February 2023

Celebrating Independent Physicians

At the Cooperative of American Physicians (CAP), we celebrate you—the independent and solo practitioner who keeps healthcare personal. We are here to support you with exceptional medical malpractice coverage supplemented by a host of outstanding risk management and practice management services, so you can stay focused on what’s important—patient care.

For over 40 years, CAP has delivered financially secure medical malpractice coverage options and practice solutions to help California physicians realize professional and personal success. Find out what makes CAP different.

CAPphysicians.com

800-356-5672

MD@CAPphysicians.com

More than 12,500 California physicians rely on CAP to protect their practices every day.

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

OFFICERS

President: Toluwalase (Lase) A. Ajayi, MD

President–Elect: Nicholas (dr. Nick) J. Yphantides, MD, MPH

Secretary: Steve H. Koh, MD

Treasurer: Preeti S. Mehta, MD

Immediate Past President: Sergio R. Flores, MD

GEOGRAPHIC DIRECTORS

East County #1: Catherine A. Uchino, MD

East County #2: Rakesh R. Patel, MD

Hillcrest #1: Kyle P. Edmonds, MD

Hillcrest #2: Stephen R. Hayden, MD (Delegation Chair)

Kearny Mesa #1: Anthony E. Magit, MD, MPH

Kearny Mesa #2: Alexander K. Quick, MD

La Jolla #1: Karrar H. Ali, DO, MPH

(Board Representative to the Executive Committee)

La Jolla #2: David E.J. Bazzo, MD, FAAFP

La Jolla #3: Sonia L. Ramamoorthy, MD, FACS, FASCRS

North County #1: Arlene J. Morales, MD

North County #2: Christopher M. Bergeron, MD, FACS

North County #3: Nina Chaya, MD

South Bay #1: Paul J. Manos, DO

South Bay #2: Maria T. Carriedo-Ceniceros, MD

(Board Representative to the Executive Committee)

AT–LARGE DIRECTORS

#1: Thomas J. Savides, MD

#2: Kelly C. Motadel, MD, MPH

#3: Irineo (Reno) D. Tiangco, MD

#4: Miranda R. Sonneborn, MD

#5: Daniel Klaristenfeld, MD

#6: Marcella (Marci) M. Wilson, MD

#7: Karl E. Steinberg, MD, FAAFP

#8: Alejandra Postlethwaite, MD

ADDITIONAL VOTING DIRECTORS

Young Physician: Emily Nagler, MD

Resident Director: Alexandra Kursinskis, MD

Retired Physician: Mitsuo Tomita, MD

Medical Student: Jessica Kim

CMA OFFICERS AND TRUSTEES

President: Robert E. Wailes, MD

Trustee: William T–C Tseng, MD, MPH

Trustee: Sergio R. Flores, MD

Trustee: Timothy A. Murphy, MD

AMA DELEGATES AND ALTERNATE DELEGATES

District I: Mihir Y. Parikh, MD

District I Alternate: William T–C Tseng, MD, MPH

At–Large: Albert Ray, MD

At–Large: Robert E. Hertzka, MD

At–Large: Theodore M. Mazer, MD

At–Large: Kyle P. Edmonds, MD

At–Large: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM

At–Large: David E.J. Bazzo, MD, FAAFP

At–Large: Sergio R. Flores, MD

At–Large Alternate: Bing Pao, MD

CMA DELEGATES

District I: Steven L.W. Chen, MD, FACS, MBA

District I: Franklin M. Martin, MD, FACS

District I: Vimal I. Nanavati, MD, FACC, FSCAI

District I: Peter O. Raudaskoski, MD

District I: Kosala Samarasinghe, MD

District I: James H. Schultz, MD, MBA, FAAFP, FAWM, DiMM

District I: Mark W. Sornson, MD

District I: Wynnshang (Wayne) C. Sun, MD

District I: Patrick A. Tellez, MD, MHSA, MPH

RFS Delegate: Rachel B. Van Hollebeke, MD

FEATURES

4

Paxlovid Has Been Free. Later This Year, Sticker Shock Awaits

By Hannah Recht

6 Behavioral Telehealth Loses Momentum Without a Regulatory Boost

By Darius Tahir

DEPARTMENTS

2 Briefly Noted: SDCMS Membership * Practice Management * Medical Regulations

8 California Attorney General Sues Drugmakers Over Inflated Insulin Prices

By Angela Hart and Samantha Young 10 Healthcare-Related Injury Found in Nearly OneFourth of Hospitalizations

14

The Status of Methamphetamine Use in San Diego County

By San Diego County Meth Strike Force

16

Surgeons Will Probably Want to Avoid This Scrub Color

By Sophie Putka

18

Dementia Tied to Hearing Loss

By Judy George

19

Hip and Knee Replacements: An Examination of Malpractice Claims

By Jacqueline Ross, RN, PhD

20

A Question for Us All: What Do You Want?

By Helane Fronek, MD, FACP, FASVLM, FAMWA 21

Classifieds 16

BRIEFLY NOTED

Dr. James Grisolia Is Chosen As New Chief of Staff at Scripps Mercy Hospital

THE PHYSICIANS of Scripps Mercy Hospital’s San Diego and Chula Vista campuses have elected neurologist James Grisolia, MD, as their chief of staff. Dr. Grisolia took over as head of the 1,100-member physician team on Jan. 1.

As chief of staff for Scripps Mercy Hospital’s two campuses, Dr. Grisolia will serve as a medical staff liaison to administrative staffs at the two locations, as well as to Scripps Health’s board of trustees. During his twoyear term, he will play a key role in driving continuous improvement in the delivery of healthcare services to the more than 200,000 patients who visit the hospital’s two campuses annually. He succeeds the hospital’s outgoing chief of staff, Beverly Harrell-Bruder, MD.

“In addition to the exceptional care he delivers to our patients, Dr. Grisolia has demonstrated exemplary leadership as he enters his 40th year on the hospital’s medical staff,” says Tom Gammiere, Scripps Health’s corporate senior vice president and southern regional chief executive. “His guidance will benefit physicians, staff, and patients alike.”

Dr. Grisolia has been a member of the medical staff at Scripps Mercy Hospital San Diego since 1983 and has served on the medical staff at Scripps Mercy Chula Vista since 1986. Scripps Mercy’s San Diego and Chula Vista campuses previously operated as separate hospitals before merging in 2004 as one hospital and one medical staff on two campuses. Grisolia has been a member of CMA for 44 years.

PRACTICE MANAGEMENT

The Doctors Company Offers Educational Video Series: ‘Financial and Workplace Well-Being for Doctors: Lessons for Life After Medical School’

THE DOCTORS COMPANY, THE nation’s largest physician-owned medical malpractice insurer and part of TDC Group, is offering a new lecture series, “Financial and Workplace Well-Being for Doctors: Lessons for Life After Medical School,” from Ronald H. Wender, MD, FACA, chairman emeritus and professor of anesthesiology at Cedars-Sinai Medical Center and member of The Doctors Company Board of Governors.

The 23-part video series is free and provides renowned experts’ advice about the realities of financial planning, medical malpractice, and hospital economics encountered upon graduating medical school.

The average medical school graduate owes $241,600 in total student loan debt — six times as much as the average college graduate.

In a study published last September, the International Journal of Medical Education found that medical residents and fellows have high debt and low levels of financial literacy. A California Medical Association survey in 2021 found that 64% of physicians expressed a need for financial assistance, and 95% of physician practices reported concern about their financial wellbeing.

“When you leave medical school, you need to be prepared for managing debt, finances, and patients who may sue you; we want medical providers to be ready for these harsh realities,” says Dr. Wender. “In my forty-six years of practice, I saw many healthcare providers overwhelmed with life challenges. I hope this will be a useful resource for new physicians in their future endeavors.”

Find all these insights at www.thedoctors.com/aftermedschool.

Updated Medical Board Notice to Patients Required Effective Now

AS OF JAN. 1, 2023, ALL PHYSICIANS LICENSED BY THE MEDICAL

Board of California must provide an updated “notice to consumers” that informs patients that physicians are licensed and regulated by the medical board, and provides details about how patients can check the status of a license or file a complaint.

Under the new regulation, the notice must be provided in a language understood by the patient or patient representative and include a quick response (QR) code that leads to the board’s Notice to Consumer webpage, and shall contain the following statement:

NOTICE TO PATIENTS

Medical doctors are licensed and regulated by the Medical Board of California. To check up on a license or to file a complaint go to www.mbc.ca.gov, email licensecheck@mbc.ca.gov, or call (800) 633-2322.

Physicians can comply with this requirement by doing one of the following:

1. Post a notice in an area visible to patients on the premises where the physician provides medical services;

2. Provide the patient with a notice and retain in that patient’s medical record an acknowledgement of receipt and understanding, signed and dated by the patient or the patient representative;

3. Include the notice in a statement on letterhead, discharge instructions or other document given to a patient or the patient representative.

The medical board has posted a notice template in the following languages: English, Spanish, Chinese, Vietnamese, Tagalog, Korean, Armenian, Farsi, Arabic, Russian, Japanese, Punjabi, and Khmer.

If the physician chooses to post a sign to comply with the notice requirement, and the sign is not in a language understood by the patient or their representative, then a notice must be provided under option 2 or 3 above in a language understood by the patient or patient representative, so long as the board has provided a translated notice understood by the patient or their representative on its Notice to Consumers webpage.

A physician will be deemed to be in compliance if the hospital, clinic, or other location where the physician is practicing posts the notice on its premises in an area visible to patients consistent with the requirements of the regulation. For more information, see the medical board’s Notice to Consumer webpage.

Paxlovid Has Been Free. Later This Year, Sticker Shock Awaits

By Hannah Recht

NEARLY SIX MILLION AMERICANS HAVE TAKEN

Paxlovid for free, courtesy of the federal government. The Pfizer pill has helped prevent many people infected with COVID-19 from being hospitalized or dying, and it may even reduce the risk of developing long COVID. But the government plans to stop footing the bill within months, and millions of people who are at the highest risk of severe illness and are least able to afford the drug — the uninsured and seniors — may have to pay the full price.

That means fewer people will get the potentially lifesaving treatments, experts say.

“I think the numbers will go way down,” says Jill Rosenthal, director of public health policy at the Center for American Progress, a left-leaning think tank. A bill for several hundred dollars or more would lead many people to decide the medication isn’t worth the price, she explains.

In response to the unprecedented public health crisis caused by COVID, the federal government spent billions of dollars on developing new vaccines and treatments, to swift success: Less than a year after the pandemic was declared, medical workers got their first vaccines. But as many people have refused the shots and stopped wearing masks, the virus still rages and mutates. In 2022 alone, 250,000 Americans have died from COVID, more than from stroke or diabetes.

But soon the Department of Health and Human Services will stop supplying COVID treatments, and pharmacies will purchase and bill for them the same way they do for antibiotic pills or asthma inhalers. Paxlovid is expected to hit the private market in mid-2023, according to HHS plans shared in an October meeting with state health officials and clinicians. Merck’s Lagevrio, a less effective COVID treatment pill, and AstraZeneca’s Evusheld, a preventive therapy for the immunocompromised, are on track to be commercialized sooner, sometime in the winter.

The U.S. government has so far purchased 20 million

courses of Paxlovid, priced at about $530 each, a discount for buying in bulk that Pfizer CEO Albert Bourla called “really very attractive” to the federal government in a July earnings call. The drug will cost far more on the private market, although in a statement to KHN, Pfizer declined to share the planned price. The government will also stop paying for the company’s COVID vaccine next year — those shots will quadruple in price, from the discount rate the government pays of $30 to about $120.

Bourla told investors in November that he expects the move will make Paxlovid and its COVID vaccine “a multibillion-dollar franchise.”

Nearly 9 in 10 people dying from the virus now are 65 or older. Yet federal law restricts Medicare Part D — the prescription drug program that covers nearly 50 million seniors — from covering the COVID treatment pills. The medications are meant for those most at risk of serious illness, including seniors.

Paxlovid and the other treatments are currently available under an emergency use authorization from the FDA, a fast-track review used in extraordinary situations. Although Pfizer applied for full approval in June, the process can take anywhere from several months to years. And Medicare Part D can’t cover any medications without that full stamp of approval.

Paying out of pocket would be “a substantial barrier” for seniors on Medicare — the very people who would benefit most from the drug, wrote federal health experts.

“From a public health perspective, and even from a healthcare capacity and cost perspective, it would just defy reason to not continue to make these drugs readily available,” says Dr. Larry Madoff, medical director of Massachusetts’ Bureau of Infectious Disease and Laboratory Sciences. He’s hopeful that the federal health agency will find a way to set aside unused doses for seniors and people without insurance.

In mid-November, the White House requested that Congress approve an additional $2.5 billion for COVID therapeutics and vaccines to make sure people can afford the medications when they’re no longer free. But there’s little hope it will be approved — the Senate voted that same day to end the public health emergency and denied similar requests in recent months.

Many Americans have already faced hurdles just getting a prescription for COVID treatment. Although the federal government doesn’t track who’s gotten the drug, a Centers for Disease Control and Prevention study using data from 30 medical centers found that Black and Hispanic patients with COVID were much less likely to receive Paxlovid than white patients. (Hispanic people can be of any race or combination of races.) And when the government is no longer picking up the tab, experts predict that these gaps by race, income, and geography will widen.

People in Northeastern states used the drug far more often than those in the rest of the country, according to a KHN analysis of Paxlovid use in September and October. But it wasn’t because people in the region were getting sick from COVID at much higher rates — instead, many of those states offered better access to healthcare to begin with and created special programs to get Paxlovid to their residents.

About 10 mostly Democratic states and several large counties in the Northeast and elsewhere created free “test-totreat” programs that allow their residents to get an immediate doctor visit and prescription for treatment after testing positive for COVID. In Massachusetts, more than 20,000 residents have used the state’s video and phone hotline, which is available seven days a week in 13 languages. Massachusetts, which has the highest insurance rate in the country and relatively low travel times to pharmacies, had the second-highest Paxlovid usage rate among states this fall.

States with higher COVID death rates, like Florida and Kentucky, where residents must travel farther for healthcare and are more likely to be uninsured, used the drug less often. Without no-cost test-to-treat options, residents have struggled to get prescriptions even though the drug itself is still free.

“If you look at access to medications for people who are uninsured, I think that there’s no question that will widen those disparities,” Rosenthal says.

People who get insurance through their jobs could face high copays at the register, too, just as they do for insulin and other expensive or brand-name drugs.

Most private insurance companies will end up covering COVID therapeutics to some extent, says Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms. After all, the pills are cheaper than a hospital stay. But for most people who get insurance

through their jobs, there are “really no rules at all,” she says. Some insurers could take months to add the drugs to their plans or decide not to pay for them.

And the additional cost means many people will go without the medication. “We know from lots of research that when people face cost sharing for these drugs that they need to take, they will often forgo or cut back,” Corlette says.

One group doesn’t need to worry about sticker shock. Medicaid, the public insurance program for low-income adults and children, will cover the treatments in full until at least early 2024.

HHS officials could set aside any leftover taxpayer-funded medication for people who can’t afford to pay the full cost, but they haven’t shared any concrete plans to do so. The government purchased 20 million courses of Paxlovid and 3 million of Lagevrio. Fewer than a third have been used, and usage has fallen in recent months, according to KHN’s analysis of the data from HHS.

Sixty percent of the government’s supply of Evusheld is also still available, although the COVID prevention therapy is less effective against new strains of the virus. The health department in one state, New Mexico, has recommended against using it.

HHS did not make officials available for an interview or answer written questions about the commercialization plans.

The government created a potential workaround when it moved bebtelovimab, another COVID treatment, to the private market this summer. It now retails for $2,100 per patient. The agency set aside the remaining 60,000 government-purchased doses that hospitals could use to treat uninsured patients in a convoluted dose-replacement process. But it’s hard to tell how well that setup would work for Paxlovid: Bebtelovimab was already much less popular, and the FDA halted its use on Nov. 30 because it’s less effective against current strains of the virus.

Federal officials and insurance companies would have good reason to make sure patients can continue to afford COVID drugs: They’re far cheaper than if patients land in the emergency room.

“The medications are so worthwhile,” says Madoff, the Massachusetts health official. “They’re not expensive in the grand scheme of healthcare costs.”

Hannah Recht is a data reporter for Kaiser Health News, where this article first appeared. She was a member of the KHN-AP public health reporting team on the Underfunded and Under Threat project that won the Online News Association’s Award for Investigative Data Journalism and an AAAS Kavli Science Journalism Award.

Behavioral Telehealth Loses Momentum Without a Regulatory Boost

CONTROLLED SUBSTANCES BECAME A LITTLE less controlled during the pandemic. That benefited both patients (for their health) and telehealth startups (to make money).

Some potentially addictive medications — like buprenorphine and Adderall — are now far more available online to patients because of regulatory changes. Given the scarcity of qualified doctors to treat some of the behavioral health conditions associated with these drugs, like opioid use disorder or attention-deficit/hyperactivity disorder, doctors’ new ability to prescribe online or, in some cases, by telephone is a huge change. But easier access to the drugs has both upsides and downsides, since they’re often dispensed without accompanying therapy that improves the odds of a patient’s success.

Pre-pandemic, patients sometimes traveled several hours

By Darius Tahir

for addiction care, says Emily Behar, director of clinical operations for Ophelia, a New York startup serving people with opioid addictions. Or patients might be struggling with multiple jobs or a lack of child care. Such obstacles made sustaining care fraught.

“How do you reach those people?” she asks.

It’s a question preoccupying much of the behavioral health sector, complicated by the reality that most patients with opioid use disorder aren’t in treatment, says Dr. Neeraj Gandotra, chief medical officer of the Substance Abuse and Mental Health Services Administration.

Increased access to telehealth has started to provide an answer. Behar, the startup executive, says its patients can see expert providers at their convenience. Missed appointments are dropping, according to many in the industry.

The startup has secured solid funding — nearly $68 million, according to Crunchbase, an industry database — but addiction specialists and other prescribers of controlled substances online are a mixed group. Some are nonprofits; others are large startups attracting scrutiny from the news media and law enforcement for allegedly sloppy prescription practices.

The influx of new providers is attributable to loosened requirements born of pandemic-era necessity. To help patients get access to care while maintaining physical distance, the Drug Enforcement Administration and SAMHSA waived restrictions on telehealth for controlled substances.

But whether those changes will endure is uncertain. The federal government is working piecemeal to codify new rules for prescribing controlled substances, in light of the healthcare system’s pandemic experience.

On Dec. 13, SAMHSA issued a proposal to codify telehealth regulations on opioid treatment programs — but that affects only part of the sector. Left unaddressed — at least until the DEA issues rules — is the process for individual providers to register to prescribe buprenorphine. The new rules “get us at least a little bit closer to where we need to go,” says Sunny Levine, a telehealth and behavioral health lawyer at the firm Foley & Lardner.

Congress also tweaked rules around buprenorphine, doing away with a long-standing policy to cap the number of

patients each provider can prescribe to. Ultimately, however, the DEA is the main regulatory domino yet to fall for telehealth providers.

In addition, pharmacies are taking a more skeptical stance on telehealth prescriptions — especially from startups. Patients were getting accustomed to using telemedicine to fill and refill their prescriptions for medications for some controlled substances, like Adderall, primarily used to treat ADHD. A shortage of Adderall has affected access for some patients. Now, though, some pharmacies are refusing to fill those prescriptions.

Cheryl Anderson, one Pennsylvanian with ADHD, says she sought online options because of her demanding schedule.

“My husband is frequently out of town, so I don’t have someone to reliably watch the baby to go to an in-person appointment,” she says. It was tough, with three kids, to find the time. Telehealth helped for about half of 2022. Previously, the DEA and state governments imposed tough rules on obtaining controlled substances from online pharmacies.

But in September, after her doctor wrote a refill prescription, she got a phone call saying her local pharmacy wouldn’t dispense medications if the prescription came through telehealth. Other local pharmacies she called took the same position.

Those denials seem to reflect a broader cultural shift in attitudes. Whereas patients and politicians hailed telemedicine at the beginning of the pandemic — first for its safety but also for its increased convenience and potential to extend care to rural areas and neighborhoods without specialists — hints of skepticism are creeping in.

The telehealth boom attracted shady actors. “You had a lot of people who saw an opportunity to do things that were less than scrupulous,” particularly in the behavioral health market, says Michael Yang, a managing partner at the venture capitalist firm OMERS Ventures. Skeptical media coverage has proliferated of startups that, allegedly, shotgun prescriptions for mental health conditions without monitoring patients receiving those medications.

The startups pose quandaries for local pharmacists, says Matt Morrison, owner of Gibson’s Pharmacy in Dodge City, Kansas.

Pharmacists have multiple obligations related to prescriptions, he says: to make sure incoming prescriptions are from legitimate physicians and that they’re connected to an actual health condition before filling the order. The sense around the industry, Morrison explains, is that prescriptions from startups are tricky. They might come from a distant provider, whom the pharmacist can’t contact easily.

Those qualms pose difficulties for addiction treatment. Persuading pharmacists to fill prescriptions is one of the biggest administrative tasks for Ophelia, Behar says. Still,

the shift online has been helpful.

“Telehealth picks up the gaps,” says Josh Luftig, a founding member of CA Bridge, a program based in Oakland, California, that helps patients in emergency departments initiate treatment for substance misuse. The supply of care providers wasn’t enough to meet demand. “Across the board, there’s been a lack of access to treatment in the outpatient setting,” Luftig explains. “Now all they need is a phone and to get to a pharmacy.”

Treatment is more efficient for patient and provider alike, providers say. “The majority of our patients prefer to have a telehealth experience,” he says. “The telehealth appointments are more efficient. It increases the capacity of each person involved.”

Well-established organizations also report success: According to Geisinger, a large mid-Atlantic health system, 94% of participants in one maternity-focused program were compliant, spokesperson Emile Lee says.

Ophelia, which started up just before the pandemic, expected to treat patients both in-office and online. “We have an office in Philadelphia we’ve never used,” Behar says. Now the company labors every few months — in anticipation of the end of state and federal public health emergencies — to make sure that the end of the associated looser rules doesn’t lead to disruptions in care for their patients.

More clarity on the future of online treatment could result from permanent regulations from the DEA. What the agency’s rule — which would create a registration process for providers interested in prescribing controlled substances online — will say is “anyone’s guess,” says Elliot Vice, an executive specializing in telehealth with the trade group Faegre Drinker. That rule has been pending for years. “To see this still not move, it is puzzling,” Vice explains.

The agency, which declined to comment specifically for this article, pointed to previous statements praising increased access to medication-assisted treatment.

“There shouldn’t be any change in the rules for telehealth,” Luftig says. “It would be the most horrific thing in terms of access for our communities. It would be an unmitigated disaster.” Darius Tahir is a correspondent for Kaiser Health News, where this article first appeared. He is based in Washington, DC, and reports on health technology with an eye toward how it helps (or doesn’t) underserved populations; how it can be used (or not) to help government’s public health efforts; and whether or not it’s as innovative as it’s cracked up to be.

California Attorney General Sues Drugmakers Over Inflated Insulin Prices

By Angela Hart and Samantha Young

CALIFORNIA

ATTORNEY GENERAL ROB BONTA

recently sued the six major companies that dominate the U.S. insulin market, ratcheting up the state’s assault on a profitable industry for artificially jacking up prices and making the indispensable drug less accessible for diabetes patients.

The 47-page civil complaint alleges three pharmaceutical companies that control the insulin market — Eli Lilly and Co., Sanofi, and Novo Nordisk — are violating California law by unfairly and illegally driving up the cost of the drug. It also targets three distribution middlemen known as pharmacy benefit managers: CVS Caremark, Express Scripts, and OptumRx.

“We’re going to level the playing field and make this lifesaving drug more affordable for all who need it by putting an end to Big Pharma’s big profit scheme,” Bonta said at a news conference after filing the lawsuit in a state court in Los Angeles. “These six companies are complicit in aggressively hiking the list price of insulin, at the expense of patients.”

In the lawsuit, Bonta argued that prices have skyrocketed and that some patients have been forced to ration their medicine or forgo buying insulin altogether. The attorney general said a vial of insulin, which diabetics rely on to control blood sugar, cost $25 a couple of decades ago but now costs about $300.

A 2021 U.S. Senate investigation found that the price of a long-acting insulin pen made by Novo Nordisk jumped 52% from 2014 to 2019 and that the price of a rapid-acting pen from Sanofi shot up about 70%. From 2013 to 2017, Eli Lilly had a 64% increase on a rapid-acting pen. The investigation implicated drug manufacturers and pharmacy benefit managers in the increases, saying they perpetuated artificially high insulin prices.

“California diabetics who require insulin to survive and who are exposed to insulin’s full price, such as uninsured consumers and consumers with high deductible insurance plans, pay thousands of dollars per year for insulin,” according to the complaint.

Eli Lilly spokesperson Daphne Dorsey said the company is “disappointed by the California attorney general’s false

allegations,” arguing that the average monthly out-of-pocket cost of insulin has fallen 44% over the past five years, and the drug is available to anyone “for $35 or less.”

Mike DeAngelis, a spokesperson for CVS, said the company would vigorously defend itself, explaining that pharmaceutical companies alone set list prices. “Nothing in our agreements prevents drug manufacturers from lowering the prices of their insulin products, and we would welcome such action. Allegations that we play any role in determining the prices charged by manufacturers are false,” he said.

OptumRx, a division of UnitedHealthcare, said it welcomes the opportunity to show California “how we work every day to provide people with access to affordable drugs, including insulin.” And company spokesperson Isaac Sorensen said it has eliminated out-of-pocket costs for insulin.

Other companies targeted in the suit, and the trade associations that represent them, did not immediately respond to inquiries seeking comment, or declined to comment on the lawsuit. Instead, they either blamed one another for price increases or outlined their efforts to lower costs. Costs for consumers vary widely depending on insurance coverage and severity of illness.

California follows other states, including Arkansas, Kansas, and Illinois, in going after insulin companies and pharmaceutical middlemen, but Bonta said California is taking an aggressive approach by charging the companies with violating the state’s Unfair Competition Law, which could carry significant civil penalties and potentially lead to millions of dollars in restitution for Californians.

If the state prevails in court, the cost of insulin could be “massively decreased” because the companies would no longer be allowed to spike prices, Bonta said.

Bonta joins fellow Democratic leaders in targeting the pharmaceutical industry. Gov. Gavin Newsom has launched an ambitious plan to put the nation’s most populous state in the business of making its own brand of insulin as a way to bring down prices for roughly 3.2 million diabetic Californians who rely on the drug.

“Big Pharma continues to put profits over people — driv-

ing up drug prices and restricting access to this vital medicine,” Newsom spokesperson Brandon Richards told KHN. “That is why California is moving toward manufacturing our own affordable insulin.”

By launching an aggressive attack against the pharmaceutical industry, California is also wading into a popular political fight. Many Americans express outrage at drug costs while manufacturers blame pharmacy middlemen and health insurers. Meanwhile, the middlemen point the finger back at drugmakers.

Edwin Park, a California-based research professor with Georgetown University’s Center for Children and Families, said California’s push to enter the generic drug business, while also suing the pharmaceutical industry, could ultimately lead to lower patient costs at the pharmacy counter.

“It can put downward pressure on list prices,” Park said, referring to the sticker price of drugs. “And that can lead to lower out-of-pocket costs.”

There isn’t much transparency in how drug prices are set in the U.S. Manufacturers are predominantly to blame for high drug costs, because they set the list prices, Park said.

A growing body of research also indicates that the pharmaceutical middlemen are a prime driver of high patient drug costs. To lower prices, it’s critical to target the entire supply chain, experts say.

“The list price has definitely gone up,” said Dr. Neeraj Sood, a professor of health policy, medicine, and business at the University of Southern California who has studied drivers of high insulin costs. “But over time a larger share of the money is going to the middlemen rather than the manufacturers.”

Angela Hart, senior correspondent for Kaiser Health News (KHN), where this article first appeared, covers healthcare politics and policy in California and the West, with a focus on California Gov. Gavin Newsom, government accountability, and political influence. Samantha Young, also a senior correspondent for KHN, is an award-winning journalist with 25 years of experience who covers healthcare politics and policy in California, focusing on government accountability and industry influence.

Healthcare-Related Injury Found in Nearly One-Fourth of Hospitalizations

Study Suggests ‘Disturbing’ Rate of Potentially Preventable Errors By

Crystal Phend

NEARLY A QUARTER OF HOSPITAL STAYS involve adverse events from healthcare errors, and nearly one in 10 cause serious harm, according to a study replicating the landmark 1991 Harvard Medical Practice Study (HMPS).

In a random sample of 2,809 admissions at 11 Massachusetts hospitals, 23.6% had at least one adverse event, 32.3% of which required substantial intervention or prolonged recovery, David W. Bates, MD, of Brigham and Women’s Hospital in Boston, and colleagues reported in The New England Journal of Medicine.

Fully 22.7% of the adverse events were judged to be preventable, with a preventable event happening in 6.8% of all

admissions and a serious, life-threatening, or fatal preventable event in 1.0%.

These “disturbing” new findings “suggest that the safety movement has, at best, stalled,” said Donald M. Berwick, MD, MPP, of the Institute for Healthcare Improvement in Boston, in an accompanying editorial.

After the publication

of the 2000 Institute of Medicine report “To Err Is Human: Building a Safer Health System,” built in large part on the 1991 HMPS data, improving patient safety was a priority in U.S. healthcare for a while, Berwick noted, but the decades that followed brought inklings of progress without a firm answer

on whether the national healthcare system is safer since the report rang the alarm.

The study by Dr. Bates and co-authors doesn’t provide the definitive answer either, Dr. Berwick argued, as the methods differed sufficiently from the original to make direct comparison “tempting but ... not warranted.”

The new study, like the one in 1991, randomly sampled admissions but added a trigger tool to help flag suspicious records and looked at certain types of harm that were not examined in the original, such as diagnostic errors and failure to treat decompensating patients. And, of course, the harder one looks for harm, the more one will find, Dr. Berwick noted.

In the 1991 HMPS, the rate of adverse events due to medical management seen in the 51 New York State hospitals evaluated was 3.7%, with 27.6% deemed due to negligence.

Also, “judging ‘preventability’ is not only difficult but may also be misleading,” Dr. Berwick wrote. “The more valuable approach is to regard all injuries as potentially preventable.” Nor did either iteration of the HMPS pay attention to “near misses.”

Bates and co-authors also acknowledged that many aspects of healthcare have changed over the

past 34 years (i.e., in the time since the New York hospital records were first sampled for HMPS in 2018), including the shift to electronic health records and much care moving from the inpatient to ambulatory settings.

Pushing patient safety back to the top of the numerous urgent priorities, like supply-chain shortages and preparedness issues, facing healthcare systems today is a “sacred obligation” for all who sign up to “first do no harm,” Dr. Berwick noted. “Without renewed board and executive leadership and accountability for safety, and without concerted, persistent investment in and monitoring of change, a summary study 34 years from now may again look all too familiar, with millions upon millions of patients, families, and healthcare staff paying the price for inaction.”

The updated HMPS was a retrospective look at 11 hospitals in Massachusetts with the same malpractice insurance carrier (a sponsor of the study) and selected to represent the range of large and small hospitals across three healthcare systems. The random sample of admissions for adult patients occurring in 2018 excluded hospice, rehabilitation, psychiatric care, addiction treatment, and observation-only stays that didn’t cross two mid-

nights. A group of nine trained nurses reviewed the admissions records to identify possible adverse events, defined as “unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment, or hospitalization, or that results in death” and including both errors of omission and commission. After review of confirmed events, a random sample of 10% were reviewed by a second physician.

Adverse event type prevalence tracked with those previously reported, with drug events being most common (39.0% of all events), followed closely by surgical or procedural events (30.4%). Events associated with nursing care, including falls and pressure ulcers, accounted for 15.0% of the total, and healthcare-associated infections represented 11.9%. The surgical events were most likely to be life-threatening, while the infections were most likely to be fatal.

Admissions involved at least one event that caused unnecessary harm but with rapid recovery — defined as significant harm — occurred in 18.6% of all admissions, while the rate of serious adverse events requiring substantial intervention or prolonged recovery was 7.5%, and 1.2% were life-threatening.

Of the seven deaths (0.2%) from adverse events, one was deemed to be preventable.

Patient characteristics associated with higher rates of adverse events included older age, male gender, Black or white versus Asian race, non-Hispanic versus Hispanic ethnicity, and private or Medicare insurance versus Medicaid.

Notably, the larger hospitals had higher adverse healthcare error adverse event rates than the smaller hospitals in the study. That variation from center to center “suggests that if hospitals had data that were more reliable and more routinely collected, it is possible that monitoring could be improved, adverse event rates could be reduced, and improvement strategies could be shared through careful study of interventions,” the researchers wrote.

“Other key organizational elements such as safety culture and strong leadership with respect to safety and quality are also needed to advance performance,” the team wrote. “Our findings are an urgent reminder to all healthcare professionals of the need for continuing improvement in the safety of the care we deliver.”

Crystal Phend is a contributing editor of MedPage Today, where this article first appeared.

The Status of Prescription Drug and Opioid Use in San Diego County

The Status of Prescription

The Status of Prescription Drug and Opioid in San Diego County

The Report Card provides looking at multiple factors are cautioned not to consider presented herein, as well as the direction of trends over All data sources are identified on page 2.

The Status of Prescription Drug and Opioid Use

Indicator

THE REPORT CARD PROVIDES A RANGE OF AVAILABLE DATA ON THE SCALE OF PRESCRIPTION

The Report Card provides a range of available data on the scale of prescription drug misuse by looking at multiple factors and data points over the last five years in San Diego County. Readers are cautioned not to consider a single data point alone, but rather look at all the information presented herein, as well as the direction of trends over time. Additional detailed data is available in the 2022 PDATF Addendum. All data sources are identified on page 2.

Unintentional Prescription Opioid-Caused Death

Note: Count includes bothprescribedandillicitly obtainedpharmaceu

The

1

The Report Card provides a range of available data on the scale looking at multiple factors and data points over the last five years in San Diego County. Readers are cautioned not to consider a single data point alone, but rather look at presented herein, as well as the direction of trends over time. Additional detailed data is available in the 20 All data sources are identified on page 2.

• Rate per 100,000 residents

drug misuse by looking at multiple factors and data points over the last five years in San Diego County. Readers are cautioned not to consider a single data point alone, but rather look at all the information presented herein, as well as the direction of trends over time. Additional detailed data is available in the 2022 PDATF Addendum.

• % of Total Unintentional Prescription Opioid-Caused (excluding fentanyl)

The Status of Prescription Drug and Opioid Use

Unintentional Fentany l-Caused Deaths b

Note: This indicator is a subset ofIndicator 1

2

Status of Prescription Drug and Opioid Use in San Diego County

The Report Card provides a range of available data on the scale of prescription drug misuse by looking at multiple factors and data points over the last five years in San Diego County. Readers are cautioned not to consider a single data point alone, but rather look at all the information presented herein, as well as the direction of trends over time. Additional detailed data is available in the 2022 PDATF Addendum. All data sources are identified on page 2.

• Rate per 100,000 residents

• % of Total Unintentional Prescription Opioid-Caused (Indicator 1)

The Report Card provides a range of available data on the scale of looking at multiple factors and data points over the last five years in are cautioned not to consider a single data point alone, but rather presented herein, as well as the direction of trends over time. Additional detailed data is available in All data sources are identified on page 2.

3 Opioid-Related Emergency Department (ED) Visi

• Rate per 100,000 residents

4. Opioid-Related Hospitalizations c

• Rate per 100,00 Residents

5 11th Graders Self Report of Lifetime Prescription

6 Adult Drug Treatment Admissions

• % of Prescribed and Illicitly Obtained Pharmaceutical Opioids

7 Arrestees Self Report of Prescription Misuse

• Adult

• Juvenile

8 Prescription Drug Pr osecutions e

• Prescription-specific Fraud Charge

• Other Charges with Prescription-Drugs Involved

9 Pharmacy Robberies/Burglar ies f

• Night Break-Ins/Burglaries

• Armed Robberies

10 Pounds of Safely Disposed Medications

• Take Back Events

• Sheriff’s Department Collection Boxes

11 Annual Number of Dispensed Pills Per County Re

• Opioid Prescriptions

• Benzodiazepines

• Stimulants

a. These deaths are unintentional/accidental overdose deaths in which a prescription factor in death. Additionally, these data represent only deaths examined by the 22,000 deaths each year in San Diego County, the Department of the Medical

b. These deaths are accidental overdose deaths in which fentanyl alone or with misused prescription fentanyl caused most of these deaths, in recent years, illicitly

c. Diagnoses are coded for any mention of opioid related disorders (including

Health Care Access and Information (HCAI), Emergency Department and Patient

a. These deaths are unintentional/accidental overdose deaths in which a prescription or illicitly obtained pharmaceutical opioid drug alone or with other drugs and/or alcohol was a causative factor in death. Additionally, these data represent only deaths examined by the County of San Diego Department of the Medical Examiner and those that had toxicology. There are over 22,000 deaths each year in San Diego County, the Department of the Medical Examiner investigates around 3,000 deaths a year.

d The Organized Delivery System Drug-MediCAL (ODS-DMC) implementation account for the increased number of treatment admissions.

a. These deaths are unintentional/accidental overdose deaths in which a prescription or illicitly obtained pharmaceutical opioid drug alone or factor in death. Additionally, these data represent only deaths examined by the County of San Diego Department of the Medical Examiner and 22,000 deaths each year in San Diego County, the Department of the Medical Examiner investigates around 3,000 deaths a year.

b. These deaths are accidental overdose deaths in which fentanyl alone or with other drugs and/or alcohol was a causative factor in death. As opposed to the previous decade in which misused prescription fentanyl caused most of these deaths, in recent years, illicitly manufactured and obtained fentanyl has been responsible for almost all of these deaths

e Prosecution data reported from the San Diego County District Attorney and misdemeanors and infractions within the San Diego City limits. The District Attorney's City of San Diego

b. These deaths are accidental overdose deaths in which fentanyl alone or with other drugs and/or alcohol was a causative factor in death. As misused prescription fentanyl caused most of these deaths, in recent years, illicitly manufactured and obtained fentanyl has been responsible c. Diagnoses are coded for any mention of opioid related disorders (including abuse, dependence, and unspecified use) in the encounter record. Health Care Access and Information (HCAI), Emergency Department and Patient Discharge Data, 2016-2020

c. Diagnoses are coded for any mention of opioid related disorders (including abuse, dependence, and unspecified use) in the enc ounter record. Data Source: California Department of Health Care Access and Information (HCAI), Emergency Department and Patient Discharge Data, 2016-2020

f Federal law enforcement identified organized criminal street gangs as being prosecuted.

d The Organized Delivery System Drug-MediCAL (ODS-DMC) implementation began July 2018 which increased access to treatment facilities throughout account for the increased number of treatment admissions.

a. These deaths are unintentional/accidental overdose deaths in which a prescription or illicitly obtained pharmaceutical opioid drug alone or with other drugs and/or alcohol was a causative factor in death. Additionally, these data represent only deaths examined by the County of San Diego Department of the Medical Examiner and those that had toxicology. There are over 22,000 deaths each year in San Diego County, the Department of the Medical Examiner investigates around 3,000 deaths a year.

d The Organized Delivery System Drug-MediCAL (ODS-DMC) implementation began July 2018 which increased access to treatment facilities throughout San Diego County. This change may account for the increased number of treatment admissions.

a. These deaths are unintentional/accidental overdose deaths in which a prescription or illicitly obtained pharmaceutical opioid drug alone or with other drugs and/or alcohol was a causative factor in death. Additionally, these data represent only deaths examined by the County of San Diego Department of the Medical Examiner and those that had toxicology. There are over 22,000 deaths each year in San Diego County, the Department of the Medical Examiner investigates around 3,000 deaths a year.

e Prosecution data reported from the San Diego County District Attorney and City of San Diego City Attorney are presented as a combined total. misdemeanors and infractions within the San Diego City limits. The District Attorney's office handles all felony matters in the County of San Diego City of San Diego f Federal law enforcement identified organized criminal street gangs as being responsible for the increase in nighttime pharmacy burglaries for prosecuted.

b. These deaths are accidental overdose deaths in which fentanyl alone or with other drugs and/or alcohol was a causative factor in death. As opposed to the previous decade in which misused prescription fentanyl caused most of these deaths, in recent years, illicitly manufactured and obtained fentanyl has been responsible for almost all of these deaths c. Diagnoses are coded for any mention of opioid related disorders (including abuse, dependence, and unspecified use) in the encounter record. Data Source: California Department of Health Care Access and Information (HCAI), Emergency Department and Patient Discharge Data, 2016-2020

b. These deaths are accidental overdose deaths in which fentanyl alone or with other drugs and/or alcohol was a causative factor in death. As opposed to the previous decade in which misused prescription fentanyl caused most of these deaths, in recent years, illicitly manufactured and obtained fentanyl has been responsible for almost all of these deaths

e Prosecution data reported from the San Diego County District Attorney and City of San Diego City Attorney are presented as a combined total. The City Attorney's office prosecutes misdemeanors and infractions within the San Diego City limits. The District Attorney's office handles all felony matters in the County of San Diego and misdemeanors that occur outside the City of San Diego

c. Diagnoses are coded for any mention of opioid related disorders (including abuse, dependence, and unspecified use) in the enc ounter record. Data Source: California Department of Health Care Access and Information (HCAI), Emergency Department and Patient Discharge Data, 2016-2020

f Federal law enforcement identified organized criminal street gangs as being responsible for the increase in nighttime pharmacy burglaries for 2017. Offenders have been arrested and were prosecuted.

d The Organized Delivery System Drug-MediCAL (ODS-DMC) implementation began July 2018 which increased access to treatment facilities throughout San Diego County. This change may account for the increased number of treatment admissions.

d The Organized Delivery System Drug-MediCAL (ODS-DMC) implementation began July 2018 which increased access to treatment facilities throughout San Diego County. This change m account for the increased number of treatment admissions.

e Prosecution data reported from the San Diego County District Attorney and City of San Diego City Attorney are presented as a combined total. The City Attorney's office prosecutes misdemeanors and infractions within the San Diego City limits. The District Attorney's office handles all felony matters in the County of San Diego and misdemeanors that occur outside the City of San Diego f Federal law enforcement identified organized criminal street gangs as being responsible for the increase in nighttime pharmacy burglaries for 2017. Offenders have been arrested and were prosecuted.

e Prosecution data reported from the San Diego County District Attorney and City of San Diego City Attorney are presented as a combined total. The City Attorney's office prosecutes misdemeanors and infractions within the San Diego City limits. The District Attorney's office handles all felony matters in the County of San Diego and misdemeanors that occur outside the City of San Diego

f Federal law enforcement identified organized criminal street gangs as being responsible for the increase in nighttime pharmacy burglaries for 2017. Offenders have been arrested and prosecuted.

2022 PDATF REPORT CARD SNAPSHOT

SAN DIEGO COUNTY

9 out of 10 (93%) opioid-related deaths were due to fentanyl

869% increase

Unintentional Fentanyl-Caused Deaths, 2017 - 2021 in unintentional fentanylcaused deaths between 2017 (84 deaths) to 2021 (814 deaths)

Unintentional Prescription Opioid-Caused Deaths vs. Fentanyl-Caused Deaths, 2017 - 2021

Unintentional Prescription Opioid-Caused Deaths (excluding fentanyl)

What does this mean?

There has been a 52% decrease in unintentional prescription opioid-caused deaths (excluding fentanyl) between 2017 (124) to 2021 (59).

During that same time, unintentional fentanyl-caused deaths have increased by 869% between 2017 (84) to 2021 (814).

Number of Dispensed Pills Per County Resident, Opioids, 2017 - 2021

20172018201920202021

Pounds of Safely Disposed Medications, 2021

13,049 lbs. Take Back Events 13,661 lbs. Sheriff's Department Collection Boxes

There has been a 44% decrease in the annual number of dispensed prescription opioid pills per resident from 2014 (36.5) to 2021 (20.6).

To view the full 2022 PDATF Report Card and access additional information, please visit the www.sdpdatf.org website.

The Status of Methamphetamine Use in San Diego County

The Status of Methamphetamine Use in San Diego County

THE METHAMPHETAMINE STRIKE FORCE (MSF) WAS established by the San Diego County Board of Supervisors in 1996. Today the MSF is a collaboration at federal, state and local levels, with contributions from more than 70 participating agencies. The annual MSF Report Card provides data from 2021 on leading indicators of methamphetamine problems.

The Methamphetamine Strike Force (MSF) was established Board of Supervisors in 1996. Today the MSF is a levels, with contributions from more than 70 participating agencies. The annual MSF 2021 on leading indicators of methamphetamine problems. All data sources are identified

a. These deaths are accidental overdose deaths in which methamphetamine alone or with other drugs and/or alcohol was

b. Diagnoses are coded for any mention of amphetamine misuse and amphetamine dependence in the encounter record; discharges and hospitalizations are in fact methamphetamine. Source: California Department of Health Care Access and Discharge Data, 2009‐2020.

c. The Organized Delivery System Drug‐MediCAL (ODS‐DMC) implementation began July 2018 which increased access to treatment facilities throughout San Diego County. This change may account for the increased number of treatment admissions.

d. This total includes both felony and misdemeanor arrests and citations.

e. When considering Substance Abuse Monitoring (SAM) statistics for 2020, please note that while the interviews were able to continue, administrative procedures and survey methodologies were refined to ensure the health and safety of both the interviewers and those being interviewed. These changes, coupled with changes in terms of who was booked into jails at this time, may affect the statistics presented here and limit the validity of comparisons to prior years.

2022 MSF REPORT CARD SNAPSHOT

SAN DIEGO COUNTY

Unintentional Methamphetamine-Caused Deaths

5 out of 10 (50%) methamphetaminecaused deaths involved fentanyl

179% increase

in unintentional methamphetaminecaused deaths between 2017 (271 deaths) to 2021 (756 deaths)

Relationship Between Unintentional Methamphetamine, Fentanyl, and Alcohol Caused Deaths

What does this mean? Among the 756 unintentional methamphetamine-caused deaths:

50% involved both methamphetamine and fentanyl (n=377)

9% involved methamphetamine, fentanyl, and alcohol (n=66)

Unintentional MethamphetamineCaused Deaths by Age, 2021

5% involved both methamphetamine and alcohol

To view the full 2022 MSF Report Card and access additional information, please visit the www.no2meth.org website.

Surgeons Will Probably Want to Avoid This Scrub Color

Some Survey Respondents Said Black Scrubs Were Deathlike or Resembled a Mortician

By Sophie Putka

CLINICIANS WEARING GREEN SCRUBS WERE most strongly recognized as surgeons, a small survey study found, while black scrubs consistently evoked negative associations.

Of 113 adult patients and visitors who looked at pictures of models in four scrub colors, green was chosen most frequently as strongly identifying male (45.1%) or female (41.6%) examples of surgeons, followed by light blue scrubs, reported Casey Hribar, BS, a medical student at the University of North Carolina at Chapel Hill, and colleagues.

Respondents chose blue scrubs, however, as their top pick for most caring in both male (56.6%) and female (48.7%) clinicians, the group detailed in a JAMA Surgery research letter.

For each trait tested, male and female clinicians wearing black scrubs ranked most negatively among the four scrub colors (the fourth being navy):

• Least caring: male (55.8%), female (58.4%)

• Least trustworthy: male (44.3%), female (54.9%)

• Least knowledgeable: male (44.3%), female (40.7%)

• Least skilled: male (40.7%), female (45.1%)

The scrub color a physician wears can leave a small-yet-important first impression, Hribar told MedPage Today, as verbal, nonverbal, and physical cues all play a role in the doctor-patient relationship.

“We’re spending a lot of money in scrubs for hospital systems, but has anyone stopped to ask the patients?” she said, explaining the impetus for the research.

Participants also characterized their choices, with some finding green to seem janitorial, and “black scrubs to seem like morti-

cians or death,” said Hribar. Scrub colors were selected based on television shows set in hospitals, Hribar said, because not everyone surveyed might have spent time in a hospital setting seeing doctors in scrubs. By looking at shows from M*A*S*H to Grey’s Anatomy to Chicago Med, the researchers hoped to capture scrub colors that participants of different ages might have been exposed to. The four traits were chosen based on what Hribar’s group thought might be “most impactful,” but also what others had examined in prior research.

“There was more and more research coming out about scrubs versus formal attire, or formal attire versus white coats, and it seemed like especially as we got closer to the pandemic ... there was a big transition to scrubs, and patients seemed to be OK with that, especially in procedural settings,” said Hribar. “But that’s kind of where the literature stops.”

Participants were adult patients and visitors at the University of North Carolina Medical Center at Chapel Hill who responded to an electronic survey.

Researchers used Likert-style scales to rank two sets of four images (male and female sets).

Respondents were also stratified by age — 18–30 years (n=24), 31–60 years (n=60), and over 60 years (n=29) — and researchers noted an association between the youngest age group of respondents and selection of least trustworthy for the male models wearing green (41.7%) and blue (29.2%) scrubs, with a similar trend for least caring.

The narrow variety of physician models and age being the only demographic information collected were among the study limitations cited by the authors.

Hribar said that colors worn in hospitals have changed over time to serve various purposes or convey meaning. Early physicians did wear black to signify the formality and seriousness of medical matters. Later, white outfits became a signifier of cleanliness, and a white coat communicated scientific credibility. Increasing efforts have been made to build “humanized” healthcare spaces, with color among the considerations.

But with limited resources, small changes like the color of scrubs could be better than none. “We can’t always change the color of every single wall. We can’t always change that every room has a window,” Hribar said. “But we can take something

that’s super simple and make these tiny adjustments.”

The next step, Hribar said, is to expand the research to include more types of providers and patients. Ultimately, though, she said it could affect system-wide choices. “I think it could scale all the way up to saying we change the way hospitals purchase their scrubs, or the way they assign or don’t assign dress codes.”

Perhaps just as important is clinicians actually knowing how their choices might affect a patient’s perception.

“What if we ask the physicians what they think?” said Hribar. “We might overwhelmingly get a bias in the opposite direction — that they love the black [scrubs] because they hide stains, they’re flattering.”

For now, it’s changed at least one person’s awareness. “It did make me double-take the last time I was ordering scrubs,” said Hribar.

Sophie Putka is an enterprise and investigative writer for MedPage Today, where this article first appeared. Her work has appeared in The Wall Street Journal, Discover, Business Insider, Inverse, Cannabis Wire, and more.

Dementia Tied to Hearing Loss

Likelihood of Developing Dementia Was Lower for Older Adults Who Used Hearing Aids

By Judy George

MODERATE-TO-SEVERE HEARING LOSS WAS linked with a higher prevalence of dementia, a cross-sectional study of Medicare beneficiaries showed.

Among 2,413 older adults in the National Health and Aging Trends Study (NHATS), dementia prevalence among people with moderate-to-severe hearing loss was higher than it was among people with normal hearing (prevalence ratio 1.61, 95% CI 1.09–2.38), reported Nicholas Reed, AuD, of the Johns Hopkins Bloomberg School of Public Health in Baltimore, and colleagues.

But among people with moderate-to-severe hearing loss in the study, hearing aid use was associated with a lower prevalence of dementia compared with no hearing aid use (prevalence ratio 0.68, 95% CI 0.47-1.00), they wrote in a JAMA research letter.

The findings support a recent systematic review and metaanalysis that showed treating hearing loss led to cognitive benefits. They also support the availability of over-the-counter hearing aids, which people with mild-to-moderate hearing loss now can purchase directly due to new regulations.

Reed and colleagues used data from the continuous NHATS panel study of Medicare beneficiaries. The NHATS cohort was oversampled for age (53.3% were 80 or older) and race (18.8% were Black). Participant information was collected through in-home interviews.

Hearing was assessed with a portable audiometer. Researchers calculated a pure tone average in the better-hearing ear as the mean of four frequencies — 500, 1,000, 2,000, and 4,000 Hz — most important for understanding speech.

Normal hearing was defined as a pure tone average of 25 dB or less; mild hearing loss was 26–40 dB; and moderateto-severe loss was over 40 dB. About a third of participants (33.47%) had normal hearing after weighting; 36.74% had mild hearing loss, and 29.79% had moderate-to-severe loss. People with moderate-to-severe hearing loss tended to be older, male, and white, and had less education than others.

The weighted prevalence of dementia was 10.27% overall. Dementia prevalence rose as severity of hearing loss increased: for normal hearing, it was 6.19%; for mild hearing

loss, it was 8.93%; and for moderate-to-severe hearing loss, it was 16.52%.

The study’s cross-sectional design was a limitation. In addition, nursing home and residential care residents were excluded from the analysis because the researchers did not have cognitive data about them.

The top modifiable risk factor for dementia prevention is hearing loss, which accounts for 8% of the global dementia burden, according to a recent Lancet Commission report.

“This study refines what we’ve observed about the link between hearing loss and dementia, and builds support for public health action to improve hearing care access,” co-author Alison Huang, PhD, also of Johns Hopkins, said in a statement.

How hearing loss is linked to dementia isn’t clear, and studies point to several possible mechanisms. “Mediation analyses to characterize mechanisms underlying the association and randomized trials to determine the effects of hearing interventions on reducing dementia risk are needed,” Reed and colleagues wrote.

Information about hearing loss treatment and cognition from the three-year randomized ACHIEVE trial is expected later this year.

Judy George is deputy managing editor of MedPage Today, where this article first appeared. She covers neurology and neuroscience news, writing about brain aging, Alzheimer’s, dementia, MS, rare diseases, epilepsy, autism, headache, stroke, Parkinson’s, ALS, concussion, CTE, sleep, pain, and more.

Hip and Knee Replacements

An Examination of Malpractice Claims Against Orthopedic Surgeons from the Ambulatory and Inpatient Settings

By Jacqueline Ross, RN, PhD

MORE THAN ONE MILLION TOTAL HIP AND knee replacements are completed annually in the United States. Dramatic increases are projected for both the total number of procedures and the proportion of procedures performed in the ambulatory setting.

The literature related to malpractice claims comparing inpatient and ambulatory knee and hip replacements has so far been limited. Therefore, the purpose of this novel study was to explore potential differences between the two settings in malpractice claims for surgery.

Study Design

The sample of 453 claims included all closed, coded malpractice claims in The Doctors Company database during the loss years between 2009 and 2019 where an orthopedic surgeon was the primary responsible party and the claim involved hip or knee replacement. The sample was also limited to cases that concerned either improper performance of surgery or the improper management of the patient. Major injury, gender, and age of the patient, final diagnosis, location of injury, and contributing factors (risk management issues) were included.

Results

• The top three major intraoperative injuries were related to an aggravated or worsened preoperative condition, like pain or mobility (19%), nerve damage (16 percent), and/or postoperative pain (13%).

• Infections, including nosocomial infections, were more common in the ambulatory setting. One reason may be related to a need for greater compliance with the protocol for antibiotic dosing — individuals having ambulatory procedures often must take the third of three doses at home, and may be less adherent to their medication regimen than their inpatient counterparts.

• The contributing factors of communication between the patient and provider and patient assessment issues both appeared more frequently in claims deriving from the ambulatory setting. This finding presents an opportunity for practices to consider how they create opportunities for physicians to establish rapport and pursue shared decision making.

Conclusion

For both inpatient and outpatient settings, the study’s findings reinforce the necessity of upfront communication with patients about risks, and reveal how actions taken before surgery can influence outcomes after. Specifically, this study identifies risks related to potential gaps in patient prescreening and patient selection. These findings also emphasize the risk-reduction benefits of engaging in a complete process of patient preoperative optimization, which includes focusing on modifiable risk factors and setting expectations with the patient and family.

Claims against providers in the ambulatory setting, though, were far likelier to involve issues with patient assessment and/or communication. This is perhaps unsurprising, as both may be easier when the patient is hospitalized. Among other modifications, ambulatory providers might consider adding a telemedicine visit during the first few days following a joint replacement. This provides an opportunity to assess the patient’s postoperative status, review expectations

for recovery, and ensure the patient understands their postoperative plan of care.

Increasing understanding of where breakdowns in pre- and post-procedure patient assessment and communication are occurring can assist providers in evaluating and addressing these gaps as needed in their own practices. Physicians cannot always avoid complications, but effective communication with patients may help to avoid both errors and claims.

Read the full study at www.thedoctors.com/hipandknee.

Author’s Note: 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.

Jacqueline Ross is coding director in the department of Patient Safety and Risk Management for The Doctors Company.

A Question for Us All: What Do You Want?

By Helane Fronek, MD, FACP, FASVLM, FAMWA

intelligent course toward it. On beginning a career in medicine, many choose a specialty based on someone we admired, because the physiology was intriguing, or we enjoyed the available treatments. Unfortunately, the reality of practice often conflicts with other things in life we want, and we become disillusioned.

We often look at retirement the same way: We believe a life of golf, travel, volunteer work, or reading will provide a sustainably enjoyable experience, but many physicians “fail” at retirement because they fail to understand what they actually want.

experiences make you feel good about others? What subjects hold the greatest interest for you and what activities involve them?

What aspects of your life, education, or career brought you a sense of achievement or a sense of triumph over challenge?

In what situations do you feel a sense of belonging? Where or with whom do you feel most authentic? These are situations that you will want to include in your ideal life.

A HIGHLIGHT OF NEW YEAR’S EVE WAS THE opportunity to speak with the young adult children of dear friends, and to experience what kind, thoughtful, and engaged people they have become. In discussing the circuitous route one had taken to finally reach her enjoyable career, I recalled what Arthur C. Brooks, professor of leadership and management practice and author of Love Your Enemies, mentioned during an interview. Too often, he said, young people are asked what they want to do in their life. A better question, he offered, would be to ask what they want.

At some point in nearly every coaching session, I end up asking my clients, “What do you want?” And nearly every time I ask, I’m met with silence. They eventually respond by saying, “That’s a great question.” In my mind, it’s the question.

Until we know what we want, we cannot begin to plot an

What if we began by asking ourselves what we want, then created a life based on that? Here are some prompts that will assist you with this inquiry.

In your life, what experiences brought you your greatest moments of joy? What was present in those experiences that created that sense of delight? What experiences make you feel good about yourself? What

Then, consider your core values and your personality characteristics. If family is an important value, being away from the people you love will cause significant stress. If adventure is important to you, staying home too much will deprive you of this essential aspect of life. If you’re an extrovert, you’ll need to include lots of group activities. Introverts will require quiet or alone time to make their life work.

As we kick off the new year, let’s take some time to discover what we want. (This makes a great family, couple, or friend activity.) Then, we can intelligently construct a year filled with activities, interactions, and experiences that will guarantee that 2023 will feel enjoyable, stimulating, and fulfilling.

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

CLASSIFIEDS

VOLUNTEER OPPORTUNITIES

PHYSICIANS: HELP US HELP IMPROVE THE HEALTH LITERACY OF OUR SAN DIEGO COUNTY COMMUNITIES by giving a brief presentation (30–45 minutes) to area children, adults, seniors, or employees on a topic that impassions you. Be a part of Champions for Health’s Live Well San Diego Speakers Bureau and help improve the health literacy of those with limited access to care. For further details on how you can get involved, please email Andrew.Gonzalez@ ChampionsFH.org.

CHAMPIONS FOR HEALTH - PROJECT ACCESS SAN DIEGO: Volunteer physicians are needed in the following specialties: endocrinology, rheumatology, vascular surgery, ENT or head and neck, general surgery, GI, and gynecology. These specialists are needed in all regions of San Diego County to provide short term pro bono specialty care to adults ages 26-49 who are uninsured and not eligible for Medi-Cal. Volunteering is customized to fit your regular schedule in your office. Champions for Health is the foundation of the San Diego County Medical Society. Join hundreds of colleagues in this endeavor: Contact Evelyn.penaloza@championsfh.org or at (858) 300-2779.

PHYSICIAN OPPORTUNITIES

MEDICAL DIRECTOR, FULL-TIME, FATHER JOE’S VILLAGES: Join us in ending homelessness! We are a dynamic team that runs an FQHC. The Medical Director oversees clinical aspects of the primary care, psychiatry, dental and behavioral health. This position will be a mix of clinic and admin time and will have direct reports (Dental Director, Director of Behavioral Health, and frontline primary care/psychiatry providers). Reports to the Chief Medical Officer, who is responsible for all aspects of the clinic. The Medical Director is a counterpart to the Clinic Director (who oversees admin staff, MA/RN team, billing, PSRs, etc.). To apply, visit https://my.neighbor.org/jobs-careers.

SEEKING MEDICAL DIRECTOR: subcontracted position 4-8 hours per month. Responsibilities:

1. Support case conferences, refractory SUD, co-occurring conditions, specialty populations.

2. Conduct clinical trainings on issues relevant to staff (e.g., documentation, ASAM Criteria, DSM-5, MAT, WM, co-occurring conditions).

3. Provide oversight and clinical supervision. 4. Refer co-occurring conditions. 5. Lead Quality Improvement functions (e.g., Quality Improvement Projects, clinical team meetings, etc.) 6. Attend annually 5 hours of continuing medical education on addiction medicine. Required by contract with San Diego County BHS, position is for a Physician licensed by CA Medical Board or CA Osteopathic Medical Board. Contact Name: Jennifer Ratoff: e-mail: jratoff@secondchanceprogram.org, phone: 619-839-0950

PSYCHIATRIST SPECIALIST: The County of San Diego is currently accepting applications from qualified candidates. Annual Salary: $258,294.40. Note: An additional 10% is paid for Board Certification, or 15% for Board Certification that includes a subspecialty. Why choose the County?

high–quality care to our patients. We provide a competitive salary, paid time off, health insurance, 401K benefits, etc. We provide plenty of opportunities to refine your clinical competency. Our CEO Dr. Venu Prabaker who has 30 years of teaching experience as a faculty at multiple universities Including Stanford, UCSD, USC, Midwestern, Western, Samuel Merritt, Mayo, etc. — will be providing teaching rounds once a week. You will also get plenty of opportunities to attend other clinical lectures at many of the 4- to 5-star restaurants in San Diego. We also have a weekly one-hour meeting for all the staff for team building and to create a “family atmosphere” to improve productivity and thereby create a win-win situation for all. Visit us at caremd.us.

RADY CHILDREN’S HOSPITAL PEDIATRICIAN POSITIONS: Rady Children’s Hospital of San Diego seeks board-certified/eligible pediatricians or family practice physicians to join the Division of Emergency Medicine in the Department of Urgent Care (UC). Candidate will work at any of our six UC sites in San Diego and Riverside Counties. The position can be any amount of FTE (full-time equivalent) equal to or above 0.51 FTE. Must have an MD/DO or equivalent and must be board certified/eligible, have a California medical license or equivalent, PALS certification, and have a current DEA license. Contact Dr. Langley glangley@rchsd.org and Dr. Mishra smishra@rchsd.org.

PER DIEM OBGYN LABORIST POSITION AVAILABLE: IGO Medical Group is seeking a per diem laborist to cover Labor and Delivery and emergency calls at Scripps Memorial Hospital in La Jolla. 70 deliveries/ month. 24-hour shifts preferred but negotiable. Please send inquiries by email to IGO@IGOMED.com.

MEDICAL CONSULTANT, SAN DIEGO COUNTY: The County of San Diego, Health and Human Services Agency’s Public Health Services is looking for a Board Certified Family Practice or Internal Medicine physician for the Epidemiology and Communicable Disease Division. Under general direction, incumbents perform a variety of duties necessary for the identification, diagnosis, and control of communicable diseases within the population. This position works closely with the medical and laboratory community, institutional settings, or hospital control practitioners. Learn more here: https://www.governmentjobs.com/careers/ sdcounty?keywords=21416207

KAISER PERMANENTE SAN DIEGO PER DIEM PHYSIATRIST: Southern California Permanente Medical Group is an organization with strong values, which provides our physicians with the resources and support systems to ensure they can focus on practicing medicine, connecting with one another, and providing the best possible care to their patients. For consideration or to apply, visit https://scpmgphysiciancareers.com/specialty/physical-medicine-rehabilitation. For questions or additional information, please contact Michelle Johnson at 866-5031860 or Michelle.S1.Johnson@kp.org. We are an AAP/EEO employer.

patient relationships and referral streams. Consistent total gross income of $600,000 for the past couple years; even through pandemic. Located in a professional-medical building with professional contract staff. All records and billing managed by a professional service who can assist with insurance integration. Office, staff & equipment are move-in ready. Seller will assist buyer to ensure a smooth transition. Being on-call optional. Contact Ferdinand @ (858) 752-1492 or ferdinand@ zybex.com.

OTOLARYNGOLOGY HEAD & NECK SURGERY SOLO PRACTICE

FOR SALE: Otolaryngology Head & Neck Surgery solo practice located in the Ximed building on the Scripps Memorial Hospital La Jolla campus is for sale. The office is approximately 3,000 SF with 1 or 2 physician offices. It has 4 fully equipped exam rooms, an audio room, one procedure room, one conference room, one office manager room as well as inhouse billing section, staff room, and a bathroom. There is ample parking for staff and patients with close access to radiology and laboratory facilities. For further information please contact Christine Van Such at (858) 354-1895 or email: mahdavim3@gmail.com.

OFFICE SPACE / REAL ESTATE AVAILABLE

PHYSICIAN OFFICE SPACE FOR LEASE: 1500 Sq ft. 3 exam room. Large private office. Large reception area and patient prep room. New upgraded flooring. Private entrance. Located in Rancho Bernardo in prime central location. Easy access to interstate 15. Palomar /Pomerado within 10 min. Security card access during off hours. $2500/month. Contact: (619) 585-0476. Ask for Peg.

HILLCREST OFFICE TO SUBLEASE OR SHARE: Gorgeous office located across from Scripps Mercy hospital. Office is approximately 2000 sq. ft. with procedure/effusion room. Office is fully staffed and looking to add a new provider. We currently have Rheumatology/ Pulmonary/Allergy specialists but can accommodate any specialty or Internal Medicine. Multiple days per week and full use of office is available. If interested please reach out to Melissa Coronado at Melissa@ sdpulmonary.com or call (619) 819-7224.

HILLCREST OFFICE TO SUBLEASE OR SHARE: Beautifully appointed office in Hillcrest next to Mercy Hospital to sublease or share. Office is approximately 1500 sq feet and has AAAASF certified operating room to share or use as needed. Currently occupied by plastic surgery, the office is ideal for Dermatology, Gynecology, Podiatry, or other specialty. Multiple days per week full use of office available as needed. Please contact amez.cookie@gmail.com or at (619) 961-7200.

SUBLEASE AVAILABLE: Sublease available in Del Mar off 5 freeway. Share rent. 2100 sq ft office in professional building. Utilities included. Great opportunity in a very desirable area. (858) 342-3104.

1. Fully paid malpractice insurance.

2. 13 paid holidays.

3. 13 sick days per year. 4. Vacation: 10 days (1-4 years of service); 15 days (5-14 years of service; 20 days (15+ years). 5. Defined benefit retirement program. 6. Cafeteria-style health plan with flexible spending.

7. Wellness incentives. Psychiatrist-Specialists perform professional psychiatric work involving the examination, diagnosis, and treatment of specialty forensics, children/adolescents and or geriatric patients. This is the specialty journey level class in the series that requires a fellowship or experience in child and adolescent psychiatry or forensic psychiatry. For more information visit our website at sandiegocounty. gov/hr.

PRIMARY CARE PHYSICIAN: Imperial Valley Family Care Medical Group is looking for Board Certified/Board Eligible Primary Care Physician for their clinics in Brawley & El Centro CA. Salaried/full time position. Please fax CV/salary requirements to Human Resources (760) 355-7731. For details about this and other jobs please go to www. ivfcmg.com.

ASSISTANT, ASSOCIATE OR FULL PROFESSOR (HS CLIN, CLIN X, ADJUNCT, IN-RESIDENCE) MED-GASTROENTEROLOGY: Faculty Position in Gastroenterology. The Department of Medicine at University of California, San Diego, Department of Medicine (http://med.ucsd. edu/) is committed to academic excellence and diversity within the faculty, staff, and student body and is actively recruiting faculty with an interest in academia in the Division of Gastroenterology. Clinical and teaching responsibilities will include general gastroenterology. The appropriate series and appointment at the Assistant, Associate or Full Professor level will be based on the candidate’s qualifications and experience. Salary is commensurate with qualifications and based on the University of California pay scales. In-Residence appointments may require candidates to be self-funded. For more information: https:// apol-recruit.ucsd.edu/JPF03179 For help, contact: klsantos@health. ucsd.edu.

CARDIOLOGIST POSITION AVAILABLE: Cardiology office in San Marcos seeking part-time cardiologist. Please send resume to albertochaviramd@yahoo.com.

DERMATOLOGIST NEEDED: Premier dermatology practice in La Jolla seeking a part-time BC or BE dermatologist to join our team. Busy practice with significant opportunity for a motivated, entrepreneurial physician. Work with three 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/surgical and cosmetic dermatology in an updated medical office with state-of-the art tools and instruments. Incentive plan will be a percentage based on production. If you are interested in finding out more information, please forward your C.V. to jmaas12@hotmail.com.

INTERNAL MEDICINE PHYSICIAN: Healthcare Medical Group of La Mesa located at 7339 El Cajon Blvd is looking for a caring, compassionate, and competent physician for providing primary care services. We require well-organized and detail-oriented with excellent written and oral communication skills, and excellent interpersonal skills to provide

PRIMARY CARE PHYSICIAN POSITION: San Diego Family Care is seeking a Primary Care Physician (MD/DO) at its Linda Vista location to provide direct outpatient care for acute and chronic conditions to a diverse adult population. San Diego Family Care is a federally qualified, culturally competent and affordable health center in San Diego. Job duties include providing complete, high quality primary care, and participation in supporting quality assurance programs. Benefits include flexible schedules, no call requirements, a robust benefits package, and competitive salary. If interested, please email CV to sdfcinfo@ sdfamilycare.org or call us at (858) 810- 8700.

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.

PUBLIC HEALTH LABORATORY DIRECTOR: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a qualified individual to work for a Level 3 Public Health Laboratory. The Public Health Services department, part of the County’s Health and Human Services Agency, is a local health department nationally accredited by the Public Health Accreditation Board and first of the urban health departments to be accredited. Public Health Laboratory Director-21226701UPH

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.

PRACTICE FOR SALE

GASTROENTEROLOGY GI PRACTICE FOR SALE: Looking to expand or move? Established 25+ years Gastroenterology GI office practice for sale in beautiful San Diego County, California. 500 active strong

CHULA VISTA MEDICAL OFFICE: Ready with 8 patient rooms, 2000sf, excellent parking ratios, Lease $4,000/mo. No need to spend a penny. Call Dr. Vin, (619) 405-6307 vsnnk@yahoo.com

OFFICE SPACE AVAILABLE IN BANKERS HILL: Approximately 500sq foot suite available to lease, includes private bathroom. Located at beautiful Bankers Hill. For more details, please call Claudia at (619) 501-4758.

OFFICE AVAILABLE IN MISSION HILLS, UPTOWN SAN DIEGO: Close to Scripps Mercy and UCSD Hillcrest. Comfortable Arts and Crafts style home in upscale Mission Hills neighborhood. Converted and in use as medical/surgical office. Good for 1-2 practitioners with large waiting and reception area. 3 examination rooms, 2 physician offices and a small kitchen area. 1700 sq. ft. Available for full occupancy in March 2022. Contact by Dr. Balourdas at greg@thehanddoctor.com.

OFFICE SPACE IN EL CENTRO, CA TO SHARE: Office in El Centro in excellent location, close to El Centro Regional Medical Centre Hospital is seeking doctors of any specialty to share the office space. The office is fully furnished. It consists of 8 exam rooms, nurse station, Dr. office, conference room, kitchenette and beautiful reception. If you are interested or need more information, please contact Katia at (760) 427-3328 or email at Feminacareo@gmail.com.

OFFICE SPACE/REAL ESTATE WANTED

MEDICAL OFFICE SPACE WANTED IN HILLCREST/BANKERS

HILL AREA. Mercy Physicians Medical Group (MPMG) specialist is looking for office space near Scripps Mercy Hospital. Open to lease or share office space, full time needed. Please respond to rjvallonedpm@ sbcglobal.net or (858) 945-0903.

NON-PHYSICIAN POSITIONS AVAILABLE

OFFICE MANAGER: 1. Hiring, training, managing staff on procedures/ policies. Monitors continuing compliance and office statistics. Oversee stocking/maintenance of supplies, retail. Equipment/facilities management. Daily bookkeeping, collections. 2. Ensure smooth/ efficient patient flow with increasing production/collections. 3. Create a friendly environment where patients expectations are exceeded, where staff can work together as a team. 4. Ensure staff working at maximum productivity/efficiency. Salary: $60-70K depending on experience/qualifications. Benefits: healthcare reimbursement, PTO, retirement, employee discount, bonuses, commission. Contact: info@ manageyourage.com.

ASSISTANT PUBLIC HEALTH LAB DIRECTOR: The County of San Diego is currently accepting applications for Assistant Public Health Lab Director. The future incumbent for Assistant Public Health Lab Director will assist in managing public health laboratory personnel who perform laboratory activities for the purpose of identifying, controlling, and preventing disease in the community, as well as assist with the development and implementation of policy and procedures relating to the control and prevention of disease and other health threats. Please visit the County of San Diego website for more information and to apply online.