February 2020

FEBRUARY 2020

Official Publication of SDCMS

ars

Celebrating 150 Ye

Artificial Intelligence and Medicine THE DEBATE

150th ANNIVERSARY

ReNDEZ ReNDEZVOUS VOUS Friday, JUNE 19, 2020 6:00 PM-10:00 PM THE ABBEY ON FIFTH

Please join the San Diego County Medical Society in celebrating our 150th Anniversary, welcoming Holly B. Yang, MD, MSHPEd, FACP, FAAHPM as SDCMS President for 2019 and thanking James H. Schultz, MD, MBA, FAAFP for his service as Immediate Past President.

Suggested Attire: Cocktail Elegance, Black Tie Optional For additional information and to purchase tickets visit www.SDCMS.org/2020Rendezvous

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February 2020

Contents FEBRUARY

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

VOLUME 107, NUMBER 2

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 #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 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.]

feature:

4

A Reality Check on Artificial Intelligence: Are Healthcare Claims Overblown?

By Liz Szabo

Departments 2

Briefly Noted: Calendar • Federal Healthcare Policy • Practice Management • Professional Development & Education

8

Tackling Physician Burnout Requires Unprecedented Leadership

By Robert D. Morton, CPHRM, CPPS

12

California Launches First-ofIts-Kind ACEs Initiative

By California Medical Association Staff

14

Cultural Diversity Creates Language Barriers: Reducing Claims with Multilingual Patients

By Rich Cahill, JD, and Susan Shepard, MSN, RN

17

Immunizations

By Adama Dyoniziak

18

Physician Classifieds

20

A Profession That Values and Respects All Its Members

By Helane Fronek, MD, FACP, FACPh

21

San Diego County Medical Society 150th Anniversary Historical Fee Table SanDiegoPhysician.org 1

CALENDAR

FEDERAL HEALTHCARE POLICY

FEB 28–29: Fundamentals of Obesity Treatment Course, 9.5 CME, presented

by Obesity Medicine Association, Hotel Republic, San Diego

CALIFORNIA MEDICAL Association (CMA) President Peter N. Bretan,

MAR 12–13: Future of Individualized Medicine, hosted by Scripps Research Translational Institute, Samuel H. Scripps Auditorium, La Jolla MAR 28: 6–9 p.m. Second annual Champions for Health Soirée: ‘Waves of Wellness,’ Birch Aquarium, La Jolla APR 2–5: California Society of Anesthesiologists Annual Meeting, Paradise Point Resort, San Diego JUN 19: 6–10:30 p.m.

Save the Date! SDCMS 150th Anniversary ‘Rendezvous’ Gala, The Abbey on Fifth Avenue, San Diego

2

February 2020

CMA Warns New Surprise Billing Proposal Would Limit Patient Access to In-Network Physicians and Increase Costs MD, issued the following statement on the Senate HELP and House E&C Committee surprise billing proposal: “CMA physicians agree it’s time to end surprise medical billing, but Congress should not repeat the mistakes made in California that have given insurers the power to game the system, drop physicians from their networks, and make it harder to have on-call specialists in emergency rooms. CMA looks forward to working with Congress to find a comprehensive solution that does not disrupt patient care.”

The HELP/E&C Committee fee schedule is similar to a 2016 California law that has given undue leverage to the insurance companies to cancel physician contracts. The proposal will also increase healthcare costs by accelerating consolidation of physician practices with larger systems, as we have seen in California. It would be a grave error to impose the California policy mistakes on a national level.

CMA supports the inclusion of arbitration as a means to resolve disputes between physicians and insurance companies but remains concerned that the $750 arbitration threshold in this new proposal creates a barrier to fair resolution for physicians whose claims are much less.

Any solution to surprise billing will have a substantial impact on the entire healthcare system. We urge Congress not to rush a bad policy on such an important issue to meet a false deadline.

CMA believes that Congress should keep working to find the right solution. We continue to urge the following: • Protect patients from surprise bills • Allow insurers to determine a reasonable initial payment for out-ofnetwork care • Establish baseball arbitration to resolve disputes • Instead of setting an arbitrary threshold to take cases to arbitration, allow physicians to batch claims together to lower the number of arbitrations • Establish fair payment criteria in arbitration that includes commercially reasonable rates and prior contracting history that is based on existing rates and would not trigger a cost • Require insurers to have adequate physician networks to meet patients’ medical needs.

OFFICE MANAGEMENT

SDCMS Names 2019 Office Manager of the Year SDCMS IS HAPPY TO RECOGNIZE

Ron Almirol of Genesee Family Medicine Clinic and the Sports Medicine Clinic as the 2019 Office Manager of the year. Ron was nominated by SDCMS member Dr. Alan Shahtaji.

Ron manages Genesee Family Medicine Clinic and the Sports Medicine Clinic. He has done an exceptional job with all key indicators of quality, service, and finance. Highly competent and reliable in all aspects of clinic management, Ron is a top-notch manager who is highly respected and appreciated by his peers, subordinates, and superiors alike.

Always looking out for his staff, Ron goes above and beyond for them. He helped ensure maximum voluntary leave donations were offered for a staff member who was in need due to unforeseen circumstances. Ron also collected funds to purchase a funeral wreath and provide monetary donations for one of his staff members whose spouse had unexpectedly passed away.

Being very creative and forward thinking, Ron developed a heat map spreadsheet tool for displaying Press Ganey service scores in a one-page format.

It made the data much easier to read, allowing leaders to more easily see service areas with opportunities for improvement. His design was so well-received by the primary care leadership that it was implemented within all clinics for family and sports medicine, internal medicine, and medicine for seniors.

Ron has been chosen to participate in numerous improvement projects and he has significantly contributed to each of the following: Care Navigation Hub, Care Assistance Line Committee and Call Center Committee.

One of the practice’s busiest clinicians says, “I fully support choosing Ron Almirol as SDCMS office manager of the year! Our office has been through a lot over the last several years and has endured a lot of challenges. Ron has stuck with us through thick and thin and has never wavered, even when other strong leaders would have left. He has done wonders to improve staff morale, and all the doctors admire his work ethic and morals. He is always smiling and is often at work before and after everyone else. Back when I was the medical director in the midst of what seemed to be many insurmountable challenges, I told Ron, ‘I can’t believe you’re still here after all this.’ And he said, ‘When I took this job I told myself I would see this through to the end and I intend to be a man of my word.’ That moment summed him up perfectly. UCSD La Jolla Family Medicine is by far a better place to work thanks to Ron Almirol. My only hesitation in recommending him for office manager of the year is that he should actually get office manager of the decade!”

Congratulations Ron and keep up the good work!

TrusT

UCSD La Jolla Family and Sports Medicine Practice Manager Bobby Cherry, Office Manager of the Year Ron Almirol, and Dr. Alan Shahtaji.

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A REALITY CHECK ON ARTIFICIAL INTELLIGENCE Are Healthcare Claims Overblown? By Liz Szabo 4

February 2020

HEALTH PRODUCTS POWERED BY ARTIFICIAL intelligence, or AI, are streaming into our lives, from virtual doctor apps to wearable sensors and drugstore chatbots.

IBM boasted that its AI could “outthink cancer.” Others say computer systems that read X-rays will make radiologists obsolete.

“There’s nothing that I’ve seen in my 30-plus years studying medicine that could be as impactful and transformative [as AI],” says Dr. Eric Topol, a cardiologist and executive vice president of Scripps Research in La Jolla. AI can help doctors interpret MRIs of the heart, CT scans of the head and photographs of the back of the eye, and could potentially take over many mundane medical chores, freeing doctors to spend more time talking to patients, according to Dr. Topol.

Even the Food and Drug Administration — which has approved more than 40 AI products in the past five years — says, “the potential of digital health is nothing short of revolutionary.” Yet many health industry experts fear AI-based products won’t be able to match the hype. Many doctors and consumer advocates fear that the tech industry, which lives by the mantra “fail fast and fix it later,” is putting patients at risk — and that regulators aren’t doing enough to keep consumers safe. Early experiments in AI provide a reason for caution, says Mildred Cho, a professor of pediatrics at Stanford’s Center for Biomedical Ethics.

Systems developed in one hospital often flop when deployed in a different facility, Cho says. Software used in the care of millions of Americans has been shown to discriminate against minorities. And AI systems sometimes learn to make predictions based on factors that have less to do with disease

than the brand of MRI machine used, the time a blood test is taken or whether a patient was visited by a chaplain. In one case, AI software incorrectly concluded that people with pneumonia were less likely to die if they had asthma — an error that could have led doctors to deprive asthma patients of the extra care they need.

“It’s only a matter of time before something like this leads to a serious health problem,” says Dr. Steven Nissen, chairman of cardiology at the Cleveland Clinic.

Medical AI, which pulled in $1.6 billion in venture capital funding in the third quarter alone, is “nearly at the peak of inflated expectations,” concluded a July report from the research company Gartner. “As the reality gets tested, there will likely be a rough slide into the trough of disillusionment.”

That reality check could come in the form of disappointing results when AI products are ushered into the real world.

Even Dr. Topol, the author of Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again, acknowledges that many AI products are little more than hot air. “It’s a mixed bag,” he says.

Experts such as Dr. Bob Kocher, a partner at the venture capital firm Venrock, are blunter. “Most AI products have little evidence to support them,” Dr. Kocher says. Some risks won’t become apparent until an AI system has been used by large numbers of patients. “We’re going to keep discovering a whole bunch of risks and unintended consequences of using AI on medical data,” Dr. Kocher says.

None of the AI products sold in the U.S. have been tested in randomized clinical trials, the strongest source of medical evidence, according to Dr. Topol. The first and only randomized trial of an AI system — which found that colonoscopy with computer-aided diagnosis found more small polyps than standard colonoscopy — was published online in October.

Few tech startups publish their research in peer-reviewed journals, which allow other scientists to scrutinize their work, according to a January article in the European Journal of Clinical Investigation. Such “stealth research” — described only in press releases or promotional events — often overstates a company’s accomplishments.

And although software developers may boast about the accuracy of their AI devices, experts note that AI models are mostly tested on computers, not in hospitals or other medical facilities. Using unproven software “may make patients into unwitting guinea pigs,” says Dr. Ron Li, medical informatics director for AI clinical integration at Stanford Health Care.

AI systems that learn to recognize patterns in data are often described as “black boxes” because even their developers don’t know how they have reached their conclusions. Given that

SanDiegoPhysician.org 5

AI is so new — and many of its risks unknown — the field needs careful oversight, according to Pilar Ossorio, a professor of law and bioethics at the University of Wisconsin-Madison.

Yet the majority of AI devices don’t require FDA approval.

“None of the companies that I have invested in are covered by the FDA regulations,” Dr. Kocher says.

Legislation passed by Congress in 2016 — and championed by the tech industry — exempts many types of medical software from federal review, including certain fitness apps, electronic health records, and tools that help doctors make medical decisions.

There’s been little research on whether the 320,000 medical apps now in use actually improve health, according to a report on AI published Dec. 17 by the National Academy of Medicine.

“Almost none of the [AI] stuff marketed to patients really works,” says Dr. Ezekiel Emanuel, professor of medical ethics and health policy in the Perelman School of Medicine at the University of Pennsylvania.

The FDA has long focused its attention on devices that pose the greatest threat to patients. And consumer advocates acknowledge that some devices — such as ones that help people count their daily steps — need less scrutiny than ones that diagnose or treat disease.

Some software developers don’t bother to apply for FDA clearance or authorization, even when legally required, according to a 2018 study in Annals of Internal Medicine.

Industry analysts say that AI developers have little interest in conducting expensive and time-consuming trials. “It’s not the main concern of these firms to submit themselves to rigorous evaluation that would be published in a peerreviewed journal,” says Joachim Roski, a principal at Booz Allen Hamilton, a technology consulting firm, and co-author of the National Academy’s report. “That’s not how the U.S. economy works.”

But Oren Etzioni, chief executive officer at the Allen Institute for AI in Seattle, says AI developers have a financial incentive to make sure their medical products are safe. “If failing fast means a whole bunch of people will die, I don’t think we want to fail fast,” Etzioni says. “Nobody is going to be happy, including investors, if people die or are severely hurt.”

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February 2020

Relaxing Standards at the FDA The FDA has come under fire in recent years for allowing the sale of dangerous medical devices, which have been linked by the International Consortium of Investigative Journalists to 80,000 deaths and 1.7 million injuries over the past decade. Many of these devices were cleared for use through a controversial process called the 510(k) pathway, which allows companies to market “moderate-risk” products with no clinical testing as long as they’re deemed similar to existing devices. In 2011, a committee of the National Academy of Medicine concluded the 510(k) process is so fundamentally flawed that the FDA should throw it out and start over.

Instead, the FDA is using the process to greenlight AI devices.

Of the 14 AI products authorized by the FDA in 2017 and 2018, 11 were cleared through the 510(k) process, according to a November article in JAMA. None of these appear to have had new clinical testing, the study said. The FDA cleared an AI device designed to help diagnose liver and lung cancer in 2018 based on its similarity to imaging software approved 20 years earlier. That software had itself been cleared because it was deemed “substantially equivalent” to products marketed before 1976.

AI products cleared by the FDA today are largely “locked,” so that their calculations and results will not change after they enter the market, says Bakul Patel, director for digital health at the FDA’s Center for Devices and Radiological Health. The FDA has not yet authorized “unlocked” AI devices, whose results could vary from month to month in ways that developers cannot predict.

To deal with the flood of AI products, the FDA is testing a radically different approach to digital device regulation, focusing on evaluating companies, not products. The FDA’s pilot “pre-certification” program, launched in 2017, is designed to “reduce the time and cost of market entry for software developers,” imposing the “least burdensome” system possible.

FDA officials say they want to keep pace with AI software developers, who update their products much more frequently than makers of traditional devices, such as X-ray machines.

Scott Gottlieb said in 2017 while he was FDA commissioner that government regulators need to make sure its approach to innovative products “is efficient and that it fosters, not impedes, innovation.” Under the plan, the FDA would precertify companies that “demonstrate a culture of quality and organizational excellence,” which would allow them to provide less upfront data about devices.

Pre-certified companies could then release devices with a “streamlined” review — or no FDA review at all. Once products are on the market, companies will be responsible for monitoring their own products’ safety and reporting back to the FDA. Nine companies have been selected for the pilot: Apple, FitBit, Samsung, Johnson & Johnson, Pear Therapeutics, Phosphorus, Roche, Tidepool, and Verily Life Sciences.

High-risk products, such as software used in pacemakers,

will still get a comprehensive FDA evaluation. “We definitely don’t want patients to be hurt,” says Patel, who noted that devices cleared through pre-certification can be recalled if needed. “There are a lot of guardrails still in place.”

But research shows that even low- and moderate-risk devices have been recalled due to serious risks to patients, says Diana Zuckerman, president of the National Center for Health Research. “People could be harmed because something wasn’t required to be proven accurate or safe before it is widely used.”

Johnson & Johnson, for example, has recalled hip implants and surgical mesh.

In a series of letters to the FDA, the American Medical Association and others have questioned the wisdom of allowing companies to monitor their own performance and product safety. “The honor system is not a regulatory regime,” says Dr. Jesse Ehrenfeld, who chairs the physician group’s board of trustees.

In an October letter to the FDA, Sens. Elizabeth Warren (D-Mass.), Tina Smith (D-Minn.), and Patty Murray (D-Wash.) questioned the agency’s ability to ensure company safety reports are “accurate, timely and based on all available information.”

When Good Algorithms Go Bad Some AI devices are more carefully tested than others.

An AI-powered screening tool for diabetic eye disease was studied in 900 patients at 10 primary care offices before being approved in 2018. The manufacturer, IDx Technologies, worked with the FDA for eight years to get the product right, says Dr. Michael Abramoff, the company’s founder and executive chairman.

The test, sold as IDx-DR, screens patients for diabetic retinopathy, a leading cause of blindness, and refers high-risk patients to eye specialists, who make a definitive diagnosis.

IDx-DR is the first “autonomous” AI product — one that can make a screening decision without a doctor. The company is now installing it in primary care clinics and grocery stores, where it can be operated by employees with a high school diploma. Abramoff’s company has taken the unusual step of buying liability insurance to cover any patient injuries.

Yet some AI-based innovations intended to improve care have had the opposite effect.

A Canadian company, for example, developed AI software to predict a person’s risk of Alzheimer’s based on their speech. Predictions were more accurate for some patients than others. “Difficulty finding the right word may be due to unfamiliarity with English, rather than to cognitive impairment,” said Frank Rudzicz, an associate professor of computer science at the University of Toronto.

Doctors at New York’s Mount Sinai Hospital hoped AI could help them use chest X-rays to predict which patients were at high risk of pneumonia. Although the system made accurate predictions from X-rays shot at Mount Sinai, the

technology flopped when tested on images taken at other hospitals. Eventually, researchers realized the computer had merely learned to tell the difference between that hospital’s portable chest X-rays — taken at a patient’s bedside — with those taken in the radiology department. Doctors tend to use portable chest X-rays for patients too sick to leave their room, so it’s not surprising that these patients had a greater risk of lung infection.

DeepMind, a company owned by Google, has created an AI-based mobile app that can predict which hospitalized patients will develop acute kidney failure up to 48 hours in advance. A blog post on the DeepMind website described the system, used at a London hospital, as a “game changer.”

But the AI system also produced two false alarms for every correct result, according to a July study in Nature. That may explain why patients’ kidney function didn’t improve, said Dr. Saurabh Jha, associate professor of radiology at the Hospital of the University of Pennsylvania. Any benefit from early detection of serious kidney problems may have been diluted by a high rate of “overdiagnosis,” in which the AI system flagged borderline kidney issues that didn’t need treatment, Dr. Jha said. Google had no comment in response to Dr. Jha’s conclusions.

False positives can harm patients by prompting doctors to order unnecessary tests or withhold recommended treatments, Dr. Jha says. For example, a doctor worried about a patient’s kidneys might stop prescribing ibuprofen — a generally safe pain reliever that poses a small risk to kidney function — in favor of an opioid, which carries a serious risk of addiction.

As these studies show, software with impressive results in a computer lab can founder when tested in real time, Stanford’s Cho says. That’s because diseases are more complex — and the healthcare system far more dysfunctional — than many computer scientists anticipate.

Many AI developers cull electronic health records because they hold huge amounts of detailed data, Cho says. But those developers often aren’t aware that they’re building atop a deeply broken system. Electronic health records were developed for billing, not patient care, and are filled with mistakes or missing data.

A KHN investigation published in March found sometimes life-threatening errors in patients’ medication lists, lab tests, and allergies.

In view of the risks involved, doctors need to step in to protect their patients’ interests, says Dr. Vikas Saini, a cardiologist and president of the nonprofit Lown Institute, which advocates for wider access to healthcare.

“While it is the job of entrepreneurs to think big and take risks,” Dr. Saini says, “it is the job of doctors to protect their patients.”

Liz Szabo is a reporter for Kaiser Health News, where this article was originally published.

SanDiegoPhysician.org 7

PHYSICIAN WELLNESS

Tackling Physician Burnout Requires Unprecedented Leadership

By Robert D. Morton, CPHRM, CPPS

THE TERM “BURNOUT” HAS BEEN

questioned as a labeling error — and rightfully so. Burnout implies victim shaming. What many healthcare professionals on the frontlines are experiencing is a normal response (symptoms) to an abnormal situation (cause), like sick fish in a tank of toxic water. A diagnosis of burnout suggests that the solution is to medicate the fish. A more holistic view is to say, “There’s really nothing wrong with you; let’s clean the tank.”

The World Health Organization (WHO) announced plans to include what it labels “burn-out” as an occupational phenomenon in the International Classification of Diseases (ICD-11). The syndrome, which results from chronic workplace stress, is characterized by feelings of exhaustion, increased mental distancing from one’s work or cynicism about work, and reduced professional efficacy.1 The WHO’s actions seem to further legitimize what many are experiencing: an evermore exhausting, distancing, and 8

February 2020

chronically stressful healthcare system that makes connecting with patients and providing quality care more challenging and contributes to burnout, healthcare professional distress, or to what some have even labeled moral injury or human rights violations.2,3,4 Physician Burnout Thought Leaders Weigh In Drs. Simon Talbot and Wendy Dean, who co-founded the nonprofit organization MoralInjury.healthcare, borrowed the expression “moral injury” from Jonathan Shay, MD, PhD, a clinical psychiatrist who coined the phrase. Briefly, it is (1) a betrayal of what’s right (2) by someone who holds authority (3) in a high-stakes situation.5 Discussions of moral injury include the view that repeated daily betrayals by authorities within the system are manifest in healthcare every day in the form of mandates from leaders to see more patients with less time to care for them, forced use of dysfunctional

electronic health record (EHR) systems, overburdens by payers, competing financial considerations, fear of litigation, and more. These types of betrayals run counter to patients’ best interests — which pains doctors, whose unifying creed is that patients come first.

While other physician thought leaders like Dr. Dike Drummond (thehappymd. com), Dr. Paul DeChant (author, Preventing Physician Burnout), Dr. Zubin Damania (aka ZDoggMD), and Dr. Pamela Wible (idealmedicalcare.org) may differ on the terminology, each makes a similar call for leadership and action equal to the severity and scope of the dilemma. They all call for partnering with enlightened leaders to change the systemic and institutional patterns that inflict betrayals on the practice of good medicine.

Dr. Wible calls these issues humanrights violations that begin in medical education and training due to labor law abuses, sleep/food/water deprivation, discrimination, violence, understaffing,

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PHYSICIAN WELLNESS

and more — driving up depression and suicide rates.6 Because of the profound impact on individuals, there is broad consensus about the immediate need to expand access to confidential, nonpunitive mental healthcare for doctors and nurses.

In response to systemic conditions, some doctors are quitting because having less time with patients has driven morale to rock bottom, and those who remain are warning of a mass exodus if things don’t improve.7 According to Paul DeChant, MD, MBA, a failure to step up and meet this challenge is a failure of leadership and constitutes management malpractice, with some administrators asserting that they are suffering from management burnout.8 Dr. Howard Marcus, an internist in Austin, Texas, responded, “Most of us do not see our administrators as oppressors but, rather, as stuck along with the rest of us in a system that has piled on time-consuming burdens — which saps us of the time and energy required to do the best we can for our patients in the time available.”

An Annals of Internal Medicine costconsequence analysis reported that physician burnout is costing $4.6 billion per year related to physician turnover and reduced clinical hours. The authors offer a prescription that burnout “can effectively be reduced with moderate levels of investment,” suggesting there is “substantial economic value for policy and organizational expenditures for burnout reduction programs for physicians.”9 The National Academy of Medicine issued a report that offers a bold vision for systemic change — because “the system,” the amorphous healthcare-industrial complex, is designed, unwittingly or not, to produce the results it is producing.

When you take what is at its core a moral and scientific enterprise, that is the practice of medicine, and relentlessly mess with it in an unscientific manner driven by economics and regulation, physician burnout is the expected outcome. The scope and breadth of the problem requires unprecedented leadership, shared “collective and coordinated action across all levels of the healthcare system — front line care delivery, the health care organization, and the external environment.”10 Leadership matters. The Mayo Clinic reported that a one-point increase in the leadership score of a physician’s 10

February 2020

immediate supervisor was associated with a 3.3% decrease in the likelihood of burnout.11 This and other reports support the often-quoted conclusion that your supervisor is more important to your health than your primary care doctor.

If leadership will not make this issue a priority, lead as though no help is coming.

Executive leaders in some healthcare systems are beginning to require all executive staff to frequently round with or shadow physicians and to ask questions like “What isn’t working?” To be of value, executive leaders must be armed with the courage to lead and an organizational commitment to change. Some systems have appointed chief wellness officers and formed clinician wellness teams, giving them authority to create opportunities to support wellbeing and resiliency.

Steven Beeson, MD, founder of the Clinician Experience Project, urges “to advance care for patients and take on the healthcare imperatives in front of us, we have to care for those caring for others first. To care for the care team we must listen to clinicians, respond to the things they need, invest in burden reduction, support and develop them to be their best, empower them to lead the way, allow them to be the clinician they envisioned, and appreciate the impact they make when we do these things.”

Efforts to Improve EHR Usability EHR rescue and optimization work is becoming more common to regain lost relationships with patients. Executive leaders who are desperate for help often contact firms like Medical Advantage Group (MAG), a subsidiary of The Doctors Company. MAG conducts system database audits, followed by workflow analysis, previsit planning, and redesign of work screens to make the EHR function better as a convenient, accessible clinical source of truth. Ironically, this improvement in EHR accessibility and usability makes the EHR function more like old paper charts when everything was at hand. Other benefits of this work include increases in qualitybased payments, improved EHR user efficiency and experience, reduced time spent searching, and reduced or eliminated “pajama time” (charting at home).

On a smaller scale, Dr. Gabe Charbonneau (fightburnout.org), a family physician and EHR problem-solver who is on

a mission to disrupt burnout, finds his greatest fulfillment in helping doctors one-on-one. Another example related to EHR usability is at Atrius Health, where a collaboration with its IT department reduced inefficiencies by cutting 1,500 clicks per day per physician.12 This sustained, resourced commitment to improvements resulted in less time spent in the EHR and improved professional satisfaction.

Like any meaningful change, improvements require leadership with a growth mindset that demonstrates a deep respect for people and for the nature of their work. This means exhibiting leadership behaviors such as deference to expertise and sensitivity to clinical operations — two characteristics of the continuous improvement mindset on the journey toward high reliability. Effective leaders meet physicians where they live — on the frontlines of care — and seek to understand what is getting in the way of connecting with patients and providing quality care. The best leaders then work tirelessly to remove the barriers.

Additional Resource American Hospital Association and AHA Physician Alliance Well-Being Playbook: A guide for hospital and health system leaders. https://www.aha.org/system/ files/media/file/2019/05/plf-well-beingplaybook.pdf. Published May 2019.

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References 1. Burn-out an “occupational phenomenon”: International Classification of Diseases. World Health Organization. https://www.who.int/mental_ health/evidence/burn-out/en/. May 28, 2019. Accessed June 12, 2019.

2. Swenson S. Esprit de corps: turning vicious cycle virtuous. Talk presented at: NEJM Catalyst event Essentials of High-Performing Organizations; July 25, 2018; Institute for Healthcare Policy and Innovation, University of Michigan. https://catalyst.nejm.org/videos/ esprit-de-corps-vicious-virtuouscycle/. Accessed March 4, 2019.

3. Talbot SG, Dean W. Physicians aren’t ‘burning out.’ They’re suffering from moral injury. Stat website. https:// www.statnews.com/2018/07/26/

4.

5.

6.

7.

physicians-not-burning-out-they-aresuffering-moral-injury/. Published July 26, 2018. Accessed April 30, 2019.

Wible P. Not “burnout,” not moral injury — human rights violations. https:// www.idealmedicalcare.org/not-burnout-not-moral-injury-human-rightsviolations/. Posted March 18, 2019.

Accessed May 10, 2019.

Shay J. Moral injury. Psychoanal Psychol. 2014;31(2):182–191. https:// www.law.upenn.edu/live/files/4602moralinjuryshayexcerptpdf.

Wible P. Not “burnout,” not moral injury — human rights violations. https:// www.idealmedicalcare.org/not-burnout-not-moral-injury-human-rightsviolations/. Posted March 18, 2019.

Accessed May 10, 2019.

Eichacker C. Doctors quit EMMC as changes leave less time with patients, push morale to ‘all-time low.’ Bangor Daily News. May 13, 2019. https:// bangordailynews.com/2019/05/13/

news/bangor/doctors-quit-emmcas-changes-leave-less-time-with-patients-push-morale-to-all-time-low/.

Accessed May 14, 2019.

8. DeChant P. Management burnout. www.pauldechantmd.com/management-burnout/. Posted April 26, 2019.

Accessed April 29, 2019.

9. Han S, Shanafelt TD, Sinsky CA, et al. Estimating the attributable cost of physician burnout in the United States. Ann Intern Med. [Epub ahead of print 28 May 2019] 170:784–790. https://annals.org/aim/ article-abstract/2734784/estimatingattributable-cost-physician-burnoutunited-states. Accessed June 12, 2019.

10. Taking action against clinician burnout: A systems approach to professional wellbeing. Slide 19. National Academy of Medicine. https://nam. edu/wp-content/uploads/2019/10/ Public-release-PPT-10-23-19.pdf.

Published October 23, 2019. Accessed

October 25, 2019.

11. Shanafelt TD, Noseworthy JH. Executive leadership and physician wellbeing: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc.

2017;92(1):129-146. https://www.mayoclinicproceedings.org/article/S00256196%2816%2930625-5/pdf.

12. Berg S. How collaboration with IT cut 1,500 clicks a day per physician. American Medical Association. https:// www.ama-assn.org/practice-management/digital/how-collaborationit-cut-1500-clicks-day-physician.

Published March 7, 2019. Accessed May 1, 2019.

Mr. Morton is assistant vice president, Department of Patient Safety and Risk Management at The Doctors Company.

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SanDiegoPhysician.org 11

PUBLIC HEALTH

California Launches First-of-ItsKind ACEs Initiative Beginning Now, Medi-Cal Will Pay for ACEs Screenings

By California Medical Association Staff CALIFORNIA SURGEON GENERAL

Nadine Burke Harris, MD, and Karen Mark, MD, medical director at the state’s Department of Health Care Services (DHCS), recently unveiled an initiative to address the public health crisis of toxic stress from childhood trauma. Called the ACEs Aware initiative, it’s a first-ofits-kind statewide effort for California healthcare providers to screen patients for Adverse Childhood Experiences (ACEs) that increase the likelihood of ACE-associated health conditions due to toxic stress.

Detecting ACEs early and connecting patients to interventions, resources, and other support can significantly improve the health and wellbeing of individuals and families.

California is offering provider training to screen pediatric and adult patients for 10 categories of ACEs, which include abuse, neglect, and household dysfunction. The two-hour online curriculum will be easy to access for a wide range of healthcare professionals and will provide continuing medical education (CME) and maintenance of certification (MOC) credits. Since Jan. 1, Medi-Cal physicians can now be paid for ACEs screenings for Medi-Cal patients.

ACEs are stressful or traumatic events experienced before age 18. A consensus of scientific research demonstrates that 12

February 2020

cumulative adversity, especially when experienced during critical periods of early development, is a root cause to some of the most harmful, persistent, and expensive health challenges facing our state and nation.

In November, the U.S. Centers for Disease Control and Prevention issued a special report on Adverse Childhood Experiences and suggested that prevention of ACEs may lead to reduction in a large number of health conditions including heart disease, stroke, cancer and diabetes, as well as depression, unemployment, and substance dependence.

“The ACEs Aware initiative is harnessing and building upon the momentum and expertise that has been growing in the scientific community for more than a decade now,” says Dr. Burke Harris, California’s first Surgeon General. “We have set a bold goal to cut ACEs in half in a generation, and this initiative represents a historic step in tackling one of the greatest public health threats of our time.”

According to the most recent California Department of Public Health data reporting from the Behavioral Risk Factor Surveillance System (BRFSS, 2017), 63.5% of Californians have experienced at least one of the ACEs and 17.6% of Californians have experienced four or more.

Nationally, the prevalence rate is similar.

Additionally, research shows that individuals who experienced ACEs are at greater risk of numerous ACE-Associated Health Conditions, including nine of the

10 leading causes of death in the United States, and that early detection, early intervention and trauma-informed care can improve outcomes.

“I am proud that California is leading the way on this important work,” Dr. Mark says. “Identifying a history of trauma in children and adults and providing treatment can lower long-term health costs and support individual and family wellness and healing.”

All providers are encouraged to receive training on how to screen patients for ACEs and respond with trauma-informed care. By screening for ACEs, providers can better determine the likelihood a patient is at increased health risk due to a toxic stress response, which can inform patient treatment. Trauma-informed care recognizes and responds to the signs, symptoms, and risks of trauma to better support the health needs of patients who have experienced ACEs and toxic stress.

Funding for the ACEs Aware initiative comes from the Proposition 56 tobacco tax and is part of Governor Gavin Newsom’s “California for All” initiative, which aims to improve health and bolster early interventions for the state’s youngest Californians. In the 2019–20 budget, Governor Newsom provided $40.8 million to DHCS for ACEs screenings for children and adults enrolled in Medi-Cal, California’s Medicaid program.

Additional details about the ACEs Aware initiative are available at ACEsAware.org.

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PRACTICE MANAGEMENT

Cultural Diversity Creates Language Barriers: Reducing Claims with Multilingual Patients

By Rich Cahill, JD, and Susan Shepard, MSN, RN MS. D., A NATURALIZED U.S. CITIZEN

from Southeast Asia, presented to Dr. P. for a consultation regarding extensive acne scarring on her face and neck. The patient reported that she felt self-conscious about her appearance and sought advice on possible treatment options. According to the chart, Ms. D. spoke limited English. Her reading proficiency was not noted.

Following an examination of the affected area, Dr. P. offered CO2 laser resurfacing. The benefits and potential disadvantages of the procedure were discussed, including the possibility that her complexion type posed an increased risk of scarring and changes in pigmentation.

Ms. D. subsequently agreed to undergo laser resurfacing and signed a written consent that specifically identified scarring and changes in skin color as possible postoperative outcomes.

The patient returned the following week. The treatment record reflects that Dr. P. performed the procedure under local anesthesia and conscious sedation.

The surgery was uneventful, and no intraoperative complications occurred.

Ms. D. presented on numerous occasions over the next several months.

Hyperpigmentation was noted, and Solaquin Forte 4% and Pramosone lotion were prescribed. At one point, the patient complained of experiencing a burning sensation on her face. Approximately one year after the procedure, Ms. D. returned for further evaluation. The scarring was 14

February 2020

barely visible; the discoloration on her neck was noticeably improved. However, the patient expressed dissatisfaction with the result.

Ms. D. thereafter retained counsel and initiated a suit alleging causes of action for medical malpractice and negligent infliction of emotional distress. In substance, the patient claimed that because of her limited proficiency with English and the failure by the physician to utilize any translation services, including for any preoperative documentation, there was no informed consent.

Providing Language Services: Obligations and Benefits Clear and unambiguous communication constitutes the key component of the physician-patient relationship.

Misunderstandings often create frustration and distrust, especially when an adverse event occurs, and can result in professional liability litigation or reports to state medical boards and third-party

payers by disgruntled patients and family members. Proactively implementing office procedures for both physicians and staff to promote optimum communication reduces the risk of surprise and the potential for expensive, protracted, and unpleasant disputes.

With our culturally diverse national population, including many who speak a language other than English at home, language barriers raise the risk for an adverse event. The Department of Health and Human Services’ (HHS) Revised Guidance Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient (LEP) Persons outlines the requirements for recipients of federal financial assistance from HHS to take reasonable steps to ensure LEP persons have access to language services.

(These recipients do not include providers who only receive Medicare Part B payments. However, providers that receive funding from any government program such as Medicaid or Medicare Advantage

are subject to the requirements.)

To determine the extent of the obligation to provide language assistance, analyze the following four factors: • Number: The greater the number or proportion of LEP persons served or encountered by your clinic, the more likely language services will be needed.

• Frequency: Even if unpredictable or infrequent, there must be a plan for providing language assistance for LEP persons.

• Nature: Determine whether a delay in accessing your services could have serious or life-threatening implications. The more important the nature of the services you offer, or the greater the consequences of not accessing treatment, the more likely language services will be needed.

• Resources: Consider the resources available and the cost to provide them.

As a solo practitioner, you are not

expected to provide the same level of service as a large, multispecialty group.

Investigate technological services or sharing resources with other providers.

It is not recommended to use a family member as an interpreter. Lay personnel are rarely familiar with medical terminology. Additionally, the patient may not want a family member to access their confidential health information.

An adult family member should serve as interpreter if a family member must be used — unless no adult is available, and care must be provided immediately to prevent harm. It is preferable to have a trained clinical staff member provide interpretation; alternately, your practice can use certified interpreter services. Consult your local hospital or the patient’s health plan for a list of qualified interpreters.

Other resources include a local nationality society, the Registry of Interpreters for the Deaf, or the local center for the deaf.

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SanDiegoPhysician.org 15

PRACTICE MANAGEMENT

Also, keep consent forms — especially for invasive procedures — translated into the applicable non-English languages by a certified translator.

The Agency for Healthcare Research and Quality (AHRQ) has prepared a guide, Improving Patient Safety Systems for Patients With Limited English Proficiency, which recommends that practices focus on the following: • Medication use: Understanding medication instructions is complicated for all patients, but even more difficult for LEP patients. Both patients and providers need to communicate accurately about mode of administration, allergies, and side effects.

• Informed consent: Obtaining informed consent remains a hallmark of patient safety and a critical medical and legal responsibility. Achieving truly informed consent for LEP patients may require extra effort, but LEP patients should not be excluded from learning about choices that might affect their health and wellbeing.

• Follow-up instructions: Understanding discharge instructions is especially challenging for LEP patients. Speaking Together: National Language Services Network, a project funded by the Robert Wood Johnson Foundation, which created the Speaking Together Toolkit, found the need for greater use of interpreters at key moments of information exchange, such as at assessment and discharge — not just during the acute phase of treatment.

Relatively simple communication tools can provide some helpful solutions.

These include: • AskMe3™: Rx for Patient Safety: Ask Me 3 • The teach-back method: AHRQ: Use the Teach-Back Method: Tool #5 • The SHARE approach: AHRQ: The SHARE Approach — Using the TeachBack Technique: A Reference Guide for Health Care Providers • Patient experience surveys: The Doctors Company: Patient Experience Surveys

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To protect your patients from harm resulting from their LEP, develop and implement a plan for language access in your practice. For more information, see the Centers for Medicare and Medicaid Services’ Guide to Developing a Language Access Plan.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Rich Cahill, is vice president and associate general counsel, and Susan Shepard is senior director, Patient Safety Education at The Doctors Company.

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CHAMPIONS FOR HEALTH

Above: Adama Dyoniziak and Andrew Gonzalez with the Immunization Proclamation by the City of San Diego Top right: Immunizations at Northgate Market in Fallbrook Bottom right: Andrew Gonzalez, Community Wellness & Partnership Manager, with immunization volunteers

Immunizations

By Adama Dyoniziak ACCORDING TO 2016 DATA OBTAINED

by the California Health Interview Survey, underrepresented communities in San Diego County tend to have low flu vaccination coverage. This is largely due to issues with healthcare access, vaccine misinformation, and community-specific obstacles such as language barriers or cultural distrust in health services.

As of now, influenza coverage in the United States for adults aged 18- 64 was estimated to be 31.1% by the Centers for Disease Control and Prevention (CDC).

Using California Health Interview Survey data from within San Diego County, Latino communities reported 26.2% of their population had received a flu vaccine in 2014–2016, African-American communities 45.7%, Asian-American communities 44.4%, and 45.7% for the American Indian/Alaska Native community.

Champions for Health strives toward achieving the Healthy People 2020 goal immunization rate of 70.0% among underrepresented communities. There is no available data on pneumococcal and hepatitis A vaccines categorized by race/ethnicity; but based on flu vaccine coverage rates, we can infer that there are similar coverage rates regarding those diseases due to vaccination tendencies in each community.

Community Health & Wellness programming within Champions for Health addresses preventable and chronic dis-

eases to keep people healthy with health screenings, Live Well San Diego Speaker’s Bureau, diabetes prevention programs, and immunizations. Since September 2019, immunizations were provided by 1,258 volunteer physicians, nurses, pharmacists, and nursing and pharmacy students at 78 locations including 22 schools throughout San Diego County.

During this flu season alone, 3,418 flu and 100 hepatitis A vaccines were provided to 2,498 adults and 1,070 youth, with the majority of the adults stating they were uninsured (78%). Given that the average flu shot cost $40 per person, this is a consumer cost savings of $136,720. The savings are even higher for the hepatitis A vaccine (two doses needed), which averages an expensive $118 per dose, and provides a consumer cost savings of $1,180.

In collaboration with San Diego County Epidemiology and Services Branch, we identify areas in San Diego County that have low immunization and low insurance rates to ensure that we step into the gap and not duplicate community clinic and medical group efforts. Thank you to our newest partners who help us to mobilize our efforts to conduct field immunizations: UCSD School of Pharmacy, San Marcos UEI, San Diego City College of Nursing, Kaplan University, Christian Pharmacists Fellowship International, and San Diego County Pharmacists Association.

Recently, we were invited to present our immunization program results at

the 2019 National Adult Immunization Summit in Atlanta. Improving Flu Accessibility Among the Underserved in San Diego California was accepted as a poster presentation by William Liao, CFH Immunization Intern, and Andrew Gonzalez, Community Wellness and Partnership Manager. Here is a link to the poster itself: https://www.izsummitpartners.org/ content/uploads/2019/05/1-improvingflu-accessibility-among-underserved-Insan-diego.pdf Champions for Health is grateful to the County of San Diego Department of Health and Human Services Agency for supplying vaccines, and to our sponsors United Healthcare and Microvention Terumo for funding the needed supplies for our immunization efforts.

To end the calendar year in a festive way, CFH was awarded a capital grant from Las Patronas to acquire a new vaccine refrigerator that will more than triple our vaccine storage capacity from 5.5 cubic feet to 17 cubic feet just in time to expand vaccination efforts. In 2020 we will become a Vaccine for Children Provider, and in collaboration with the San Diego Unified School District, we will make available Human Papilloma Virus (HPV), influenza, tetanus diphtheria and pertussis (Tdap), and meningococcal conjugate for youth ages 7–18. Las Patronas is committed to financially assisting nonprofit organizations in San Diego County that provide valuable community services in the areas of health, education, social services, and cultural arts, and to continuing their tradition of service to enhance the quality of life in the community.

The dedicated physician volunteers of the San Diego County Medical Society envisioned being of service to the community, so they created the Foundation, which is now Champions for Health. For more information on how you can use your physician power to protect and heal our most vulnerable San Diegans, please contact Adama Dyoniziak at adama. dyoniziak@championsfh.org or call (858) 300-2780. Join in transforming lives one person at a time!

Ms. Dyoniziak is executive director of Champions for Health.

SanDiegoPhysician.org 17

CLASSIFIEDS PHYSICIAN OPPORTUNITIES PEDIATRIC POSITION AVAILABLE: Grossmont Pediatrics, a private pediatrics practice with Commercial HMO, PPO, Tricare, Medi-Cal patients, provides familyfocused 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, up to 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) 504-5830 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 nonprofit agency 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,

18

February 2020

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.

(Posted 09/20/2019) 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. 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 31, 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 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 (619) 417-1500.

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 and 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.

LA JOLLA OFFICE FOR SUBLEASE OR TO SHARE: Scripps Memorial Medical office building at 9834

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 & Rady Children’s. Ready-to-occupy suites ranging from 1,300-5,000 SF with mix of exam rooms and offices.

Will consider short-term & long-term leases.

For details, floor plans and photos contact David DeRoche (858) 966-8061 | dderoche@rchsd.org Genesee Ave. Amazing location by the main entrance to the hosptial between 1-5 and 1-805. 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.

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 2000 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, handicapped 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, 1600 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) 733-4068 or jo@siosd.com.

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.

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 PRACTICE ANNOUNCEMENTS GRAND OPENING OF SAN DIEGO ENT AND UNITED MEDICAL DOCTORS OFFICE IN LA JOLLA: Connect with fellow physicians, tour the new office and enjoy hors d’oeuvres and beverages! We will have free giveaways, raffles and 50% off your choice of custom noise-reducing ear plugs or surfer’s ear plugs. Additionally, receive $7/unit Botox and $100 off filler syringes, which can be used at the time of the event or scheduled for a later date. Wednesday, March 11, 2020. 5:00pm-7:00pm 4150 Regents Park Row, Suite 345 La Jolla, CA 92037 Please RSVP at info@sandiegoent.com.

MEDICAL 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.

PLACE YOUR AD HERE

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.

Contact Dari Pebdani at 858-231-1231 or DPebdani@SDCMS.org SanDiegoPhysician.org 19

PERSONAL & PROFESSIONAL DEVELOPMENT

A Profession That Values and Respects All of Its Members

By Helane Fronek, MD, FACP, FACPh AFTER PRACTICING MEDICINE FOR 37 YEARS AND coaching many physicians, I know that the experience of being a physician is different for a woman than for a man. I’m not aiming to complain — or to suggest that women be cut any slack. I know men have their own challenges. But, with our profession becoming more gender-balanced, we have an opportunity to correct behaviors that undermine our ability to encourage the best from all its members, so our profession can thrive in the coming years.

Some examples: An internship interviewer suggested that a student’s impressive evaluations resulted from her being “charming,” so people liked her. A trauma surgeon was denied promotion because she “didn’t smile enough.” Women are demeaned when taking time for family commitments, when 83% of men physicians have spouses who do most or all childcare/ household tasks, while only 5% of women physicians have this kind of home support. Women are denied leadership opportunities because “she has two little ones at home,” before being offered a chance to succeed. Women medical students wonder why their male colleagues’ insensitive interactions are accepted, 20

February 2020

while they are criticized if they’re not consistently compassionate. Women trainees often notice that attendings disproportionately direct their comments to male trainees, even when discussing the women’s patients. Underlying these behaviors are assumptions that women cannot be smart or capable, must always be “nice,” and are not as committed and thus not as worthy of investment as men. These assumptions leave half of our workforce feeling devalued.

Medicine has a long history of ignoring women. Medical research excluded women from studies of endocrine effects on their own bodies until recently. As Caroline Criado Perez demonstrates in Invisible Women, men are the default in our culture. It’s nearly automatic to view situations from the perspective of a white man. She cites numerous failed situations in which important ideas were not considered simply because men — the decision makers — never had that experience.

We are smarter than this.

We must ensure that women and other underrepresented groups are appropriately represented on committees,

boards of directors, and other decision-making groups.

Since half of physicians will be women, it’s foolish to allow decisions to be made without their perspective. As other underrepresented groups join our ranks, we must offer environments that are welcoming to them as well.

Creative changes like scheduling meetings at varying times to accommodate childcare demands will allow more women and single parents to bring their talents to leadership roles. All leaders must become better attuned to implicit bias and microaggressions in the workplace, and insist on appropriate and respectful behavior toward all physicians. While some men resent covering for women colleagues on maternity leave, a willingness to make accommodations helps physicians, regardless of gender, balance life and work. That’s good for our profession.

Let’s bring curiosity, creativity, and courage to our workplaces and schedules so we don’t have to choose between having a full life and a fulfilling career. Let’s prioritize the quality of our lives and relationships over the amount on our pay stubs.

If we want a profession that values all physicians, what choices will we make?

Dr. Fronek, SDCMS-CMA member since 2010, is an 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.

Celebrating 150 Years

The San Diego County Medical Society is celebrating the 150th anniversary of its founding in 1870. This 1874 fee schedule for San Diego physicians and surgeons is a colorful reminder of the rich historical legacy of our county's medical community.

SanDiegoPhysician.org 21

$5.95 | www.SanDiegoPhysician.org San Diego County Medical Society 5575 Ruffin Road, Suite 250 San Diego, CA 92123 [ Return Service Requested ]

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