Diego Herald ran an ad for Dr. Painter’s office, fronting on the main plaza. He held a variety of other posts, serving as Clerk for the Common Council from 1850 to 1852, and in 1851 he was listed as County Assessor and Deputy Postmaster. Common Council records indicate he was also paid for medical attendance.

In 1852, Dr. Painter was called to the execution of “Yankee Jim” Robinson, a burly miner listed as 6-foot-4-inches tall and more than 200 pounds. Yankee Jim was convicted of grand larceny for stealing a boat and sentenced to death by hanging. According to the accounts

in the local newspapers, the accused stood in the back of a mule-drawn wagon while the noose was fastened around his neck. Unexpectedly, this dour and forbidding man then began a lengthy farewell speech to the crowd who assembled for the event. Deputy Sheriff Philip Crosthwaite stood waiting for Jim to finish, then lost patience and in his Irish brogue ordered the mules driven forward, so that Jim “swung like a pendulum” according to one reporter.

After Jim died, Crosthwaite ordered the wagon backed under the gallows to receive the body. Dr. Painter and Crosthwaite climbed up into the wagon, and Dr. Painter opened Jim’s shirt, applying his ear to the chest, and pronounced him dead. Crosthwaite then cut the rope. Jim’s corpse tumbled forward onto Dr. Painter, who fell flat on his back in the wagon, unable to move beneath the immense weight. The spectacle of the physically slight Dr. Painter, pinned beneath the late Yankee Jim, caused Crosthwaite and the spectators to laugh until they were weak, and reportedly Dr. Painter was “nearly played out” by the time they succeeded in freeing him from Jim’s body. The Whaley House, now called the “most haunted house in America,” was built on the site of the old gallows. Old Tom Whaley, and many visitors since, claimed to have heard the heavy bootsteps of Yankee Jim. Other physicians began to arrive in town. Dr. George McKinstry arrived in 1850, purchasing a ranch in Santa Ysabel. He traveled through the backcountry, providing medical care to the Native Americans. His alcohol consumption was legendary, including multiday sessions with companions at Judge Witherby’s ranch, the aptly named Rincón del Diablo (Devil’s Corner). In 1858 he moved his home and medical practice to a room rented from Juana Machado Wrightington on the plaza, where he lived and practiced for the next 30 years. The Widow Wrightington was called the Florence Nightingale of Old Town, using her language skills to aid Dr. McKinstry in providing medical care for local Native Americans.

David Hoffman arrived in San Diego in 1853. Like many physicians of his day, his education was informal. He apprenticed with his father, Dr. Chauncey Hoffman, outside of Chicago, and took some classes at Rush Medical College. He was awarded a medical degree from Toland Medical College in 1865, the year after it opened. This was apparently an honorary degree as he had already practiced in San Diego since his arrival, even serving as a military surgeon to the local U.S. Army post. At the time, Toland’s full program of study offered two four-month courses leading to the MD degree.

This private school eventually formed the nucleus for UC San SanDiegoPhysician.org 5

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Francisco School of Medicine.

Dr. Hoffman held many civic and medical offices after his arrival in San Diego, and his fellow physicians elected him to be the first San Diego delegate when the California Medical Association was born. The devastating cholera epidemic of 1850 devastated both Sacramento and San Francisco, and the tragedy drew the surviving physicians together.

Each city formed a local medical society, in turn leading to the formation in 1856 of the Medical Society of the State of California, later renamed CMA. Scientific and clinical interest developed across the state, stimulating practicing doctors, including Dr. Hoffman, to publish articles in several California journals.

In response to this new spirit of organized medicine, the San Diego County Medical Society held its first meeting July 23, 1870, and began meeting in Horton Hall. Dr. Hoffman was elected the first President, giving an acceptance speech that repeatedly invoked the importance of science. He said, “When once launched out into practice scarcely a day passes but that some question connected with either the learned or natural sciences comes up, and blends itself almost intimately with medical investigation.”

Dr. Hoffman finished by inveighing against “uncouth patent medicine vendors, quacks, amateur physicians without diploma or license, and druggists who disgrace the honorable profession.” At a time when medical training was just moving from apprenticeship to scientific study and degree programs, Dr. Hoffman clearly wanted to draw a bright line between physicians and other, less scientific practitioners. The California frontier attracted both opportunists and vulnerable people with chronic illness. Not for another 40 years would 6

January 2020

Left: Four of the founding members of SDCMS 1. David B. Hoffman, MD, 2. Robert J. Gregg, MD, 3. Thomas C. Stockton, MD, 4. Charles M. Fenn, MD. Right: 5th & Broadway c. 1870.

Far right: Note written by Edward Burr, MD, to the Board of Supervisors regarding payment as county physician, June 26, 1871. Bottom right: Old Town San Diego c. 1869. This is what our town looked like when Drs. Painter, Hoffman, and McKinstry lived and practiced medicine.

the national-level Flexner Report firmly put medical education on a scientific footing, closing many disreputable schools that were still awarding medical diplomas in Dr. Hoffman’s day.

With the few physicians in town busy in their practices, the Society languished for a time, such that in 1886, Dr. Walter Lindley, editor of the Southern California Practitioner, challenged San Diego doctors to reorganize, and by August of that year the 20 or so physicians in town gathered and elected Robert Gregg their President. A native of Pennsylvania, he graduated from the Jefferson Medical College and came to San Diego in 1868. He started as an assistant to an old Irish doctor, Edward Burr, who as county physician would spray arriving stagecoach passengers with a perfumed spray to disinfect them from smallpox. With this colorful beginning, Dr. Gregg soon moved from Old Town to Horton’s Addition, or New Town, and opened his own office on Fifth Avenue. He ascended to the presidency of SDCMS with the blessings of Dr. Hoffman, who attended the reorganization meeting.

The reorganized SDCMS held several meetings throughout the fall of 1886, but in December a rival meeting elected Dr. Daniel McSwegan as president. Little is known of Dr. McSwegan, but a variety of notices from different cities suggest that he was skilled at self-promotion. In February of 1887, Dr. McSwegan announced in the SD Union a public lecture on typhoid fever, which was boycotted by other physicians.

Shortly after, a rescheduled Society meeting produced a fight regarding electing delegates to the state medical society. Dr. McSwegan threatened “exposure through the public press,” according to meeting notes. After a unanimous vote against him, Dr. McSwegan stood and swept up all the Society’s books and Official Register, storming out of the room. In his absence, the gathered body elected a new slate of officers, with Dr. W.N. Smart as president. Continued controversy impelled the president of the California State Medical Society, R.H. Plummer of Santa Clara, to personally investigate. He reported to the state medical society that the county medical society headed by Dr. Smart was the genuine society representing San Diego. By 1888, Dr. McSwegan had left town.

In a time of epidemics, medical societies like SDCMS strengthened the community response to infectious disease.

Smallpox arrived in San Diego in 1863, and in the same year Dr. Hoffman began vaccinations, including very widely in the Native American population. By 1869 Dr. Hoffman and his

Alonzo Horton started selling lots in what is now downtown San Diego, which became known as New Town, so that the former city became known as Old Town. He promoted the climate and health benefits of San Diego to the East Coast, competing with similar claims made by Florida promoters.

In 1870, he opened the Horton House, with 20 rooms designated for health and recovery, which was later razed to become the site for the U.S. Grant Hotel. By 1888, the Hotel del Coronado opened across the bay, the largest resort hotel in the world at the time, again highlighting the healthy Southern California climate.

Popular and medical beliefs continued to promote climate as a benefit, if not cure, for many other conditions.

Dr. Peter Remondino, Turin-born but trained at Jefferson Medical College, contracted malaria while serving as an Army surgeon during the Civil War. After studying climate across the United States, he elected to move to San Diego in 1874. By 1875 he became the first president of the San Diego Board of Health, and by 1879 he opened the

first private hospital in San Diego. He served as SDCMS President in 1896.

He continued to promote San Diego’s climate as a cure for disease, publishing in 1892 “The Mediterranean Shores of America. Southern California: Its Climatic, Physical and Meteorological Conditions,” which still serves as a historical reference today.

Thus our Medical Society was born in the transition from frontier medicine to the dawning age of scientific medicine.

Dr. Hoffman and our other medical pioneers would be astonished at today’s San Diego: Not only the growth of the city, but our world-class collection of hospitals, research institutions, and biotechnology companies. With all the changes, our climate and medical expertise continue to attract professionals and patients seeking hope from the rest of the U.S. and around the world.

Dr. Grisolia is San Diego Physician editor and a 40 year member of SDCMS. Sue Fledderjohn is executive assistant to SDCMS CEO Paul Hegyi and the Medical Society’s in-house amateur historian.

colleagues were fighting an outbreak of typhoid fever.

Despite the epidemics, promoters claimed amazing health benefits for San Diego’s climate. Tuberculosis was a major worldwide killer through the end of the century, and TB patients were sent to sunny, dry climates to recover. By the late 1860s, boosters had attracted a large population of “consumptives” to San Diego, as well as others with health concerns. Early San Diego physicians contributed to the local health mystique; for example, Dr. Hoffman wrote an article on healthful aspects of local climate in 1871 in Transactions of the Medical Society of the State of California, and another founding member of SDCMS, Dr. C.M. Fenn, wrote a similar article in the same journal in 1879. Both Hoffman and Fenn were members of a Standing Committee of the State Medical Society, focused on Medical Topography, Meteorology, Endemics, and Epidemics.

In 1867, the real estate promoter SanDiegoPhysician.org 7

CONGENITAL SYPHILIS

INFECTIOUS DISEASES

With complications ranging from stillbirth to bone, facial, and dental abnormalities to loss of vision or hearing during early adolescence, congenital syphilis is a catastrophic condition that is completely preventable. This article outlines what providers in San Diego County can do to prevent additional cases and improve the health and wellbeing of our newest residents.

By M. Winston Tilghman, MD, MPHÂ

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CONGENITAL SYPHILIS OVERVIEW Congenital syphilis results from transmission of Treponema pallidum, subspecies pallidum, from a pregnant woman to a fetus in utero or, less commonly, during delivery. While the risk of transmission increases with gestational age and is highest for pregnant women with early (i.e., primary, secondary, and early latent) syphilis and higher rapid plasma reagin (RPR) titers, transmission can occur at any time during pregnancy and with any stage of maternal infection. In contrast to sexual transmission of T. pallidum, which typically occurs only within the first year of infection, any stage of syphilis in a pregnant woman poses a risk to a developing fetus and requires prompt definitive treatment.

Early complications of congenital syphilis, which typically occur during the first two years after birth, include premature birth, low birth weight, bone abnormalities, hepatomegaly, rash, generalized lymphadenopathy, nasal discharge (i.e., “snuffles”), hematologic abnormalities, neurologic abnormalities, and fetal or neonatal demise. Late manifestations include hearing loss, interstitial keratitis, vision loss, bone and facial abnormalities, dental abnormalities, neurologic abnormalities, and gummas (destructive granulomatous lesions) in the skin or mucous membranes. Approximately 60–90% of neonates with congenital syphilis are asymptomatic at birth but, without treatment, will develop complications later in life.

EPIDEMIOLOGY OF CONGENITAL SYPHILIS Since 2012, there has been a marked increase in reported cases and rates of congenital syphilis in the United States (U.S.) and in California. In 2018, a total of 1,306 cases of congenital syphilis were reported nationwide, including 78 syphilitic stillbirths and 16 infant deaths, according to a recent report from the Centers for Disease Control and Prevention (CDC).1 The rate of congenital syphilis was 33.1 cases per 100,000 live births, which represents a 39.7% rate increase relative to 2017 (23.7 cases per 100,000 live births) and a 185.3% increase relative to 2014 (11.6 cases per 100,000 live births). California was among the five states that accounted for 70% of congenital syphilis cases and had the fifthhighest rate of congenital syphilis in 2018 after Texas, Nevada, Louisiana, and Arizona.1 In 2018, a total of 329 cases of congenital syphilis were reported in California, with a rate of 68.2 cases per 100,000 live births (more than double the U.S. average). This represented rate increases of 11.8% and 229.5% relative to 2017 (61.0 cases per 100,000 live births) and 2014 (20.7 cases per 100,000 live births) respectively.2 Since 2014, the number of congenital syphilis cases reported in San Diego County more than doubled from seven in 2014 to 15 in 2018. There have been five reported syphilitic stillbirths in San Diego County from 2014-2018.3 For surveillance purposes, congenital syphilis is defined as any infant who is born to a mother with untreated or inadequately treated syphilis at the time of delivery, regardless of clinical manifestations. Adequate treatment of maternal syphilis requires both (1) treatment with a CDC-recommended penicillin-based regimen based on maternal stage of infection

and (2) initiation of treatment at least 30 days prior to delivery.

Parenteral penicillin G is the only agent that has documented efficacy for syphilis during pregnancy, and the primary antibiotic used for alternative treatment of nonpregnant adults (doxycycline) is contraindicated during the second and third trimesters of pregnancy. Therefore, pregnant women with syphilis who have a penicillin allergy must undergo desensitization and receive treatment with penicillin.4 Treatment of syphilis for pregnant women is the same as for nonpregnant persons and is based on the stage of infection. For early (primary, secondary, and early latent) syphilis without neurosyphilis or ocular syphilis, treatment with one dose of longacting benzathine penicillin G (Bicillin® L-A, Pfizer) 2.4 million units intramuscularly is recommended. For late latent syphilis or latent syphilis of unknown duration, without neurosyphilis or ocular syphilis, three weekly doses of long-acting benzathine penicillin G (Bicillin® L-A) 2.4 million units intramuscularly are recommended, for a total cumulative dose of 7.2 million units.

Pregnant women on the three-dose series must adhere strictly to the seven-day interval between doses. If a dose is missed, the entire series must be restarted. For neurosyphilis, including ocular syphilis, treatment with aqueous crystalline penicillin G 18–24 million units intravenously per day is recommended for 10–14 days and can be administered as 3–4 million units every four hours or as a continuous infusion. For pregnant women with neurosyphilis or ocular syphilis that is diagnosed in the setting of late (≥1 year) syphilis or syphilis of unknown duration, up to three additional weekly intramuscular doses of benzathine penicillin G should be provided after completion of intravenous therapy in order to provide a similar duration of treatment.4 PREVENTION OF CONGENITAL SYPHILIS There are multiple things that healthcare providers can do to prevent congenital syphilis. Counseling and education about prevention of sexually transmitted infections, including syphilis, can reduce the risk of sexually active women of childbearing potential acquiring syphilis in the first place. Condom use with penetrative sex significantly reduces the risk of syphilis and should be encouraged. Minimizing the number of sexual partners and, if possible, mutual monogamy with someone who has tested negative for syphilis, also will minimize risk. Prevention of unwanted pregnancy and education regarding options for highly effective contraception also can be helpful.

Serologic screening of pregnant women for syphilis during the first prenatal visit is mandated by California law5 and is a Grade A U.S. Preventive Services Task Force recommendation6. For women who are vulnerable to acquiring syphilis during pregnancy or for women living in areas where syphilis prevalence is high, two additional screening tests are recommended during the third trimester at 28–32 weeks gestation and at delivery. No mother or neonate should be discharged from the hospital if the mother’s syphilis serologic status has not been documented at least once during pregnancy and, if the mother is at high risk, documented at delivery. In addition, any woman who has a fetal

SanDiegoPhysician.org 9

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January 2020

death after 20 weeks’ gestation should be tested for syphilis.4 In 2017, most women who gave birth to babies with congenital syphilis in California received prenatal care late in pregnancy or not at all. Therefore, providers of all specialties are encouraged to order a serologic test for syphilis if providing services to a pregnant woman who is not receiving prenatal care or for whom receipt of prenatal care is in doubt.

Prompt evaluation and treatment of any pregnant woman who has a reactive serologic test for syphilis is also crucial, and delays in treatment may increase risk for congenital syphilis, particularly if treatment is not initiated at least 30 days prior to delivery. As with all patients with syphilis, pregnant women should have a physical examination to assess for signs of primary (e.g., chancre(s), inguinal lymphadenopathy) or secondary (e.g., rash, mucous patches, condylomata lata, patchy alopecia, generalized lymphadenopathy) syphilis. A neurological examination also should be performed to assess for signs of neurosyphilis and ocular syphilis. Treatment must be in accordance with CDC recommendations based on the stage of infection, with strict adherence to dosing intervals, and should be penicillin-based.4 DIAGNOSIS AND MANAGEMENT OF CONGENITAL SYPHILIS The diagnosis of congenital syphilis is complex and complicated by transplacental transfer of maternal antibodies that make interpretation of nontreponemal and treponemal serologic tests difficult. Any neonate at risk for congenital syphilis should receive a full evaluation for congenital syphilis and testing for HIV. Management is based on multiple factors, which include: • Maternal syphilis history; • Adequacy and timing of maternal treatment; • Results of clinical, laboratory, and radiographic evaluation of the neonate; and • Comparison of maternal serum RPR titer at delivery and the serum RPR titer of the neonate, with a neonatal titer that is fourfold (i.e., two dilutions) higher than the maternal RPR titer indicative of congenital syphilis (e.g., a neonatal titer of 1:16 and a maternal titer at the time of delivery of 1:4).4 All neonates who are born to women with reactive serologic tests for syphilis should have, at a minimum, a thorough clinical examination to assess for signs of congenital syphilis (e.g., nonimmune hydrops, jaundice, hepatosplenomegaly, rhinitis, rash, pseudoparalysis of an extremity) and a semiquantitative nontreponemal test (RPR or Venereal Diseases Research Laboratory (VDRL) test). Direct identification of T. pallidum may be possible through specific staining of the placenta or umbilical cord or darkfield microscopy or polymerase chain reaction (PCR) of suspicious lesions or body fluids (e.g., nasal discharge or bullous rash).4 In the 2015 STD Treatment Guidelines, the CDC outlines four different clinical scenarios that are based on the results of initial work-up (i.e., maternal treatment status, clinical examination, and maternal and neonatal nontreponemal testing) and the likelihood of congenital syphilis. For each scenario, specific recommendations for additional evaluation and treatment are provided. Additional tests that may be indicated include complete blood count with differential and platelet count, cerebrospinal fluid examination (VDRL, cell count, and protein), long bone radiographs, chest radiograph, liver panel, neuroimaging, ophthalmologic examination, and auditory brain stem response. As with treatment of syphilis in pregnancy, treatment of congenital syphilis must be penicillin-based, and the formulation, method of administration (intravenous versus intramuscular), and duration of treatment are dependent on the final diagnosis (proven/highly probable vs. possible vs. less likely vs. unlikely). All neonates with reactive nontreponemal tests should be followed clinically and with nontreponemal testing every two to three months until the test becomes nonreactive.

RESOURCES FOR PROVIDERS CDC recommendations regarding the management of syphilis in pregnancy are available at https://www.cdc.gov/std/tg2015/ syphilis-pregnancy.htm. Recommendations regarding management of congenital syphilis are available at https://www.cdc.gov/ std/tg2015/congenital.htm. Providers can request expert consultation by contacting the County of San Diego HIV, STD, and Hepatitis Branch (http://www.stdsandiego.org) and can obtain syphilis treatment history for patients with reactive serologic tests by calling (619) 692-8501. Expert consultation also is available through the STD Clinical Consultation Network (https:// www.stdccn.org/).

Dr. Tilghman is senior physician/STD controller; HIV, STD, and Hepatitis Branch of Public Health Services at County of San Diego.

References 1 Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2018. Atlanta: U.S. Department of Health and Human Services; 2019. DOI: 10.15620/cdc.79370.

California Department of Public Health Sexually Transmitted Diseases Control Branch. Sexually Transmitted Diseases Data.

California STD Data Tables 2018. Accessed at https://www.cdph. ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/ CA_STD_Data_Tables_2018.pdf on 10/30/19.

3 County of San Diego, Health and Human Services Agency, Division of Public Health Services, HIV, STD, and Hepatitis Branch. October 2019. Sexually Transmitted Diseases in San Diego County, 2018 Data Slides. Accessed on 10/30/19 from www.STDSanDiego.org.

4 Frieden T.R., Jaffe H.W., Cono J., Richards C.L., and Iademarco M.F. Sexually Transmitted Diseases Treatment Guidelines, 2015.

MMWR Recomm Rep 2015;64(No. RR-3):34-51.

5 California Health and Safety Code. Section 120685. Accessed at https://leginfo.legislature.ca.gov/faces/codes_displaySection.xht ml?lawCode=HSC&sectionNum=120685. on 10/30/19.

6 Final Update Summary: Syphilis Infection in Pregnant Women: Screening. U.S. Preventive Services Task Force. September 2018.

Accessed at https://www.uspreventiveservicestaskforce.org/ Page/Document/UpdateSummary/Final/syphilis-infection-inpregnancy-screening1 on 10/30/19.

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SanDiegoPhysician.org 11

INFANT AND MATERNAL NUTRITION

Promoting Mothers’ Milk THE IMPORTANT ROLE ALL PHYSICIANS CAN PLAY TO IMPROVE INFANT AND MATERNAL HEALTH

By Naomi Billups, Shaila Serpas, MD, MPH, Dean E. Sidelinger, MD, MSED, Alison Sipler, MPH, CHES, Lisa Stellwagen, MD, FAAP, and Wilma J. Wooten, MD, MPH MOTHER’S MILK IS SO MUCH

more than pure nutrition — its biological role is vital to infant health and wellbeing. Along with nutritional elements it has cellular, bacterial, immunologic, hormonal, anti-inflammatory, and anti-infection components, plus so much more. These biological activities provide many benefits for infants: improving their ability to fight off infection, enhancing immune responses to vaccination, and driving healthier intestinal microbiomes. These advantages in turn lead to improved infant health outcomes including less middle ear, respiratory, urinary, and intestinal infections; lower rates of Sudden Infant Death Syndrome; less allergy, eczema, and asthma; less obesity; and lower rates of Necro12

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tizing Enterocolitis and improved neurodevelopmental outcomes for the smallest premature infants.

More and more families across our region are realizing the vast benefits of breastmilk over formula and are initiating breastfeeding and trying to extend the duration of feeding breast milk. There are many environmental supports and education that can assist mothers in accomplishing their goals.

All physicians have a role to help meet the American Academy of Pediatrics recommendation of exclusive breastfeeding for the first six months of a baby’s life, followed by breastfeeding in combination with the introduction of complementary foods until at least 12 months of age, and continuation of breastfeeding for as long as mutually desired by mother and baby.

The implications of mother’s milk for mothers and babies range from psychological wellbeing to helping build lifelong healthy eating habits.

As a community, San Diego is working on many fronts to improve breastfeeding rates. Local efforts to support breastfeeding include advocating for supportive policy implementation, home visiting programs for pregnant women

and families with young children, educational forums for families and providers, scientific research, direct breastfeeding counseling, and the first San Diego Milk Bank. Physicians have a role in contributing to these efforts to make breastfeeding an easy choice for mothers and their babies in our region. Policies and other programs that support breastfeeding and lactation for all families can contribute to making San Diego County a healthier, thriving community. As you’ll read below, San Diego efforts are having impacts not just locally, but nationally and internationally. No matter what type of physician you are, you have an immense supportive impact as well.

Public Health in Action

Since 2010, the Lactation Supportive Environments (LSE) project has designed and implemented a variety of strategic efforts to support families to reach their breastfeeding goals. The County of San Diego Health and Human Services Agency’s Public Health Services Department, under the leadership of Dr. Wilma Wooten, has guided the project, funded through First 5 San

“

Diego and successfully implemented by the University of California, San Diego (UC San Diego) Center for Community Health. This work focused on improving policies, systems, and environments in worksites, community healthcare centers, and early childcare settings. Increasing the number of breastfeeding-friendly employers in San Diego County means healthier babies, healthier moms, and healthier employers’ bottom lines. Returning to work after the birth of a baby is a critical transition point — many mothers choose to stop breastfeeding at this time due to concerns about pumping in the workplace. Other mothers may prolong their leave or not return to work at all if they perceive an unsupportive environment. Although there are federal and state laws that require worksites to offer provisions for lactating women, many employers do not have lactation policies or procedures to guide effective implementation. Recognizing that creating supportive worksite environments reduces barriers to breastfeeding, LSE project has engaged more than 55 businesses in San Diego County to implement lactation-supportive policies, reaching more than 84,000 employees.

Having a lactation policy made a huge difference.

Before the policy, I had to search for rooms to borrow — some of which did not have locks. After the policy, I felt I had a lot more support and knew of appropriate, secure rooms that I could use. I was even able to exceed my goals!”

— NINA C. IWANAGA, EMPLOYEE, COUNTY OF SAN DIEGO HEALTH AND HUMAN SERVICES AGENCY

The LSE poject transitioned into working with the dedicated staff at six Community Health Centers in San Diego to create baby-friendly environments. A comprehensive model was utilized and included implementation of financial sustainability systems for breastfeeding and lactation services and infant feeding policies. The project’s next phase was to increase the number of baby-friendly childcare settings that adopt policies supportive of breastfeeding and lactation accommodation. This is being accomplished through education and direct technical assistance in creating and implementing tailored lactation policies.

Childcare providers across the county are enthusiastic about this effort and have embraced it. Staff collaborated with the San Diego County Breastfeeding Coalition to place all project materials and resources, including information on how to create a breastfeedingfriendly worksite, on their website www.breastfeeding.org.

Physicians in Action

Centering Pregnancy is a nationally recognized and standardized approach to prenatal care in a group setting. Pregnant women share experiences, teach each other, and develop a supportive network. Research has demonstrated Centering can lead to improved maternal-child outcomes, higher breastfeeding rates, and reduction of health disparities. In 2010, Scripps Family Medicine Residency Program piloted Centering Pregnancy with San Ysidro Health in Chula Vista under the leadership of Dr. Mariane McKennett, Program Director of Scripps Family Medicine Program. The pilot was a huge success for both patient and provider satisfaction. Data demonstrated that women had higher rates of exclusive breastfeeding at the time of discharge from the hospital. However, the data also revealed that many women disSanDiegoPhysician.org 13

INFANT AND MATERNAL NUTRITION

continue breastfeeding by three months.

There was clearly a need to support breastfeeding mothers during the early weeks, identify problems, and provide support and education. In 2014, under the leadership of Dr. Shaila Serpas, a four-year CDC grant funded Scripps and San Ysidro Health to increase breastfeeding services for the Chula Vista clinic. A lactation room was created at the clinic, a breast pump loan program was launched, and staff members completed UC San Diego’s Certified Lactation Educator course. This led to a team approach, offering women more immediate, one-on-one lactation assistance at the time of their newborn and postpartum visits. The lactation team at the clinic has already helped more than 300 women to overcome breastfeeding challenges and many of these mothers were able to successfully reach the recommended guidelines of six months with encouragement to continue breastfeeding for a full year.

UC San Diego has been a leader in the work on human milk feeding from the

1980s, when Dr. Audrey Naylor started the work that led to the WHO/UNICEF program called the Baby Friendly Hospital Initiative, and now it is prevalent worldwide in more than 152 countries. UC San Diego hospitals, led by Dr. Lisa Stellwagen and Dr. Michelle Leff of the Department of Pediatrics, have been working on breastfeeding programs for healthy babies and mothers and achieved Baby Friendly Hospital designation in 2006 for UC San Diego Hillcrest and 2018 for UC San Diego Jacobs Medical Center. Over the years, improvements in support for family-centered care have led to other quality initiatives. These include standardized lactation support for late preterm infants, infants at risk for Neonatal Abstinence Syndrome, updates in policies regarding neonatal bathing, safe sleeping, and fall prevention. Most recently, this support has led to the introduction of pasteurized donor milk to avoid formula supplementation. Additional information: https://health.ucsd.edu/ specialties/obgyn/maternity/newborn/ lactation/Pages/default.aspx

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Very Low Birthweight Infants, those premature babies born weighing less than 1500 grams, have been found to benefit most from the effects of human milk feeding. These infants, however, are not able to feed orally for many weeks or months after birth and are reliant on their mother’s expressed milk or pasteurized milk from a certified milk bank. Success at breastfeeding promotion for full term infants at UC San Diego led Dr. Stellwagen and colleague Dr. Jae Kim in neonatology to work with a multidisciplinary team to develop a similar model of quality improvement to support human milk nutrition and improve outcomes for these fragile babies. The Supporting Premature Infant Nutrition (SPIN) program has led to improved health and breastmilk feeding outcomes in their unit and has been adopted by other hospitals in the United States.

UC San Diego is also a leader internationally on human milk research. Dr. Lars Bode, a nutritional scientist and glycobiologist who studies sugars in human milk,

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is a leading researcher in the field. His work focuses on the third most abundant component in human milk: human milk oligosaccharides. These complex sugars, although most plentiful in human milk, are not digested by the infant. They are utilized by intestinal microbes to encourage the proper balance of bacteria in the infant gut. They also protect infants from infectious diseases and regulate the immune system. Additionally, Dr. Bode has set up a program called MOMI CORE, with generous funding from the Family Larsson-Rosenquist Foundation. This program has a goal of investigating the mysteries of mothers’ milk, encouraging pilot research projects for young investigators to research human milk. https://milk.ucsd.edu http:// bodelab.com Another key research interest at UC San Diego is how substances from the environment, maternal diets, illicit and licit substance use, and medications get into human milk and potentially impact the infant. Dr. Christina Chambers has set up a human milk biorepository — Mother to Baby — to collect human milk samples and make them available to researchers to better understand these issues. Additionally, Dr. Chambers has set up Mommy’s Milk, a forum for education of healthcare professionals and laypeople to provide information online, on paper, and even in person to improve information sharing in this arena. Another good resource is through the National Library of Medicine and ToxNet — an online tool for information about medications and lactation. This tool called LactMed was established and is maintained by Dr. Philip Anderson, a pharmacist at UC San Diego. https://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm https://mothertobaby.org https://mommysmilkresearch.org However, despite all the recent progress made in the area of infant nutrition and breastfeeding support, there are times when mothers’ own milk is not available due to illness, medical complications, or contraindications to breastfeeding. A local family interested in supporting breast milk feeding and human nutrition in our county has made a donation that will allow UC San Diego to start a local milk bank. Nonprofit milk banks exist in the US and collect excess frozen milk from mothers. These donor mothers are often either working mothers who express milk and get ahead of their baby’s own needs, NICU mothers whose tiny babies don’t need all the milk they pumped, bereaved mothers whose infants passed away and have excess milk, or women who pump specifically to donate to babies in need.

Donor mothers are carefully screened, the milk is pasteurized and tested for bacteria, and is sold at cost to Neonatal Intensive Care Units to feed small premature infants. The San Diego Mothers’ Milk Bank is currently developing a milk bank partnering with Mothers’ Milk Bank at Austin (Texas). The milk bank is accepting donations at the San Diego Blood Bank, a community partner and the site of the future facility. The team has developed an app — MothersMilk — to provide community education about breastmilk feeding, community resources, a blog to engage mothers, and a link to information and processes to donate milk. https://health.ucsd.edu/specialties/obgyn/maternity/newborn/lactation/Pages/mothers-milk.aspx.

Call to Action: All Physicians Can Play an Important Role in Infant and Maternal Nutrition The following actions are simple steps that physicians can do to make a difference!

1

Ensure that your worksite is breastfeeding-friendly for your staff and patients.

2

Speak with a positive voice about the importance of mothers’ milk for the child and mother.

3

Speak up to support breastfeeding outside of your direct clinical work — you are a respected voice and your words have power and influence.

Seeking FM/DO/IM/ Psychiatrist in San Diego County Position: Full-time and part-time. Full benefits package and malpractice coverage is provided by clinic.

Requirements: California license, DEA license, CPR certification and board certified in family medicine. Bilingual English/Spanish preferred.

Send resume to: hr@vistacommunityclinic.org or fax to 760-414-3702

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

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SanDiegoPhysician.org 15

IMPROVING PATIENT CARE

Physicians Can Help Reduce the Obesity Epidemic By Changing the Way We Treat Patients with Obesity

By Natalie Digate Muth, MD, MPH, RDN, FAAP, FACSM, and Cassandra Padgett, MS OBESITY IS A COMPLICATED, PREVALENT, AND HARD-

to-treat disease affecting the majority of American adults and over one-third of U.S. children, with rates even higher in minority and lower-income communities. While it is a frustrating disease for many clinicians, we all need to do better in providing evidence-based, patient-centered care to patients affected by obesity.

It starts with changing the way we think and talk about obesity.

Many doctors believe that if patients who are affected by obesity and its related comorbidities would just “move more and eat less” or simply “have more willpower,” they could be at a healthy weight and reduce their risk for chronic diseases. These widespread beliefs are damaging and oversimplify the complex causes of obesity. They also contribute to the high prevalence of weight bias that patients experience within healthcare. Just like it is necessary to offer the most effective treatment plans and provide patient-centered care for patients with disease like cancer, heart disease, and diabetes, it is also necessary to improve the way we treat patients with obesity.

Healthcare providers spend less time and provide less health education to patients with obesity. Many believe that patients with obesity are “lazy, weak-willed, unsuccessful, unintelligent, lack self-discipline, have poor willpower, and are noncompliant with weight-loss treatment” (Puhl & Heuer, 2010). These attitudes exemplify weight bias and predict worsened health outcomes for patients.

Patients who have experienced weight bias worry they will not be taken seriously, and believe weight is to blame for all of their

16

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medical problems. Many have even delayed or avoided care due to their fear of how they may be treated. A study examining the impact of weight stigma on quality care in the clinical setting found that “Experiences of or expectations for poor treatment may cause stress and avoidance of care, mistrust of doctors and poor adherence among patients with obesity. Stigma can reduce the quality of care for patients with obesity despite the best intentions of healthcare providers to provide high-quality care.”

(Phelan et al, 2015).

Shaming, blaming, or over-emphasizing weight worsens health outcomes and contributes to weight gain by increasing “likelihood of engaging in binge-eating behaviors, maladaptive weight control, disordered eating patterns, increased calorie intake avoidance of exercise, and lower motivation for physical activity” (Puhl et al, 2016). Further, when patients don’t feel heard or respected in their doctor’s office, they are unlikely to return for necessary follow-up care, which can worsen existing health issues. Weight bias also leads to poor psychological outcomes including anxiety, stress, and depression, in addition to negative self-talk. (Hayward et al, 2018).

organizations for the use of “people-first language” in the context of obesity, with the aim of treating patients with obesity with respect, as individuals, rather than labeling them by their disease” (Puhl et al, 2016). Implementing this strategy not only in front of the patient but with other providers, and encouraging other providers to do the same, can begin to change the environment on a greater scale.

4 Ways to Minimize Weight Bias and Improve Patient Care It’s not all bad news. Physicians can help improve care and outcomes for patients with obesity in many ways, such as: Use “People-First” Language People-first language (a “patient with obesity” versus an “obese patient”) avoids defining patients by their weight. According to research on strategies for overcoming weight bias for patients with diabetes and obesity, “there have been increasing calls by health experts and medical

Focus on Health, Not Weight Weight alone doesn’t give a full picture of a person’s health. Habits like nutrition, physical activity, and sleep, in addition to lab results and overall feeling of wellbeing, energy levels, and mental health, all play a role in the whole health of a person. By zoning in on weight, underlying issues like stress or sleep problems may go unaddressed. Focus on habit-based goals that are framed in a positive way. For example, a goal like “I will pack a lunch from home three days per week” is more impactful than a goal like “stop eating fast food.”

While weight can be related to health risk, going about weight loss in a healthy way is crucial to reduce health risk. Food restriction, dieting, and extremes are ineffective methods for managing health and weight. Restrictive methods often lead to yo-yo dieting, which is more harmful in the long run.

Lead With Empathy Weight loss is more complicated than “move more, eat less.” Human behavior is complex, and there are often emotional, environmental, familial, and economic

aspects that can make it challenging for patients to change their behavior, even when they want to. Taking a moment to identify your own biases and putting yourself in the patient’s shoes can help to build rapport. Empathizing with complicated life events and helping patients come up with a small action they feel comfortable working on can go a long way — and focusing on specific health behaviors is more impactful than a number on the scale.

Create a Referral Network It is challenging to dive into health habits in a short 10- or 20-minute appointment slot, especially for a patient with complex medical needs. Having a referral network of obesity medicine specialists, registered dietitians, exercise professionals, mental health professionals, and health coaches can help patients receive ongoing support, and even manage chronic illness, without taking more of your time.

Community programs such as Diabetes Prevention Programs, city recreation centers and YMCAs, grocery store tours, and Walk with a Doc (available in San Diego, Carlsbad, and Vista) can support patients in healthy behavior change.

Ultimately, weight bias is not something providers purposefully engage in or aim to perpetuate. However, being conscious of our own biases and making a concerted effort to empathize and take the focus off of weight can help to support positive health outcomes for all patients.

Dr. Muth is a pediatrician, registered dietitian, and obesity medicine specialist in Carlsbad and the chair of the American Academy of Pediatrics Section on Obesity. She is the director of the WELL pediatric healthy weight clinic for Children’s Primary Care Medical Group. Ms. Padgett is a certified health coach for the W.E.L.L. Clinician. Together they lead San Diego County’s first chapter of Walk with a Doc, held Tuesdays at 4p.m. at Stagecoach Park in Carlsbad.

References Hall, K. D. (2019). Ultra-processed diets cause excess calorie intake and weight gain: A one-month inpatient randomized controlled trial of ad libitum food intake. doi: 10.31232/osf.io/w3zh2 Hayward, L. E., Vartanian, L. R., & Pinkus, R. T. (2018). Weight Stigma Predicts Poorer Psychological Well-Being Through Internalized Weight Bias and Maladaptive Coping Responses. Obesity, 26(4), 755–761. doi: 10.1002/oby.22126 Pearl, R. L., Himmelstein, M. S., Puhl, R. M., Wadden, T. A., Wojtanowski, A. C., & Foster, G. D. (2019). Weight bias internalization in a commercial weight management sample: prevalence and correlates. Obesity Science & Practice. doi: 10.1002/osp4.354 Phelan, S. M., Burgess, D. J., Yeazel, M. W., Hellerstedt, W. L., Griffin, J. M., & Ryn, M. V. (2015). Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obesity Reviews, 16(4), 319–326. doi: 10.1111/obr.12266 Puhl, R. M., Phelan, S. M., Nadglowski, J., & Kyle, T. K. (2016).

Overcoming Weight Bias in the Management of Patients With Diabetes and Obesity. Clinical Diabetes, 34(1), 44–50. doi: 10.2337/ diaclin.34.1.44

SanDiegoPhysician.org 17

CLASSIFIEDS PHYSICIAN OPPORTUNITIES

OUTPATIENT PRIMARY CARE PHYSICIAN Located in Vista/Oceanside, Vista Community Clinic is a private, nonprofit outpatient community clinic with 5 locations in North San Diego County, serving people who experience social, cultural or economic barriers to health care.

Position: Full-time, Part-time and Per Diem FM/IM Physicians.

Responsibilities: Provide outpatient care. No hospital call. Malpractice coverage provided.

Requirements: California license, DEA license, CPR certification and board certification.

Visit us at www.vistacommunityclinic.org Forward resume to hr@vistacommunityclinic.org EEO/AA/M/F/Vet/Disabled PEDIATRIC POSITION AVAILABLE: Grossmont Pediatrics, a private pediatrics practice with Commercial HMO, PPO, Tricare, Medi-Cal patients, provides family-focused individualized care in East San Diego. Clinical cases include ADHD, asthma, adolescent behavioral health. Average 2.5 clinic patients per hour, 1-in-3 light call & newborns at one hospital. With Epic HER, access real-time care at Rady’s and area hospitals. Working 24 or 28 hours weekly, you will earn $130-150,000 annual compensation, upto 3 weeks PTO plus holidays, and future share in practice. Direct professional expenses are paid, Health, Dental, 401K, etc. Contact venk@gpeds.sdcoxmail.com or 619-5045830 with resume in .doc, .pdf or .txt.

GENERAL FAMILY MEDICINE PHYSICIAN: to provide quality patient care to all ages of patient in a full-time traditional practice. The Physician will conduct medical diagnosis and treatment of patients using medical office procedures consistent with training including surgical assist, flexible sigmoidoscopy, and basic dermatology.

The incumbent must hold a current California license and be board eligible. Bilingual Spanish/English preferred.

Founded as a small family practice in Escondido 1932

by Dr. Martin B. Graybill, today we’re the region’s largest Independent Multi-specialty Medical Group. Our location is 277 Rancheros Dr., Suite 100, San Marcos, CA 92069. We are an equal opportunity employer and value diversity. Please contact Natalie Shields at (760) 291-6637/nshields@graybill.org. You may view our open positions at: https://jobs.graybill.org.

BOARD CERTIFIED OR BOARD-ELIGIBLE PHYSICIAN DERMATOLOGIST: Needed for busy, well-established East County San Diego (La Mesa) private Practice. We currently have an immediate part-time opening for a CA licensed Dermatologist to work 2-3 days per week with the potential for full-time covering for existing physicians, whenever needed. We are a full-service Dermatology office providing general, cosmetic and surgical services, including Mohs surgery and are seeking a candidate with a desire to provide general dermatology care to our patients, but willing to learn laser and cosmetics as well. If interested, please forward CV with salary expectation to patricia@ grossmontdermatology.com.

PHYSICIAN CONSULTANT FULL-TIME: San DiegoImperial Counties Developmental Services, Inc. (San Diego Regional Center). Great opportunity to work in a multidisciplinary setting in a private non-profit agency

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January 2020

that serves persons with developmental disabilities.

Must be licensed to practice medicine in California and certified by specialty board such as Neurology, Neurodevelopmental Disabilities, Developmental Behavioral Pediatrics, Pediatrics or Internal Medicine.

Experience in the field of developmental disabilities and administrative or supervisory experience required.

Please visit our website at www.sdrc.org for more information and to submit an application.

DEPUTY PUBLIC HEALTH OFFICER: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a California licensed or license eligible physician to work for County of San Diego Public Health Services, nationally accredited by the Public Health Accreditation Board. Regular - Full Time: $220,000 - $230,000 Annually. For more information and to apply: https://www.governmentjobs.com/ careers/sdcounty/jobs/2359704/deputy-public-healthofficer-19092204u?keywords=Deputy%20Public%20 health%20&pagetype=jobOpportunitiesJobs TEMPORARY EXPERT PROFESSIONAL (TEP) MEDICAL DOCTORS (MD’s) NEEDED: The County of San Diego Health and Human Services Agency is seeking numerous MD positions to work in a variety of areas including Tuberculosis Control, Maternal and Child Health, Epidemiology and Immunizations, HIV, STD & Hepatitis, and California Children’s Services.

Applicants (MD or DO) must hold a current California medical license. Applicants must be proficient in either Opioid Abuse Prevention and Treatment Strategies, Communicable Diseases and/or Healthcare Systems, and willing to minimally work three days a week. Hourly rate is $103/hour. If interested, please e-mail CV to Anuj.

Bhatia@sdcounty.ca.gov or call (619) 542-4008.

BOARD CERTIFIED NEUROLOGIST POSITION AVAILABLE: Seeking a Board Certified Neurologist based in the San Diego region. Opportunities available on a part-time or full time basis for a prominent multispecialty medical group practice. Candidates should have interest in management of traumatic brain injury, post-concussive symptoms, medical legal evaluations including IME, and EMG. Competitive salary. Please send letter of interest and CV to admin@pacificmedicalllc.com.

SAN DIEGO COUNTY EMPLOYMENT OPPORTUNITY: The County of San Diego has a current employment opportunity for M.D.- Chief, TB Control & Refugee Health (Public Health Medical Officer). Please see the link for more information: M.D.-Chief, TB Control & Refugee Health (Public Health Medical Officer19412807UTB INTERNAL MEDICINE PHYSICIAN: Solvang, California – Established private internal medicine practice in the heart of wine country in the beautiful Santa Ynez Valley within Santa Barbara County seeks a BC/BE internist to join a busy practice within the lovely Danish town of Solvang. Competitive salary and benefits while living and working in a small community with excellent schools, short commutes, fine restaurants, entertainment and Mediterranean climate with no smog or traffic. Enjoy excellent quality of life while practicing medicine in a small clinic affiliated with the Cottage Health System. For more information please contact Office Administrator Amy Comer at (805) 688-2600.

FAMILY PRACTICE MD/DO: Family Practice MD/ DO wanted for urgent care and family practice office in Carlsbad, CA. Flexible weekday and weekend shifts available for family practice physician at busy, wellestablished office. FAX or email CV to (760) 603-7719 or gcwakeman@sbcglobal.net.

PART-TIME/FULL-TIIME RADIOLOGIST POSITION OPEN - IMPERIAL RADIOLOGY: MEDICAL DIRECTOR, CALIFORNIA CHILDREN’S SERVICES: The Our company is an outpatient diagnostic radiology facility in search of a part-time/full-time radiologist. All candidates must have an active California Medical License. Please contact us via e-mail at info@carlsbadimaging.com with your resume if this position is of interest to you. Thank you. Job Type: Part-Time/Full Time. Pay: TBD.

PRACTICE OPPORTUNITY: Internal Medicine and Family Practice. SharpCare Medical Group, a Sharp HealthCare-affiliated practice, is looking for physicians for our San Diego County practice sites. SharpCare is a primary care, foundation model (employed physicians) practice focused on local community referrals, the Patient Centered Medical Home model, and ease of access for patients. Competitive compensation and benefits package with quality incentives. Bilingual preferred but not required. Board certified or eligible requirement. For more info visit www.sharp.com/ sharpcare/ or email interest and CV to glenn.chong@ sharp.com.

DERMATOLOGIST NEEDED: Premier dermatology practice in beautiful San Diego seeking a full-time/ part-time BC or BE eligible Dermatologist to join our team. Existing practice taking over another busy practice and looking for a lead physician. This is a significant opportunity for a motivated physician to take over a thriving patient base. Work with two energetic dermatologists and a highly trained staff in a positive work environment. We care about our patients and treat our staff like family. Opportunity to do medical, cosmetic and surgical dermatology (including MOHs) in a medical office with state of the art tools and instruments. Please call Practice Administrator at (858) 761-7362 or email jmaas12@hotmail.com for more information.

PHYSICIAN POSITIONS WANTED RESEARCH PHYSICIAN (NO CLINICAL PRACTICE) PHYSICIAN Provides medical leadership, oversight, and management of human clinical trails while ensuring the integrity of the studies and the safety and wellbeing of human subjects. Performs duties in accordance with company’s values, policies, and procedures. On call responsibilities: shares in rotation of weekly call schedule. Please email resumes to tabitha.alvarado@ prosciento.com PRACTICE FOR SALE PRACTICE FOR SALE IN ENCINITAS: A GYN-only practice for sale in Encinitas with a majority of the patients in North County. Insurance accepted are PPO, cash and some Medicare patients. Could be turnkey or just charts. Practicing is closing December 31st, 2019. Please call Mollie for more information at (760) 943-1011.

CLINICAL RESEARCH SITE/MULTI-SITE SPECIALTY PHYSICIAN PRACTICE COMBO FOR SALE: Great opportunity for a Group Practice. Clinical Research offers a way for physicians to continue to practice medicine the way they like and provide an additional source of income that is compatible with their goal of providing great care and options for their patients.

Patients will have the opportunity to participate in the research of new treatments. Current site has staff and facilities for research, physician suites, and X-Ray. Use as a primary location or as a satellite office with research site. Current physicians and staff willing to train and work alongside physicians new to research.

Contact E-Mail: CL9636750@gmail.com PRACTICES WANTED PRIMARY OR URGENT CARE PRACTICE WANTED: Looking for independent primary or urgent care practices interested in joining or selling to a larger group. We could explore a purchase, partnership, and/ or other business relationship with you. We have a track record in creating attractive lifestyle options for our medical providers and will do our best to tailor a situation that addresses your need. Please call (858) 832-2007.

PRIMARY CARE PRACTICE WANTED: I am looking for a retiring physician in an established Family Medicine or Internal Medicine practice who wants to transfer the patient base. Please call (858) 257-7050.

OFFICE SPACE / REAL ESTATE AVAILABLE MEDICAL OFFICE AVAILABLE FOR RENT: Furnished or unfurnished medical office for rent in central San

LA JOLLA OFFICE FOR SUBLEASE OR TO SHARE Scripps Memorial Medical office building at 9834 Genesee Ave. Amazing location by the main entrance to the hospital between I-5 and I-805. Multidisciplinary group available to any specialty. Excellent referral base in the office and on the hospital campus.

Great need for a psychiatrist.

We have multiple research projects.

If you have an interest or would like more information, please call 858-344-9024 or 858-320-0525.

KEARNY MESA MEDICAL OFFICE - FOR LEASE 7910 Frost Street. Class A medical office building adjacent to Sharp Memorial and Rady Children’s hospitals. Suites ranging from 1,300-5,000 SF. For details, floor plans and photos contact David DeRoche (858) 966-8061 | dderoche@rchsd.org Diego. Can rent partial or full, 5 exam rooms of various sizes, attached restroom. Easy freeway access and bus stop very close. Perfect for specialist looking for secondary locations. Call 858-430-6656 or text 619417-1500.

MEDICAL OFFICE SPACE FOR SUBLEASE: Medical office space available for sublease in La Jolla-9834 Genesee Avenue, Suite 400 (Poole Building). Steps away from Scripps Memorial Hospital La Jolla. Please contact Seth D. Bulow, M.D. at 858-622-9076 if you are interested.

AMBULATORY SURGICAL CENTER FOR RENT: Freestanding, single story, fully furnished & equipped licensed Ambulatory Surgical Center immediately available for Rent 7 days per week. Very flexible & reasonable terms available including hourly rental rates, if desired, plus an income producing opportunity is also available. The facility is centrally located to all of San Diego County near Sharp Memorial hospital with easy freeway access & free parking. The facility is suitable for all surgical specialties. If interested e-mail to infosandiego1@gmail.com or call (858) 715-1822 to view the facility or for further information & details.

OFFICE SPACE FOR RENT: Recently renovated medical office space for rent. 1300 SFT which includes waiting room with a large closet, 3 exam rooms, an spacious office, a lab and plenty of closet space. $2,000 starting 12/15/19. Please email info@rheumsd.com.

ENCINITAS OFFICE SPACE TO SHARE/SUBLEASE: Longstanding (38 years) allergist in Encinitas has a 3,000 square foot office space available to share/ sublease. Six exam rooms and a permanent private office/consultation room. Office is available Tuesday morning and all day Wednesdays and Fridays. Office located on El Camino Real in Encinitas. Please contact wwpleskow@sbcglobal.net or call (760) 436-3988.

LA JOLLA (NEAR UTC) OFFICE FOR SUBLEASE OR TO SHARE: Scripps Memorial medical office building, 9834 Genesee (Poole Bldg) between I-5 and I-805. Sublease full or part of office with 5 plus rooms, bathroom/shower. Excellent referral situation.

(Interested in all specialties in particular, a Psychiatrist.)

(If interested, may participate in multiple research projects) Call (858) 344-9024 or (858) 320-0525.

MEDICAL/OFFICE SPACE AVAILABLE: Beautifully decorated, new office space 2,000 sq feet located at 6125 Paseo Del Norte in Sunny Carlsbad, CA. This unique office offers great visibility off interstate 5 and close to Carlsbad Outlet Mall. This medical office consists of 3 exam rooms, 1 big procedure room, and a large nurse’s station. To view the space, contact Katia at (760) 352-4103 or email: Feminacareo@gmail.com.

MEDICAL OFFICE SPACE SUBLET AVAILABLE SEPT. 26 2019: San Diego Eye Professionals, 5965 Severin Dr. La Mesa, CA 91942. This office is close to Sharp Grossmont Hospital and Grossmont Out Patient Surgery Center. A newly renovated beautiful 2,000 sq. ft office space with 6 exams rooms and 3 exam rooms available for sublet. Office has 2 bathrooms, laboratory, large reception office area with brand new lighting and hard wood floors throughout the office, handicap compliant office and reception with wheelchair access.

Lots of free parking directly in front of office. Single story building. Optometrist/ophthalmologist practice but all practices OK. Please contact Dagmar or Tami at (619) 583-4295 or sandiegoeyeprofessionals@gmail.com.

SHARED OFFICE SPACE: Office Space, beautifully decorated, to share in Solana Beach with reception desk and 2 rooms. Ideal for a subspecialist. Please call (619) 606-3046.

OFFICE SPACE/REAL ESTATE AVAILABLE: Scripps Encinitas Campus Office, 320 Santa Fe Drive, Suite LL4.

It is a beautifully decorated, 1,600 sq. ft. space with 2 consultations, 2 bathrooms, 5 exam rooms, minor surgery. Obgyn practice with ultrasound, but fine for other surgical specialties, family practice, internal medicine, aesthetics. Across the hall from imaging center: mammography, etc. and also Scripps ambulatory surgery center. Across parking lot from Scripps Hospital with ER, OR’s, Labor and Delivery. It is located just off Interstate 5 at Santa Fe Drive, and a half-mile from Swami’s Beach. Contact Kristi or Myra (760) 753-8413.

View Space on Website:www.eisenhauerobgyn.com.

Looking for compatible practice types.

OFFICE SPACE FOR RENT: Multiple exam rooms in newer, remodeled office near Alvarado Hospital and SDSU. Convenient freeway access and ample parking.

Price based on usage. Contact Jo Turner (619) 7334068 or jo@siosd.com.

OFFICE SPACE AVAILABLE IN MISSION VALLEY: Unique space for lease in Mission Valley. 1,300 sq. ft office space in medical/surgical office building, single story, ample free parking. Is currently in use as physical therapy suite with reception area, small waiting room, private treatment room, separate office, bathroom in suite and hook ups for washer/dryer. Easy access to all freeways. Available approximately August 1, 2018. Please contact Joan McComb, Executive Director, CA Orthopedic Institute. (619) 291-8930 or cell (619) 840-0624.

OFFICE SPACE / REAL ESTATE WANTED MEDICAL OFFICE SUBLET DESIRED: Solo endocrinologist looking for updated bright office space in Encinitas or Carlsbad to share with another solo practitioner. Primary care, ENT, ob/gyn would be compatible fields. I would ideally have one consultation room and one small exam room but I am flexible. If the consultation room was large enough I could have an exam table in the same room and forgo the separate exam room. I have two staff members that will need a small space to answer phones and complete tasks.

Please contact 858-633-695 MEDICAL OFFICE SPACE SUBLET DESIRED NEAR SCRIPPS MEMORIAL LA JOLLA: Specialist physician leaving group practice, reestablishing solo practice seeks office space Ximed building, Poole building, or nearby.

Less than full-time. Need procedure room. Possible interest in using your existing billing, staff, equipment, or could be completely separate. If interested, please contact me at ljmedoffice@yahoo.com.

EQUIPMENT / FURNITURE FOR SALE MEDICAL EQUIPMENT AVAILABLE FOR SALE/ FREE IN ENCINITAS: Orthopedic office relocating in UTC area and has medical equipment for sale or take away. Available equipment: exam tables (2), chart racks (6), Magazine Racks (4) Stools (3). Call Georgana for information at (858) 395-0693.

MEDICAL EQUIPMENT AVAILABLE IN ENCINITAS: GYN-office closing in Encinitas and has medical equipment for sale or take away. Available equipment: exam tables, chart racks, autoclave, ultrasound machine, credenza for supplies, Berkley suction machine. Call Mollie for information at (760) 943-1011.

NON-PHYSICIAN POSITIONS AVAILABLE FINANCE DIRECTOR: San Diego Sports Medicine and Family Health Center is hiring a full-time Financial Director to manage financial operations. Primary responsibilities include monitoring of income, expenses and cash flow, reconciling bank statements, supervision of accounts payable, oversee billing department, oversee accounts receivables, payments and adjustments, prepare contracts, analyze data, prepare financial reports, prepare budgets, advise on economic risks and provide input on decision making.

MBA/Master’s and 5+ years relevant work experience preferred. Excellent references and background check required. Salary commensurate with skills and experience. To apply, please send resume to Jo Baxter, Director of Operations, jobaxter@sdsm.com.

PHYSICIAN ASSISTANT/NURSE PRACTITIONER: Our growing Neurosurgery office in Chula Vista is looking for a part-time Nurse Practitioner/Physician Assistant.

The job requires running clinic two days per week and possible hospital rounds/surgical assist in the future. We are looking for an efficient, hardworking team player with communication skills, caring and ability to adequately document is expected. Must have a current CA (PA or NP) license. We are willing to train the right candidate.

For more information, fax resume to (619) 476-7963 Attn: Office Manager.

NON-PHYSICIAN POSITIONS WANTED MEDICAL OFFICE MANAGER/CONTRACTS/BILLING PERSON: MD specialist leaving group practice, looking to reestablish solo private practice. Need assistance reactivating payer contracts, including Medicare. If you have that skill, contact ljmedoffice@yahoo.com.

I’m looking for a project bid. Be prepared to discuss prior experience, your hourly charge, estimated hours involved. May lead to additional work.

PRODUCTS / SERVICES OFFERED DATA MANAGEMENT, ANALYTICS AND REPORTING: Rudolphia Consulting has many years of experience working with clinicians in the Healthcare industry to develop and implement processes required to meet the demanding quality standards in one of the most complex and regulated industries. Services include: Data management using advanced software tools, Use of advanced analytical tools to measure quality and process-related outcomes and establish benchmarks, and the production of automated reporting. (619) 913-7568 | info@rudolphia.consulting | www.rudolphia.consulting.

PHYSICIAN OFFICES IN NEED OF ASSISTANCE FOR MEANINGFUL USE ATTESTATION of their electronic health records can avail themselves of technical assistance from Champions for Health, the sister organization to SDCMS. Practices attesting on the Medi-Cal Incentive Program with at least 30% of patients billed to Medi-Cal can receive free assistance thanks to a federal funding source. Medicare practices can receive the same great service at a very reasonable rate, and SDCMS-CMA members receive a discount.

For more information, email Barbara.Mandel@ ChampionsFH.org or call (858) 300-2780. [559]

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PERSONAL & PROFESSIONAL DEVELOPMENT

Let’s Make 2020 Be the Year of Creativity

By Helane Fronek, MD, FACP, FACPh AT A RECENT GATHERING OF WOMEN

medical students, the talented Chrystal de Freitas, MD, skilled pediatrician and avid weaver, encouraged each student to cultivate a form of creativity in her life.

The wisdom of this advice has become clearer to me in the weeks since the event as I’ve reflected on my own creative adventures. As physicians, we often become stuck in a purely rational approach to work and life. We believe we can think our way through any situation. Creative pursuits help us see things outside of the lines we draw to make our lives feel safer and more predictable — we begin to think more expansively and wonder what might be possible. This enriches our lives and has the potential to enhance our skill as diagnosticians.

An old saying suggests that “how you do one thing is how you do everything.”

Many of us physicians are perfectionists. It’s how we succeeded in getting into medical school and through training, and we rely on it to ensure we don’t harm or miss anything important in our patients.

Yet its widespread application is not only unnecessary, it can come at a cost. And perfectionism impedes creativity.

As a novice musician fortunate enough to be playing with experienced professionals, I am the least skilled person in 20

January 2020

our band. Unfortunately, that rational assessment isn’t sufficient to keep my perfectionistic tendencies at bay or allow realistic expectations of myself. With each mistake, I can become increasingly frustrated. Emotions are contagious, so my irritation takes the joy out of everyone’s experience. I can also tell you, from ample experience, that it hasn’t helped me play better when it takes over! Eventually, I’m able to remember that music isn’t about perfection, and no one’s life hangs in the balance. It’s about producing a unique, creative, collaborative, emotional experience. As I relax into this new paradigm of allowing and even welcoming a less predictable and more playful experience in my life, it positively affects every aspect of my life. I’m more spontaneous, relaxed, and generally happier.

As the new year approaches, we naturally begin to consider what we hope it will hold. We may consider changes in our career, travel, development of new or existing relationships. My wish is that 2020 will be a year of greater creativity for

all of us. Whatever their form, creative pursuits will challenge, stretch, and bring out parts of you waiting to be recognized and appreciated. For my fellow perfectionists, the adage that “anything worth doing is worth doing badly” can help us remember that skill only comes after unskilled practice, so our less-thanperfect beginnings are necessary steps on our creative journey. Artistic activities also help you see your life in ways you might not have considered. This sort of personal growth can be the foundation for a life — and a year — that feels more interesting, exciting, and fulfilling.

Dr. Fronek, SDCMS-CMA member since 2010, is assistant clinical professor of medicine at UC San Diego School of Medicine and a certified physician development coach who works with physicians to gain more power in their lives and create lives of greater joy. Read her blog at helanefronekmd.com.

CHAMPIONS FOR HEALTH

1. First place bowling team: Living on a Spare 2. Third place: Spin Masters 3. Ted and Marcy Mazer; Jim and Tricia Hay 4. Top 5K women finishers: Lainie Hughes, second place; Kira Nikolaus, first place; Karina Parikh, third place 5. Team Samarasinghe

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Physician Fun in the Sun … and Striking Out Health Barriers!

By Adama Dyoniziak THE SATURDAY HAD ALL THE MAKINGS FOR A GREAT DAY:

sunshine, 75 degrees, a slight breeze, people laughing, families playing in the park. It was October 12 at the Solana Beach Sunset 5k Run/Walk and Wellness Expo. There were so many fun activities to choose from: stretching with Stretch Lab, yummy foods from Urban Remedy, healthy tips from Aetna and FitWall, Kids Zone games with Skinny Gene Project, Bulky Jones tunes to rock the 5K, frozen yogurt from FroYo food truck, a superhero costume contest, and much more! This family-friendly event at Fletcher Cove Beach Park in Solana Beach is Champions for Health’s sixth annual fundraiser benefitting our community wellness and diabetes prevention programs. Congratulations to more than 500 runners, walkers, teams, and sponsors for helping us raise more than $50,000!

From fun in the sun to the bowling alleys of East Village Tavern+Bowl, our physicians continue to strike out health barriers with our first ever physician mixer/Project Access fundraiser on Nov. 14. An anonymous donor, also a bowling and health enthusiast, and 12 teams had a super fun time bowling together. An il-

lustrious first place trophy and prizes from Tavern+Bowl for the top three teams were the incentive for people to strut their stuff in comfy bowling shoes, enjoy tasty eats, and sip their welcome cocktail.

First place went to Living on a Spare; second place went to Aetna Bowling Bureau, and third place went to Spin Masters, led by SDCMS’s own Paul Hegyi. Thank you to our supporters of Project Access: Campbell & Kaplan, Aetna, Dr. Ted Mazer and Dr. Jim Hay, Jaime Carrillo and his Lemon Grove Team, and staff from Champions for Health, SDCMS, and Mission Edge.

While Project Access San Diego gets people healthy via pro bono specialty healthcare, our Community Health & Wellness programming that addresses preventable and chronic diseases keeps people healthy. This year alone, the

500-plus volunteer physician and healthcare professionals provided 25,000 blood pressure screenings at 200 locations, more than 100 healthy living topic presentations, and 4,200 free vaccinations.

The glue that holds all these free services together is the dedication of the San Diego County Medical Society physician volunteers who first envisioned being of service to the community. These physicians created the foundation that is now Champions for Health. For more information, please contact Adama Dyoniziak at adama.dyoniziak@ championsfh.org or call (858) 300-2780. Join the fun and transform lives one person at a time!

Ms. Dyoniziak is executive director of Champions for Health.

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SanDiegoPhysician.org 21

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