February 2021

FEBRUARY 2021

Official Publication of SDCMS

Celebrating 150 Years

The Next Pandemic is

ALREADY HERE

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 Art Director: Lisa Williams Copy Editor: Adam Elder

VOLUME 108, NUMBER 2

OFFICERS President: Holly B. Yang, MD President-Elect: Sergio R. Flores, MD Secretary: Toluwalase (Lase) A. Ajayi, MD Treasurer: Nicholas J. Yphantides, MD Immediate Past President: James H. Schultz, 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 H. Koh, MD (Board Representative to the Executive Committee) Kearny Mesa #1: Anthony E. Magit, MD Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Preeti Mehta, MD La Jolla #2: David E.J. Bazzo, MD, FAAFP North County #1: Patrick A. Tellez, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Kelly C. Motadel, MD, MPH South Bay #2: Maria T. Carriedo, MD AT-LARGE DIRECTORS #1: Thomas J. Savides, MD #2: Paul J. Manos, DO #3: Irineo “Reno” D. Tiangco, MD #4: Miranda R. Sonneborn, MD #5: Stephen R. Hayden, MD (Delegation Chair) #6: Marcella (Marci) M. Wilson, MD #7: Karl E. Steinberg, MD #8: Alejandra Postlethwaite, MD ADDITIONAL VOTING DIRECTORS Young Physician Director: Brian Rebolledo, MD Retired Physician Director: Mitsuo Tomita, MD Resident Director: Nicole Herrick, MD Medical Student Director: Lauren Tronick 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: David E.J. Bazzo, MD, FAAFP At-large AMA Alternate Delegate: Kyle P. Edmonds, MD At-large AMA Alternate Delegate: Robert E. Hertzka, MD At-large AMA Alternate Delegate: Holly B. Yang, MD CMA DISTRICT I DELEGATES Karrar H. Ali, DO Steven L.W. Chen, MD, FACS, MBA Susan Kaweski, MD Franklin M. Martin, MD Vimal I. Nanavati, MD, FACC, FSCAI Peter O. Raudaskoski, MD Allen Rodriguez, MD Kosala Samarasinghe, MD Mark W. Sornson, MD Wayne C. Sun, 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.]

Features

4

The Next Pandemic is Already Here

By Marty Makary, MD, MPH, Indrani Das, Farah Hashim, and Christi Walsh, NP

8

Communicating with COVID-19 Vaccine-Hesitant Patients: Top Tips

By Debra Kane Hill, MBA, RN

Departments

2

Briefly Noted: CMA Advocacy for Struggling Practices • COVID-19 Vaccine Liability • Vaccine Administration Claims

10

Anaphylaxis Cases with Moderna COVID-19 Vax Follow a Similar Pattern

By Molly Walker

12

Will Coronavirus Variants Soon Dominate in the U.S.?

By Molly Walker

14

Benzodiazepines (Benzos) Medications Safety & Risks

By San Diego County Prescription Drug Abuse Task Force (PDATF)

16

COVID-19: A Call for Innovation and Leadership in Healthcare

By Richard E. Anderson, MD, FACP

18

‘You Saved My Life!’

By Adama Dyoniziak

19

Fully Embodying Being a Doctor: Teaching by Example

By Helane Fronek, MD, FACP, FACPh

20

Classifieds SanDiegoPhysician.org 1

BRIEFLY NOTED 2

February 2021

ADVOCACY AND PRACTICE MANAGEMENT

CMA Advocates for Bill to Protect Physician Practices Struggling Amid the Ongoing Pandemic AS PART OF ITS EFFORTS TO PROTECT physician practices that have been hit hard by the COVID-19 pandemic, the California Medical Association (CMA) has partnered with a coalition — including business groups, healthcare providers, and Assemblymember Autumn Burke — to advocate for a bill (AB 281) that would conform California law with recent changes to federal law that allows the deduction of expenses paid with forgiven Paycheck Protection Program loans.

Federal lawmakers made the change as part of its second COVID-19 relief package passed in late December. Burke’s bill seeks to align state law with federal policy, afford increased financial support to hard-hit practices, and eliminate the burden of preparing separate sets of books for state and federal tax purposes.

The federal government created the Coronavirus Aid, Relief and Economic Security (CARES) Act and PPP loans through the Small Business Administration (SBA) to offer much needed financial support to struggling businesses across the nation. The loans may ultimately be forgiven if they are used for specified purposes, including payroll costs, business mortgage interest payments, rent, or utilities.

These loan programs became a necessary lifeline to many businesses including physician practices that have endured significant financial hardship during the COVID-19 pandemic. In October a survey of California physicians found that 87% of physician practices are still worried about their financial health. Even with more than 8 out of 10 practices now utilizing telehealth, the average volume of patient visits and practice revenue is still down by one third, with 25% of practices still experiencing a revenue decline of 50% or greater. Surgical specialties are particularly impacted because of their inability to practice via

telehealth, with average revenue declines of 41%, compared to 34% for all specialties.

While revenue is down, practice costs have gone up 14%, with practices having to purchase personal protective equipment, comply with public health disinfecting guidelines, implement telehealth, and make other changes due to the pandemic.

Conforming state law to the federal loan guidelines will help physician practices keep their doors open to ensure Californians can have access to a physician when they need one.

In addition, it will help keep physician offices staffed at a time when state unemployment levels are more than double what they were before the pandemic hit. Statewide, 56% of practices report their staffing levels have not returned to normal. In addition to providing vital medical care to patients, physician practices play an important role in local economies, helping to sustain jobs and economic viability during these uncertain times.

Failure to bring state law in line with federal policy would create additional financial strain on physician practices and other small businesses that needed these funds to stay open and continue to pay their employees through the closures of the pandemic.

COVID-19 VACCINES

DHCS Now Ready to Process COVID-19 Vaccine Administration Claims

COVID-19 VACCINES

Newsom Order Protects Physicians From Liability When Administering COVID-19 Vaccines AS THE STATE OF CALIFORNIA moves to speed up the distribution and administration of COVID-19 vaccinations, Governor Gavin Newsom signed an executive order on Jan. 27 that will help expand the state’s vaccination administration capacity by safeguarding physicians and other healthcare professionals who administer vaccinations.

The order, which was sought by the California Medical Association (CMA), confirms that all COVID-19 vaccination efforts, whether administered through a private practice or public effort, are pursuant to the state’s vaccine program and therefore safeguarded under existing law that protects physicians and other vaccine administrators from lawsuits when they render services at the request of state or local officials during a state of emergency. (See Gov-

ernment Code §8659).

The order also proclaimed that “healthcare professionals and providers who render services during an emergency should not be subject to discipline for performing their duties consistent with standards of care prevailing during the emergency, and boards … responsible for professional discipline should ensure that such professionals’ and providers’ actions are assessed in the context of the standards of care, including any state waivers or health orders, in effect during an emergency, rather than the benefit of hindsight … ” The order “will provide assurance to vaccinators that they are protected from professional discipline when otherwise performing their duties,” according to a statement from the governor’s office.

THE CALIFORNIA DEPARTMENT OF Health Care Services (DHCS) announced its systems have been updated and are now able to process claims for COVID-19 vaccine administration.

On Dec. 18, 2020, DHCS announced its plan for reimbursement of the administration of the COVID-19 vaccine, but at that time its systems were not yet able to accept the claims. On Dec. 29, systems were updated to accept claims, but additional updates were needed before those claims could be paid. As of Jan. 25, 2021, DHCS is now able to accept and adjudicate claims for COVID-19 vaccine administration.

Now that the system has been updated, electronic and hard-copy claims submitted since Dec. 29, 2020, are now being processed. Claims for the administration of the COVID-19 vaccine that were inadvertently denied or processed incorrectly instead of being put into “pending” status will be automatically reprocessed via Erroneous Payment Correction (EPC).

Providers submitting vaccine administration claims for beneficiaries who have Other Health Care (OHC) coverage and claims from facilities that fall under the Los Angeles County waiver will continue to see submissions appear in “pending” status for a period of time. System changes to properly adjudicate these claims are still in process.

SanDiegoPhysician.org 3

INFECTIOUS DISEASE

THE NEXT PANDEMIC IS ALREADY HERE

Tools for Stopping It Are Readily Available, If Only We Agree to Use Them By Marty Makary, MD, MPH, Indrani Das, Farah Hashim, and Christi Walsh, NP

T

he casualties of a global pandemic are now vivid to everyone, and many wished we could have acted earlier to stem the death toll. But another pandemic has already started. It’s not one that rips through countries in months. It’s a slower growing pandemic, yet it threatens to kill 10 million people a year by 2050.

Even so, it has received little attention.

We’re talking about the global pandemic of antimicrobial resistance — a pandemic increasingly claiming the lives of patients on our hospital floors. Unlike pandemics caused by novel viruses, this one can be addressed through our prescribing routines and the purchasing decisions and food choices made on a societal level.

The antimicrobial resistance crisis stems from the simple fact that new antibiotic development cannot keep pace with the rate of bacterial resistance.

Because of a smaller market size and profit incentive for pharma companies to develop new antibiotics compared to lifestyle medications and other therapies with broader indications, the number of new antibiotics that the FDA approved annually has slowed to a trickle. Over the same time, the rate of bacterial mutation is growing exponentially. It used to take 21 years on average for bacteria to become

4

February 2021

resistant when antibiotics were first used.

Now it takes just one year on average for bacteria to develop drug resistance. Today, the CDC lists 18 different types of antibiotic-resistant bacteria and classifies five as urgent threats to human health.

Among the most concerning mutating bacteria are carbapenem-resistant Enterobacteriaceae (CRE), carbapenem being a “drug of last resort.” CREs already pose a major concern for patients and healthcare

professionals, causing about 13,100 infections in hospitalized patients and killing 1,100 every year in the U.S. The CDC estimated mortality due to CRE infection to be as high as 40%–50%. Antibiotic-resistant bacteria found in the healthcare setting, including CRE and methicillin-resistant Staphylococcus aureus, represented more than 85% of the antibiotic-resistant deaths in the CDC analysis. Yet this earlystage pandemic has received almost no

Alexander Fleming, the discoverer of penicillin.

media attention.

This pandemic has already started. I’ve seen it. Increasingly, we as surgeons will remove an organ simply because there is no other way to manage the infection.

In the case of Clostridioides difficile (C. diff) colitis, an emergency colectomy is performed when patients don’t respond to antibiotics or fecal bacteriotherapy.

CDC data show C. diff infections occurred in half a million patients each year, and at least 29,000 had fatal outcomes within one month of initial diagnosis; 15,000 of those deaths were directly attributable to the pathogen. Again, this pandemic has received almost no media attention. Today, up to 30% of patients with severe C. diff colitis and sepsis will require emergency surgery, and the mortality of patients who undergo the surgery remains high.

Prophetically, Alexander Fleming, the discoverer of penicillin, warned of antimicrobial resistance from the overuse of antibiotics in his 1945 Nobel Prize acceptance speech. His discovery was an accident, but his warning was deliberate.

Overuse of antibiotics is the primary driver of antibiotic resistance today.

According to the CDC, in 2018 an astonishing seven antibiotic prescriptions were written for every 10 Americans. One-third were deemed unnecessary, and very often were for viral illnesses that do not respond to antibiotics including sinus infections, ear infections, viral sore throats, and the common cold. Clinicians writing these prescriptions frequently argue that the antibiotic can help if the infection includes a small bacterial component or creates opportunity for bacterial infection.

In medical school, it’s amazing how much time is spent on memorizing and regurgitating information, only to forget it days later, as a method for getting familiar with a new medical vocabulary. In all that time spent on rote memorization, a reflex is created, pairing bacteria with antibiotics. But in that education, what is lost is the appropriateness of treatment.

We should be teaching not just what antibiotic to use, but when to use it. We need to emphasize thresholds for treating

patients and how to stand firm when patients are begging for antibiotics that are clearly not indicated.

Nowhere has the overuse of antibiotics been more apparent than in the treatment of the COVID-19 virus. In a recent meta-analysis in the Journal of Clinical and Infectious Diseases of 18 studies, of 2,010 patients hospitalized with COVID-19, a stunning 72% of them received an antibiotic, even though only 8% had a bacterial co-infection. (Azithromycin was commonly given early in the pandemic because some questionable evidence suggested it had an antiviral effect.)

Data actually suggest that antimicrobial resistance might be getting worse during the COVID-19 pandemic. As global health efforts focus on the growing viral pandemic, antibiotic resistance eradication efforts have been neglected.

The adoption of mitigation strategies to prevent the spread of COVID-19 suggest that we can take action now to battle antibiotic resistance. In addition, current SanDiegoPhysician.org 5

INFECTIOUS DISEASE

a. From the Johns Hopkins University global COVID-19 tracker. b. Estimate based on American Family Physician 2014 (Solomon et al.), U.S. data for COVID cases, and U.S. share of global population having 2.8 million annually and 4.31% of the global population. c. Estimate based on same sources

infection control measures may also be beneficial to reducing the risk of spread and incidence of antibiotic-resistant infection.

The comparison table below, adapted from a 2020 viewpoint in Clinical Infectious Diseases, exhibits the differences in urgency and action for both pandemics.

Medications clinicians prescribe, however, are not the only source of our 6

February 2021

antibiotic resistance crisis. In the U.S., 70%-80% of all antibiotics are given to animals, where crowded conditions facilitate mutations. Once the animals develop drug resistance to the bacteria, it can spread to the environment and to our food, eventually transferring to people who eat that food.

Beyond land-based livestock, antibiotics are rampant in salmon farms, which

is especially concerning, considering that 90% of fresh salmon eaten in the U.S. comes from farms. In response to a growing resistance threat in the food industry, fast-food chains such as Chipotle and Panera have championed antibiotic-free animal products. Many fast-food chains, in fact, have shown progress in reducing antibiotic use in chickens, though beef practices have yet to catch up. The public interest group PIRG has created a scorecard to compare antibiotic practice patterns of popular fast-food chains, which can help guide consumers away from antibiotic-using establishments.

Growing public demand can move markets toward better health and address the next antimicrobial resistance pandemic.

Despite the U.S. government’s comprehensive action plan for combating antibiotic resistance, efforts to carry it out have been inconsistent. In 2017, the FDA banned the use of antibiotics to promote growth in livestock. That same year, the U.S. proposed major budget cuts to agencies that fund research for new antimicrobials and work to curtail the global spread of multidrug-resistant pathogens; these agencies include the CDC through its Antibiotic Resistance Solution Initiative, the National Institute of Allergy and Infectious Diseases, and the U.S. Agency for International Development. The U.S. Department of Agriculture also removed federal oversight of meat inspection at pork processing plants, effectively eliminating up to 40% of the inspection staff at plants.

Clinicians — doctors, nurses, physician assistants, and others — play a critical role in preventing antimicrobial resistance and improving the appropriateness of antibiotic use both in the clinical setting and in the food industry.

Explaining the situation to patients or

hospital food service administrators can ultimately move food markets by creating increased demand for antibiotic-free products. In the same way that clinicals tackled smoking with a concerted educational effort, clinicians can be leaders in explaining the health, social, and economic benefits of conscious consumption of responsibly sourced animal products.

In summary, here are some actionable stands that we can all take to combat this pandemic in our everyday clinical routines: • Educate every patient you see about the importance of buying antibioticfree foods.

• Discuss with them the potential direct harms such as allergic reactions — as many as one in five antibiotics

come with side effects.

• Encourage your hospital’s food service to use antibiotic-free foods only to help fight the antimicrobial resistance pandemic.

• When prescribing, remember that antibiotics are not always appropriate, such as for viral infections, open wounds, and minor improving infections.

• Encourage fellow clinicians to adopt safe antibiotic practices in hospitals and clinics.

• When prescribing, make sure to use the right dose, duration, and coverage of the antibiotic • Promote hand hygiene to prevent transmission of resistant bacteria.

Remember that alcohol-based gels do not kill spores like C. diff.

• Promote antibiotic stewardship programs in your clinical setting.

Find CDC recommendations for such programs here.

Dr. Makary is editor-in-chief of MedPage Today, where this article first appeared, as well as a professor of surgery and health policy at the Johns Hopkins University School of Medicine, and author of The Price We Pay: What Broke American Health Care — and How to Fix It. Indrani Das is a medical student at Weill Cornell Medicine and a researcher at the Johns Hopkins University School of Medicine.

Farah Hashim is a research fellow at the Johns Hopkins University School of Medicine. Christi Walsh, NP, is director of clinical research at the Johns Hopkins School of Medicine.

PLACE YOUR AD HERE FEBRUARY 2020

Official Publication of SDCMS

Celebrating 150 Years

MARCH 2020

Official Publication of SDCMS

NOVEMBER/DECEMBER 2019 Official Publication of SDCMS

Celebrating 150 Years

Artificial Intelligence and Medicine THE DEBATE

PREVENTION DIABETES Reversing the Risks

DEMENTIA Reducing the Burden How to Engaging Patients GUN SAFETY

BUILD TRUST

Seeking FM/DO/IM/ Psychiatrist in San Diego County

BREAST CANCER Preventing Deaths

in 15-Minute Office Visits

Contact Jennifer Rohr 858.437.3476 • jennifer.rohr@SDCMS.org

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.

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

SanDiegoPhysician.org 7

COVID-19 VACCINES

Communicating With COVID-19 Vaccine-Hesitant Patients: Top Tips

By Debra Kane Hill, MBA, RN

A

s the early phase of the COVID-19 vaccine rollout occurs across the United States, physicians should proactively prepare for the upcoming administration of vaccines to the general population. This includes implementing a plan to initiate effective informed consent conversations with patients to guide them to an informed decision about the vaccine.

Senior citizens in Florida waited hours in line when vaccines were initially available, and these long waits were caused by offering shots on a first-come, first-served basis rather than through organized registration. In addition, not everyone is eager for a vaccination. A Kaiser Family Foundation survey in early December 2020 revealed that more than a quarter of the American population has strong reservations about receiving the COVID-19 vaccine, should it be made freely available to them.

Reasons cited in the study for vaccine hesitancy include: • Potential vaccine side effects.

• Safety concerns and questions about effectiveness.

• Distrust of the government or political positions.

• The rush to push the vaccine to market with the perspective that it is “too new.”

The good news is that compared to previous studies conducted in Septem8

February 2021

ber by Kaiser and ESPN, willingness to receive the vaccine has improved from 63% to 71%. However, JAMA’s “National Trends in the U.S. Public’s Likelihood of Getting a COVID-19 Vaccine — April 1 to December 8, 2020” reported a downward trend in which the self-reported likelihood of getting the vaccine declined from 74% in early April to 56% in early December 2020.

Since many are hesitant about the COVID-19 vaccine, these tips can help optimize important conversations with patients: • Define your practice culture. For example, how will all staff members contribute to delivering the COVID-19 vaccine message to patients? If the physician is pro-vaccine, yet there are staff who are vaccine-hesitant, the physician/practice owner should ensure that messaging to patients is consistent with the defined pro-vaccine culture of the practice.

• Conduct a deliberate discussion. Conduct a thorough informed consent discussion using language the patient can understand. Include information on

the consequences of non-vaccination.

• Listen carefully to concerns. Encourage your patients to ask questions and express their fears and concerns. Be empathetic and acknowledge that it is reasonable to have concerns. Provide positive feedback when they do, and counter with facts and without argument. Avoid any disparaging remarks.

• Consider health literacy levels. Communicate in the patient’s preferred language at an educational level that the patient can understand. Written materials should be at a fourth- to sixth-grade reading level. Use interpreters, if necessary.

• Use established communication tools. To ensure patients have a clear understanding of health instructions, utilize communication tools such as Ask Me 3. Also consider the teachback method. Rather than asking the patient, “Do you have any questions?” tell the patient, “Explain to me why it is important for you to come back and get the second dose of the vaccine.”

This provides you an opportunity to assess the patient’s understanding of

their need for the follow-up visit.

• Watch your words. A recent poll found that those communicating about COVID-19 need to remove politics and partisanship, and instead, remind people that taking steps to prevent the spread of the virus is good for those they love, for the economy, and for a faster return to a more normal life. Physicians may find the “Changing the COVID Conversation: Communications Cheat Sheet” published by the de Beaumont Foundation a valuable source.

• Set realistic expectations about potential side effects. Explain to patients that they may experience a normal response of sore injection site, low-grade fever, body aches, lethargy, headaches, and other symptoms, so they will not be fearful to return for the second dose. The CDC’s What to Expect after Getting a COVID-19 Vaccine provides factual post-vaccine information for patients.

• Remind patients that the vaccine is not 100% effective. Let patients know that receiving the second dose will optimize their protection. Emphasize that they will need to continue wearing masks, social distancing, and practicing good hand hygiene even after getting the vaccine.

• Recommend available apps. To help patients comply with the second dose

of the vaccine, suggest the CDC smartphone app called V-safe After Vaccination Health Checker. This app sends reminders to patients when their second dose is due and provides them a way to report vaccine side effects.

• Provide factual vaccine information.

Distribute materials well in advance of the scheduled vaccine appointment. Vaccine information sheets are available through the Food and Drug Administration (FDA) website: PfizerBioNTech — Fact Sheet for Recipients and Caregivers and Moderna — Fact Sheet for Recipients and Caregivers.

The Centers for Disease Control and Prevention (CDC) also provides easyto-understand fact sheets for patients on its website: Benefits of Getting a COVID-19 Vaccine and Facts about COVID-19 Vaccines.

• Document the informed consent discussion. Have the patient sign a COVID-19 vaccine informed consent form prior to the administration of the vaccine, and file it in the patient’s medical record. Document the discussion, including the provision of patient educational materials, the use of established communication tools, and patient engagement (including questions, concerns, and how those concerns were addressed).

• Take advantage of CDC resources. To promote patient compliance with the vaccine, the CDC provides communication resources for physicians on Talking to Recipients about COVID-19 Vaccines, including Answering Patients’ Questions and Making a Strong Recommendation for COVID-19 Vaccination.

Understanding and acknowledging patient perspectives about the vaccine plays a principal role in promoting vaccination compliance. Frontline physicians should develop a plan for conducting candid conversations with their patients in a manner that is empathetic and supported by evidence, while emphasizing the overall benefits to the individual and society. Ultimately, however, it is up to the patient to make an informed decision about their immunization status.

TrusT A Common sense ApproACh To InformATIon TeChnology Trust us to be your Technology Business Advisor hArdwAre  sofTwAre neTworks emr ImplemenTATIon seCurITy  supporT mAInTenAnCe

(858) 569-0300

www.soundoffcomputing.com

Endorsed by

Debra Kane Hill is senior patient safety risk manager for The Doctors Company.

SanDiegoPhysician.org 9

INFECTIOUS DISEASE

Anaphylaxis Cases with Moderna COVID-19 Vax Follow a Similar Pattern

Nearly All Have Prior Allergies or Allergic Reactions, But Not to Vaccines By Molly Walker

T

EN CASES OF ANAPHYLAXIS

and more than 100 cases of severe allergic reactions were reported following administration of the first dose of the Moderna COVID-19 vaccine, but nearly all were among those with a history of allergic reactions, researchers found.

Of the 10 cases of anaphylaxis, nine were among those with a history of allergies or allergic reactions, and five had a previous history of anaphylaxis unrelated to vaccines, reported the CDC COVID-19 Response Team along with FDA officials in an early edition of the Morbidity and Mortality Weekly Report.

Rate of anaphylaxis was 2.5 cases per million Moderna doses, or 10 cases following about 4 million doses, which is higher than the widely reported 1.3 10

February 2021

cases per million following an influenza vaccine. A prior report focusing mostly on the Pfizer/BioNTech vaccine found 21 cases of anaphylaxis following about 1.9 doses, or a rate of 11.1 cases per million through Dec. 23.

Six of 10 individuals reported prior allergies or allergic reactions to drugs, including penicillin, acetaminophen, azithromycin, morphine, and codeine; two reported allergies to gadolinium, iodine, and intravenous contrast dye. Two said they had “unspecified” allergies, and one had no history of allergic reaction.

All 10 were women.

It is unclear how many total cases of anaphylaxis have been reported, as this report focused specifically on Moderna.

However, the manufacturer has been in the news for allergic reactions stemming

from a particular lot of Moderna vaccines in California. State health officials recommended pausing doses from that lot, though the CDC and FDA disagreed, according to media reports.

Current interim CDC guidance states individuals with a history of allergic reaction to vaccines or any injectable therapies should consider deferral of vaccination or consult with an allergist/ immunologist, and should be observed for 30 minutes. Any individual with a history of anaphylaxis unrelated to vaccines or injectable therapies should be observed for 30 minutes, while those with a history of unrelated allergies should be observed for 15 minutes.

Median interval from vaccine administration to symptom onset was 7.5 minutes, and while nine patients had symptom onset within 15 minutes, one had symptom onset after 30 minutes. Interestingly, the report focusing on the Pfizer/BioNTech vaccine found a median interval to symptom onset of about 13 minutes.

Researchers examined data from Dec. 21, 2020 to Jan. 10, 2021, prior to California’s reporting of allergic reactions. About 61% of those receiving doses were women.

The median age of anaphylaxis cases was 47, and all patients received epinephrine. Six patients were hospitalized, including five in intensive care and four requiring intubation. Four were treated in the emergency department, and eight patients with follow-up information available were discharged or recovered at home.

They noted that of the 108 case reports for the Moderna vaccine, four did not have enough information to assess the likelihood of anaphylaxis.

Researchers continued to stress these events are infrequent, writing, “anaphylaxis after receipt of the COVID-19 vaccine appears to be a rare event.” They added that vaccine administration sites should have providers available to recognize signs of anaphylaxis, administer epinephrine, and transport patients to facilities where they can receive care.

Molly Walker is associate editor of MedPage Today, where this article first appeared.

My Employee Got Stuck with a Dirty Needle ...

Now What?

Sample COVID-19 Checklist for the Medical Office

CAP’s Free Guide Can Help You Protect Your Practice and Your Patients!

Future-Proofing Your Practice: Eight Resources and Lessons for Success During the Pandemic and Beyond was created by CAP’s team of risk and practice management experts to help physicians: • Navigate today’s uncertain scenarios • Find new opportunities for practice profitability • Ensure safe and successful business operations • And much more!

As a leading provider of superior medical malpractice coverage in California for more than 40 years, The Cooperative of American Physicians, Inc. (CAP) is pleased to offer this free resource to help physicians and their staff run a safe and successful practice.

Request your free copy today!

CAPphysicians.com/FutureSD 800-356-5672 md@CAPphysicians.com

Medical professional liability coverage is provided to CAP members by the Mutual Protection Trust (MPT), an unincorporated interindemnity arrangement organized under Section 1280.7 of the California Insurance Code.

SanDiegoPhysician.org 11

INFECTIOUS DISEASE

Will Coronavirus Variants Soon Dominate in the U.S.?

CDC Researchers See Disturbing Indicators

By Molly Walker

T

HE SARS-COV-2 VARIANT

first documented in Britain could become the primary strain in the U.S. by March, researchers found.

Despite only 76 infections with the variant, B.1.1.7 or VOC 202012/01, detected in the U.S. through Jan. 13, models predict it will crowd out other strains and become the most common cause of COVID-19 by March, according to Summer Galloway, PhD, of the CDC, and colleagues, writing in Morbidity and Mortality Weekly Report.

In addition to public health measures, they warned “enhanced genomic surveillance” will be necessary to track its spread.

This variant is more transmissible, thanks to multiple genetic mutations, including in the S protein receptorbinding domain, they said. Not only is the virus more transmissible, but it may cause false negative results on COVID-19 diagnostic testing via PCR assays, and could be less susceptible to neutralizing antibodies, such as monoclonal antibody therapy and convalescent plasma.

Last week, the FDA alerted clinicians to the possibility of false negative results on certain molecular tests targeting only a single region of the virus’s genome.

Mutations in the variant cause S-gene target failure (SGTF) on at least one PCR-based assay, which Britain used as a proxy for identifying cases with the new variant, and offered a preview for the U.S. based on their epidemiological data.

“U.K. regions with a higher proportion of B.1.1.7 sequences had faster epidemic growth than did other areas, diagnoses 12

February 2021

with SGTF increased faster than did non-SGTF diagnoses in the same areas, and a higher proportion of contacts were infected by index patients with B.1.1.7 infections than by index patients infected with other variants,” Galloway and colleagues wrote.

The group then modeled U.S. data, based on current prevalence of the variant at an estimated <0.5% of U.S. cases, as well as immunity from previous infection at 10%–30%, a time-varying reproductive number for current variants, and incidence of an estimated 60 cases per 100,000 cases per day on Jan. 1.

They found prevalence of the variant “initially low,” but with rapid growth in early 2021 until it becomes the dominant variant in March, regardless of whether transmission of the variant is increasing or decreasing.

And the current vaccination campaign won’t corral the new strain right away.

With 1 million doses administered today and 95% efficacy against infection 14 days after completing the two-dose course,

the models showed no change in early epidemic trajectories. After the variant becomes dominant, however, its “transmission was substantially reduced.” (This assumes the vaccines prevent infection, which has yet to be demonstrated.)

Galloway and colleagues also said that while B.1.1.7 hasn’t been associated with more severe clinical outcomes, continued genomic surveillance is needed to track variants of concern. In addition, vaccination coverage must be higher than anticipated to achieve the same level of population-level disease control versus less transmissible variants, they said.

The researchers noted that no infections with either the South African variant dubbed B.1.351, or the Brazilian/ Japanese variant known as P.1 — both of which are also believed to be extratransmissible — have been confirmed in the U.S. to date.

Molly Walker is associate editor of MedPage Today, where this article first appeared.

ADVERTISE HERE The San Diego County Medical Society can help you reach every physician in San Diego County.

SEPTEMBER 2019

Official Publication of SDCMS

ELIMINATING

HEPATITIS C

We can help you reach San Diego’s physicians and medical leadership through our comprehensive print, digital and in-person channels. Our print channels are great for brand awareness and explaining your message, while digital gives you the option to drive website traffic, and events allow face-to-face time with physicians. An advertising package with the San Diego County Medical Society is your best bet to influence the purchasing decisions — both professional and personal — of this influential audience.

Learn more. Contact Jennifer Rohr today: (858) 437-3476 or JRohr@SDCMS.org

Benzodiazepines (Benzos) Medication Safety & Risks

Presented by the PDATF Healthcare Task Force

What Are Benzodiazepines?

Benzodiazepines, also referred to as "benzos" are a type of sedative used to treat a variety of disorders and for medical procedures. These medications are highly addictive and only meant for short-term use, as prescribed by a doctor.

The effects of benzodiazepines may be felt within an hour and can last from hours to several days depending on the type of benzodiazepine (short, intermediate or long acting).

Safety Extra care is needed when taking a benzodiazepine because it can cause sleepiness and affect your concentration, lasting into the following day.

• Avoid alcohol while you are taking benzodiazepines.

• Benzodiazepines are likely to affect your concentration and ability to drive, putting yourself and others at risk.

• Other medications you take may make sleepiness and impaired concentration symptoms worse.

• Benzodiazepines can also cause muscle weakness, putting you at an increased risk of falls.

Common Benzodiazepines

Questions For Your Provider

Are there any food and drinks I will need to avoid?

• How will this drug interact with my other prescriptions?

• Can I take this medication with my vitamins and herbal supplements?

• How long will I need to take the medication?

• Are there any side effects when stopping the medication?

• Will my symptoms return when I stop taking the medication?

• How will the medication help my symptoms?

Benzos Are Addictive ong&term use of benzodiazepines can be physically and psychologically addicting, in a way similar to that of opioids $i.e., xycontin, icodin, etc.) and annabinoids $i.e., marijuana), according to research done by the National Institute on Drug Abuse.

14

February 2021

Valium (diazepam) Xanax (alprazolam) Klonopin (clonazepam) Ativan ( orazepam)

Benzos are generally not recommended for long-term use. Talk with your doctor.

Risks & Side Effects of benzodiazepines

What are the risks?

If used as prescribed and recommended, benzodiazepines are effective medications.

However, there are risks and side effects, particularly if they’re not used properly, or are used for more than a few consecutive weeks. Long¾term use can lead to dependency and²or a substance use disorder.

Risks Include Dependence Blurred vision Depression Lack of motivation Irritability Aggression Delirium Sexual Dysfunction Perceptual Hallucinations Impulsivity

Impaired udgement Memory loss Confusion Drowsiness Difficulty sleeping% or disturbing dreams Breathing difficulties Withdrawals (which can lead to seizures and death if not managed correctly)

Dependency and Withdrawal When prescribed by your physician these medications are useful for short-term use. Physical dependence can develop as a result of long-term, daily use.

• Physical signs of dependence include a need for a higher or an earlier dose to achieve equal results, and uncomfortable withdrawal symptoms when missing or skipping a dose.

• Benzodiazepine withdrawal can be particularly dangerous and even life-threatening. Talk to your provider when stopping use.

The likelihood of an overdose is increased if benzodiazepines are taken with other depressant drugs such as alcohol, or opiates such as Vicodin, Percocet, or heroin.

Proper Disposal and Storage Do not share your prescription medications with anyone. It is illegal and unsafe.

•

Lock up all medications or put them out of the way of anyone, including children or pets, who might try to consume them by accident or on purpose.

• Find your nearest medication disposal bin: https://bit.ly/34IwGF6

Resources For more information and support, call 2-1-1

Access & Crisis Line: (888) 724-7240 or visit

UP2SD.org

Learn more about the Prescription %rug buse Task orce at %P% T .org December 2020

SanDiegoPhysician.org 15

HEALTHCARE TRENDS

COVID-19:

A Call for Innovation and Leadership in Healthcare

By Richard E. Anderson, MD, FACP

16

February 2021

A

CROSS THE CONTINUUM OF

care during the COVID-19 pandemic, what has changed is not so much the direction of healthcare evolution, but its speed. For the next decade, we will all be carried along on a jet stream of change. Those who innovate and lead — moving their organizations forward as the landscape continues to change — will succeed, while those unable to do so will be left behind. Ask yourself a simple question: Will the practice of good medicine in 2030 look the same as good medicine in 2020?

Before the pandemic, we saw the confluence of a shortage of primary care physicians, the increasing scope of practice for allied health professionals, the widespread availability of retail healthcare and telemedicine, and a massive generational shift in the demographics of the medical profession. There will be no unringing this bell. For example: • The pandemic has forced a growing majority of practices to offer telemedicine services. A study released by the American Medical Association (AMA) in February 2020, just before the pandemic hit the U.S. hard, revealed that telemedicine visits with physicians had already doubled from 2016 to 2019. With COVID-19, the number of patients reporting virtual healthcare visits leapt from 12% to 27% in less than three months, between late March and mid-May. • As baby boomer physicians retire and medical students choose other specialties, a shortage of primary care physicians was already looming. Now, some primary care physicians have had to lay off staff or close their practices — We’ve seen nonemergency providers and specialties not related to COVID-19 suffer massive economic losses.

Unsurprisingly, some primary care physicians are considering other professional options.

• The increasing scope of practice for allied health professionals was an established trend — now dramatically accelerated by the crush of events. We can expect this to continue for nurse practitioners, physician assistants, and others. They will help to fill gaps in primary care, while primary care physicians can expect to practice at the top of their license more of the time.

The good news is we already possess much

of the information we need to make adaptive decisions to protect patients, healthcare professionals, and organizations that serve the medical profession. However, healthcare professionals must seize this moment to show true innovation and to move forward.

True innovation has at least two stages: The first is generating novel and useful ideas and the second is applying those ideas. Unless you apply and scale the idea, it’s just an idea. It’s not an innovation. For example, researchers in California are studying data from massive pools of volunteers who have offered their smart watch and smart ring information. The goal is to spot geographic clusters of people showing small boosts in heart rate, temperature, and so on — in an attempt to predict the next cluster of COVID-19 cases before people even know they’re sick. But it’s one thing to think this is possible, and another to actually do it. That’s the gap between idea and innovation.

This pivot from idea to application at scale calls for leaders to reflect on how their style suits the moment. Most leaders have a clear style of leadership, but good leaders also know that one style cannot be expected to cover all situations. Individuals who perform well in one job or one decade may not do well in new leadership roles under different circumstances: Effective leaders must understand what is required at that particular time, not just what is comfortable.

The new normal will evolve in the context of a decade that was already headed for extraordinarily rapid change. With a mindset of openness to opportunity and a willingness to accept new challenges, we can meet the demands for great healthcare. After all, pressed by COVID-19’s cascade of emergencies, many healthcare and healthcare-supporting organizations have assembled people, equipment, and processes that we would not have imagined possible even a few months ago. At the same time, the COVID-19 crisis casts a harsh light on some areas of healthcare that have fallen dramatically short of the nation’s needs.

It is our collective responsibility to innovate to advance the practice of good medicine.

Dr. Anderson is chairman and chief executive officer of The Doctors Company.

SanDiegoPhysician.org 17

CHAMPIONS FOR HEALTH

‘You Saved My Life!’

By Adama Dyoniziak

W

HEN WE ARE BUT WEE

tykes, we feel things larger and grander, especially our dreams for the future. Who we will be when we grow up?

What will we do? We practice by pretending we are superheroes rescuing people in distress. We look for those superheroes in real life. Our Champions.

“As young as 6 or 7 years old, I enjoyed school and gravitated at a young age to help others. Maybe as a rabbi, maybe in science,” Dr. Robert Goldklang says.

“I chose to become a physician to help people: help all people, not just people with means.” Dr. Goldklang holds dual certification in internal medicine and gastroenterology. He was drawn to gastroenterology in part because of GI disease in his family. He also wanted to be a neurosurgeon and did research in geriatrics for a short time because of his grandmother’s health issues. It was during his residency that Dr. Goldklang saw how a GI surgeon could be of service through a combination of procedures and a cognitive aspect.

“The physician-patient relationship is the best thing about being a doctor,” he says. “I have long-term, established relationships of over 20 years with some patients.” Robert’s best memory is when a longtime patient exclaimed, “You saved my life!” after a CAT scan following surgery revealed an enlarged malignancy that would not have been discovered otherwise. A person rescued!

Besides his work at Coastal Gastroenterology, Dr. Goldklang enjoys being a volunteer through Temple Solel, with the Interfaith homeless shelter, and with Project Access (PASD). Since 2010 he has donated countless office visits and more than 30 colonoscopies to Project Access.

18

February 2021

One patient in particular shares, “I knew I was in good hands the second I met Dr. Goldklang. He and his staff were so warm and helpful. I’m so appreciative they took the time to see me and do the colonoscopy that I needed.” Not only is Dr. Goldklang dedicated to providing the highest quality consults and diagnostic procedures to patients, he also does so with comforting care and expertise. When our Board reached out to their physician friends for assistance in decreasing our GI waitlist, Dr. Goldklang engaged and encouraged his fellow GI practitioners, resulting in his practice stepping into the gap to provide even more consultations and colonoscopies to our patients.

Dr. Goldklang was the recipient of our Project Access Doctor of the Year award in 2019. When asked about his volunteering with Champions for Health, he said, “Project Access is easy. [PASD Care Management] staff do all the case work for the

specialist’s office — the burden associated with a referral is removed. You get to just do your specialty and Project Access takes care of all the hassles and burdens.”

An easy way to volunteer in your community, helping those who need it, while doing your superhero job. Dr. Goldklang is our GI Champion!

Dr. Goldklang lives in San Diego with Mia, his wife of 27 years, and his two sons and daughter. He loves to travel with his friends and his family. He is very active, whether in surf or on turf: scuba diving, kayaking, whitewater rafting, hiking, and exercising.

Become one of our Champions to help the most vulnerable people in San Diego.

Share your time and talent through Project Access and contact Adama Dyoniziak at (858) 300-2780 or adama.dyoniziak@ championsfh.org. Help us help others by clicking on the “Donate” button at www. championsforhealth.org.

Ms. Dyoniziak is executive director of Champions for Health.

PERSONAL AND PROFESSIONAL DEVELOPMENT

Fully Embodying Being a Doctor: Teaching by Example

By Helane Fronek, MD, FACP, FACPh

I

N MID-JANUARY, I HAD THE OPPORTUNITY TO

volunteer with UC San Diego as vaccines were given to thousands of San Diegans at Petco Park. The operation was extremely well designed and executed. The seemingly endless line of cars entered the tailgating parking lot, where they had their appointments confirmed and continued to the vaccination areas. After receiving their injection, patients were observed for adverse reactions, given information to monitor symptoms and schedule their next injection, and drove off. People were very excited to receive the vaccine they believed would allow them to be protected from this contagious virus and return to life as they knew it. Several people cried with happiness and gratitude.

It felt good to be providing this potentially life-saving treatment.

It also felt good to be part of a community-wide effort by medical professionals coming together for a common purpose and to work alongside people who shared my commitment to improving the health of our community. Given that many of us feel burned out due to changes in the practice of medicine, it was refreshing to interact directly with patients and provide

a straightforward intervention. It brought us back to the reason we went into medicine — to help people. For this reason, many providers volunteered to work even longer shifts and then left with a smile, happy to have contributed to this fulfilling and meaningful effort.

This exciting venture was occurring against the backdrop of the recent riot at the Capitol, and as I looked out at the multitude of people in their cars, I knew there were likely people with every opinion on the matter — those who saw it as insurrection and an attempt to overthrow the government, those who felt it was warranted because of election fraud, and everything in between.

The division in our country has risen to frightening levels. Yet at Petco Park, we were all one again. We were a community of citizens and their healthcare providers, working together to defeat

the pandemic that has cost over 400,000 lives and countless livelihoods, financial futures, educations, and our way of life. The unification was palpable. People smiled and waved to us as they drove off, our discord forgotten for the time.

I encourage everyone to volunteer for this unique opportunity to be part of an impressive, unified effort to end the pandemic’s devastation of our community. As other vaccination centers open, they will need our participation even more.

Being a doctor is a privilege, as we have the ability to make a positive difference in the lives of all of our patients.

This unfortunate situation offers us the chance to do that on a grand scale. It also provides us an opportunity to fully embody our title. The word “doctor” comes from the Latin root docere, which means to teach. With our coordinated effort, we can teach by example to put our differences aside and work toward the common good. Maybe we can end more than the pandemic with our actions.

Dr. Fronek is a clinical professor of medicine at UC San Diego School of Medicine and a Certified Physician Development Coach.

SanDiegoPhysician.org 19

CLASSIFIEDS CLINICAL TRIAL VOLUNTEERS NEEDED PARTICIPATION IN CLINICAL RESEARCH TRIALS: Physicians in the following specialties are needed for participation as Principal or Sub-Investigator in Pharmaceutical sponsored Clinical research trials involving COVID-19 vaccine, RSV vaccine, Flu vaccine, Migraine, Multiple sclerosis, Parkinson’s disease, Asthma, COPD, NASH, Diabetes studies. Prior Clinical Research Experience is preferred but not essential.

Our team of Clinical Research Professionals will conduct the clinical trials under your supervision.

Financial incentives and scientific publication opportunity. Will not take time away from your practice or increase liability. Primary care; Internal medicine; Pulmonology; Dermatology; Neurology; Gastroenterology. Please contact jsaleh@paradigm-research.com or anguyen@paradigm-research.com or Afalconer@ paradigm-research.com.

PHYSICIAN OPPORTUNITIES FAMILY MEDICINE OR INTERNAL MEDICINE PHYSICIAN: TrueCare is more than just a place to work; it feels like home. Sound like a fit? We’d love to hear from you! Visit our website at www.truecare.org.

Under the direction of the Chief Medical Officer and the Lead Physician, ensure the provision of effective quality medical service to the patients of the Health center. The physician is responsible for assuring clinical procedures are continually and systematically followed, patient flow is enhanced, and customer service is extended to all patients at all times.

NEIGHBORHOOD HEALTHCARE MD, FAMILY PRACTICE AND INTERNISTS/HOSPITALISTS: Physicians wanted, beautiful Riverside County and San Diego County- High Quality Family Practice for a private-nonprofit outpatient clinic serving the communities of Riverside County and San Diego County.

Work Full time schedule and receive paid family medical benefits. Malpractice coverage provided. Be part of a dynamic team voted ‘San Diego Top Docs’ by their peers. Please click the link to be directed to our website to learn more about our organization and view our careers page at www.Nhcare.org.

PHYSICIAN WANTED: Samahan Health Centers is seeking a physician for their federally qualified community health centers that emerged over forty years ago. The agency serves low-income families and individuals in the County of San Diego in two (2) strategic areas with a high density population of Filipinos/ Asian and other low-income, uninsured individuals — National City (Southern San Diego County) and Mira Mesa (North Central San Diego). The physician will report to the Medical Director and provide the full scope of primary care services, including but not limited to diagnosis, treatment, coordination of care, preventive care and health maintenance to patients. For more information and to apply, please contact Clara Rubio at (844) 200-2426 EXT 1046 or at crubio@samahanhealth.org.

DEPUTY PUBLIC HEALTH OFFICER - COUNTY OF SAN DIEGO: 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. Salary: $220-230,000 annually and candidates may receive an additional 10% premium for Board Certification and 15% premium for Board Certification and Sub-specialty. For more information click here.

PUBLIC HEALTH MEDICAL OFFICER - COUNTY OF SAN DIEGO: Under the direction of the Deputy Public Health Officer or designee, this position will be responsible for providing medical oversight of health programs and service delivery, and for performing administrative and operational duties that include the guidance and approval of policy and procedure, devel-

20

February 2021

oping strategy, and overseeing quality assurance and quality improvement efforts for County of San Diego health services programs. Salary: $190-200,000 annually and candidates may receive an additional 10% premium for Board Certification and 15% premium for Board Certification and Sub-specialty. For more information click here.

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.

FULL-TIME CARDIOLOGIST POSITION AVAILABLE: Seeking full time cardiologist in North County San Diego in busy established general cardiology practice. EP or Interventional also welcome if willing to hold general cardiology outpatient clinic also at least 50% of time while building practice. Please email resume to jhelmuth1220@gmail.com. Immediate opening.

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.

INTERVENTIONAL PHYSIATRY/PHYSICAL MEDICINE SPECIALIST POSITION AVAILABLE: Practice opportunity for part time interventional physiatry/ physical medicine specialist with well-established orthopeadic practice. Position includes providing direct patient evaluation/care of spine and musculoskeletal cases, coordinating PMR services with all referring providers. Must have excellent interpersonal and communication skills. Office located near Alvarado Hospital. Onsite digital x-ray and emr. Interested parties, please email lisas@sdsm.net.

CARDIOLOGIST WANTED: San Marcos cardiology office looking for a part-time cardiologist. If interested, send CV to evelynochoa2013@yahoo.com or via fax to (760) 510-1811.

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) 2916637/nshields@graybill.org. You may view our open positions at: https://jobs.graybill.org/.

BOARD CERTIFIED OR BOARD-ELIGIBLE PHYSICIAN DERMATOLOGIST: Needed for busy, wellestablished 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.

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 click here.

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

PHYSICIAN POSITIONS WANTED PAIN MANGEMENT POSITION WANTED: Pain Management Physician Position Wanted: Fellowshiptrained at MD Anderson Cancer Center, pain management with anesthesia background physician looking for a private practice, hospital, or academic position.

Skilled in basic and advanced procedures, chronic pain and cancer pain management. Have CA, DEA, and Fluoro licenses. Please call/text (619) 977-6300 or email Ngoc.B.Truong@dmu.edu.

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.

PRACTICES WANTED PRIMARY CARE PRACTICE WANTED: Looking for a retiring physician in an established Internal Medicine or Family Medicine practice who wants to transfer the patient base or sell the practice. Please call (858) 281-1588.

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 TURNKEY OFFICE SPACE FOR RENT NEAR ALVARADO HOSPITAL: Turnkey office space for rent.

Modern, remodeled and clean. We have a little space available or a lot, depending on your needs. We are located near Alvarado hospital. Conference room, nurses station and many exam rooms, along with Doctors and Admin spaces. To inquire or to schedule a showing, please contact Jo Turner (619) 733-4068.

OFFICE SPACE IN POWAY: Office in Poway. Centrally located. Close to Pomerado hospital. Radiology, pharmacy next door. Fully furnished, WiFi included. Three exam rooms, reception area, waiting room. Half days to full time available. Ideal for specialist who wants to expand. Call Dr. Luna if interested: (619) 472-1914.

KEARNY MESA OFFICE FOR SUBLEASE: Kearny Mesa area sublease in our orthopedic office which includes: onsite x-ray available, storage space, space for 1-2 employees and free parking. Can discuss internet, phones, fax line, access to printer/copier, and more.

Please contact Kaye Spotz at kspotz@synergysmg. com for more information.

SUBLEASE IN SHARP HOSPITAL: Sublease of a shared office space on the Sharp Hospital campus a small office on the third floor that is now shared with one other physician. Includes: two exam rooms, an office for the doctor, space for three employees, and a small amount of storage space. Please contact kspotz@synergysmg.com for more information.

REDUCED PRICE - EL CAJON MEDICAL OFFICE BUILDING FOR SALE OR LEASE: 3,700 square foot standalone medical building with 11 exam rooms & huge private parking lot available for sale or lease!

Sink in all exam rooms, nurses station, break room, abundance of storage, etc. Building has been very well cared for and $200,000+ has gone into it since 2006. Prime location only three blocks from I-8 freeway exit right off of Broadway. Property also features oversized lot with 20+ parking spaces. Asking Sale: $950,000. Asking Lease: $5,500/month + NNN. Terms are negotiable. Seller financing is available.

Please contact: Dillon.Myers@TonyFrancoRealty.com | (619) 738-2318.

MEDICAL SUITE AVAILABLE: Modern and luxurious medical suite located in the Scripps Ximed Building, on the campus of Scripps Memorial Hospital available for sublease/ space sharing. The lobby is spacious, and there is a large doctor’s office, staff room and 4 exam rooms. Terms are flexible, available to share part-time, half days or full days 4 exam rooms. Rent depends on usage. For more information, call (858) 550-0330 EXT 106.

ESCONDIDO MEDICAL OFFICE TO SHARE: Medical office space available at 1955 Citracado Parkway, Escondido. Close to Palomar Medical Center-West, Two to three furnished exam rooms, 2 bathrooms, comfortable waiting room, lab space, work area, conference room, kitchen. Radiology and Lab in the medical building. Ample free parking. Contact Jean at (858) 673-9991.

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.

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.

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 half a 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 / 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) 633-6959.

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.

MEDICAL EQUIPMENT / FURNITURE FOR SALE OBGYN RETIRING WITH OFFICE EQUIPMENT FOR DONATION: Retiring from practice and have the following office equipment for donation: speculums, biopsy equipment, lights, exam tables with electric outlets, etc. Please contact kristi.eisenhauermd@ yahoo.com or (760) 753-8413.

MEDICAL EQUIPMENT FOR SALE: 2 Electric tables one midmark, 3 Ultrasounds including high resolution Samsung UG-HE60 with endovag and linear probes, STORTZ hysteroscopy equipment, 2 NOVASURE GENERATORS ,ENDOSEE OFFICE HYSTEROSCOPY EQUIPMENT : NEW MODEL, OLDER MODEL, Cynosure laser equipment:MONALISATOUCH (menopausal atrophy), TEMPSURE Vitalia RF (300 watts!) for incontinence, ENVI for face, Cynosure SculpSure with neck attachment for body contouring by warm sculpting. Please contact kristi.eisenhauermd@yahoo.com or 760-753-8413.

FOR SALE: Nuclear medicine equipment including Ge Millennium MG system, hot lab, and sources Cs-137.

Rod Std 2. Cs-137. DCRS 3. Cs-137. Spot 4. Co-57. Flood sheet. Please contact us at (760) 730-3536 if interested in purchasing, pricing or have any questions.

Thank you.

NON-PHYSICIAN POSITIONS AVAILABLE PART-TIME BILLER POSITION AVAILABLE: Pain Management office looking for a part-time medical biller, will work directly with a variety of payors, healthcare providers and patients through the revenue cycle process to ensure claims are processed and paid in a timely manner, review EOB’s, verifying patient coverage, and assist with patient billing inquiries. Please email your resume to cestrada@ steinermd.com.

of Nursing in Public Health Services (PHS) will lead the clinical nursing enterprise of PHS, serving on the Executive Team of the PHS Department. This position will directly oversee clinical nurse management and all nursing personnel for six programmatic branches within PHS, as well as directly oversee all Public Health Nurse Managers or Leads in each branch. This position will work with Public Health Nurses in other Health and Human Services Agency (HHSA) departments such Aging and Independence Services, Child Welfare Services, and Regional Operations. Additionally, this position will have a dotted reporting line to HHSA’s Chief Nursing Officer and receive direction from the Chief Nursing Officer to HHSA-wide nursing practices. Salary: $124,092.80-$150,822.80 annually.

For more information click here.

PART-TIME BILLER POSITION AVAILABLE: Pain Management office looking for a part-time medical biller, will work directly with a variety of payors, healthcare providers and patients through the revenue cycle process to ensure claims are processed and paid in a timely manner, review EOB’s, verifying patient coverage, and assist with patient billing inquiries. Please email your resume to cestrada@ steinermd.com.

EXECUTIVE DIRECTOR, STUDENT HEALTH AND COUNSELING SERVICES: California State University San Marcos (CSUSM) has announced a national search for a visionary and collaborative leader to serve as Executive Director of Student Health and Counseling Services. Selected candidate will be appointed into an Administrator III OR Administrator IV. Appointment will be determined by education and experience. Selected candidate with an M.D. will be appointed as Administrator IV, and selected candidate without an M.D. will be appointed as Administrator III. For position specifications, benefits summary and to apply, please visit our website at https://apptrkr.com/1852486.

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.

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. Please contact: (619) 913-7568 | info@rudolphia. consulting | www.rudolphia.consulting

DIRECTOR OF NURSING - PUBLIC HEALTH SERVICES - COUNTY OF SAN DIEGO: The Director

SanDiegoPhysician.org 21

$5.95 | www.SanDiegoPhysician.org San Diego County Medical Society 8690 Aero Drive, Suite 115-220 San Diego, CA 92123 [ Return Service Requested ]

Tirelessly defending the practice of

GOOD MEDICINE. We’re taking the mal out of malpractice insurance.

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

See how at thedoctors.com

Exclusively endorsed by

PRSRT STD U.S. POSTAGE

PAID DENVER, CO PERMIT NO. 5377