March 2020 by San Diego Physician

MARCH 2020

Official Publication of SDCMS

ars

Celebrating 150 Ye

How to

BUILD TRUST

in 15-Minute Office Visits

150th ANNIVERSARY

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

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

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

March 2020

Contents MARCH

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

VOLUME 107, NUMBER 3

feature:

How to Build Trust in 15-Minute Office Visits By Hans Duvefelt, MD

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

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

Departments 2

How to Talk to Patients About Nutrition, Diet, and Preventing Heart Disease By Kerin Torpey Bashaw, MPH, RN

Briefly Noted: Calendar • Advocacy • Medical School • Public Health • State Healthcare Services

The Key Role of Women in San Diego Medicine and SDCMS Over the Past 150 Years By Holly B. Yang, MD, and Sue Fledderjohn

Coronavirus Transmission Clues: The Nose Knows By Molly Walker

What Do You Really Know? By Helane Fronek, MD, FACP, FACPh

March Is Colorectal Cancer Awareness Month By Adama Dyoniziak

Physician Classifieds

Involuntary Enlightenment By Daniel J. Bressler, MD, FACP

SanDiegoPhysician.org 1

ADVOCACY

CALENDAR

MAR 12–13 Future of Individualized Medicine, Hosted by Scripps Research Translational Institute, Samuel H. Scripps Auditorium, La Jolla MAR 28 6–9 p.m. 2nd Annual Champions for Health Soirée: “Waves of Wellness,” Birch Aquarium, La Jolla APR 2–5 California Society of Anesthesiologists Annual Meeting, Paradise Point Resort, San Diego JUN 19 6–10:30 p.m. Save the Date! SDCMS 150th Anniversary “Rendezvous” Gala, The Abbey on 5th, San Diego

Protect Healthcare Cost and Access for All, Oppose the So-Called ‘Fairness for Injured Patients Act’ By California Medical Association Staff LATE LAST YEAR, WEALTHY OUT-OF-STATE TRIAL ATTORNEYS FILED

an initiative for the November 2020 ballot that would substantially raise healthcare costs for all Californians, reduce access and exploit patients for profit. While most reporting to date has focused on the proposed changes to California’s existing law, the Medical Injury Compensation Reform Act (MICRA), this misguided initiative would effectively eliminate California’s medical lawsuit limits to create new financial windfalls for California’s trial lawyers. Proponents of this measure must collect 623,212 valid signatures, which must be verified no later than June 25, 2020. Recent reports show that they’re on track to meet those numbers and qualify for the November ballot, which is why we need your commitment to oppose this dangerous initiative now more than ever. In 2014, our coalition fought and handedly defeated Prop. 46, clearly saying NO to changes in MICRA that would have quadrupled the cap on non-economic damages. This measure goes far beyond what Proposition 46 would have done and the cost to taxpayers would be substantially greater. As recently noted by the independent Legislative Analyst Office, the “Fairness for Injured Patients Act” (FIPA) will cost California taxpayers tens of millions “to high hundreds of millions of dollars annually” in healthcare costs. Proposition 46 taught us the power of a strong coalition, and this time around it will be even more important. To learn more about the new initiative, and to donate to the No campaign, please visit www. protectmicra.org.

MEDICAL SCHOOL

Medical Students Learn About Public Policy on Sacramento Trip Robert Hertzka, MD, Dr. Alex Quick (SDCMS Board member), and Paul Hegyi, CEO of the San Diego County Medical Society, led a delegation of a dozen San Diego medical students to Sacramento to meet with key state legislators and witness the public policy process firsthand. Above: (left to right) Claire Conklin, Dr. Alex Quick, Celina Nguyen, David Reynoso, Lauren Tronick, Shelby Warren, Assemblywoman Lorena Gonzalez, Dr. Robert Hertzka, Alexandra Muise, Alec Terrana, Alice Shen, Patrick Loehr, Olivia La Monte, Jack Olmstead Left: (left to right) Jack Olmstead, Alexandra Muise, Dr. Alex Quick, Celina Nguyen, Claire Conklin, Shelby Warren, Alec Terrana, Senator Brian Jones, Olivia La Monte, Alice Shen, Dr. Robert Hertzka, Patrick Loehr, Lauren Tronick, David Reynoso, Paul Hegyi

March 2020

PUBLIC HEALTH

SDCMS Joins Councilman Cate and Supervisor Fletcher and Community Leaders in Educating and Reassuring Public on Coronavirus

Dr. Will Tseng, Chair of the San Diego County Medical Society’s Communications Committee, joined San Diego City Councilman Chris Cate, San Diego County Supervisor Nathan Fletcher, and community leaders at a press conference in the Convoy District to encourage the public to get the facts about coronavirus and reassure people that it is safe to shop, eat at, and frequent Asian-American businesses in the Convoy area.

STATE HEALTHCARE SERVICES

CMA Applauds Appointment of CMA Member Bradley Gilbert as Director of CA Dept. of Health Care Services By California Medical Association Staff

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

THE CALIFORNIA MEDICAL ASSOCIATION (CMA) APPLAUDED GOVERNOR

Gavin Newsom’s appointment of Bradley P. Gilbert, MD, as director of the California Department of Health Care Services (DHCS). “We are pleased to see the appointment of someone so dedicated to public health and Medi-Cal as Dr. Gilbert to this prestigious position,” says CMA President Peter Bretan, MD. “Because of his experience leading a local Medi-Cal plan, as a county public health director and as a practicing physician, Dr. Gilbert is uniquely qualified for this role and we are excited to see the ways in which he can help expand access to care for the millions of Californians across the state who receive their care through Medi-Cal.” Dr. Gilbert has been a member of CMA since 1989 and has served as a retired annuitant at the Inland Empire Health Plan since 2019, where he has held several positions since 1996, including medical director, chief medical officer and chief executive officer. He was director of public health at the County of Riverside Health Services Agency Department of Public Health from 1993 to 1996. Dr. Gilbert was director of public health at the San Mateo County Department of Health Services Division of Public Health. He is a board member of the California Healthcare Foundation, Planned Parenthood, and Manifest Medex.

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///////////////////////////////////////////// HOW TO BUILD TRUST IN 15-MINUTE OFFICE VISITS

Patients Need to Feel Like Youâ&#x20AC;&#x2122;re Their Ally

By Hans Duvefelt, MD

March 2020

////////////////////////////////////////////// IT IS WELL KNOWN BY NOW THAT A physician’s demeanor influences the clinical response patients have to any prescribed treatment. We also know that even when nothing is prescribed, a physician’s careful listening, examination, and reassurance about the normalcy of common symptoms and experiences can decrease patients’ suffering in the broadest sense of the word. This has been the bread and butter of counselors for years. People will faithfully attend and pay for weeks, months, and even years of therapy visits just to have an attentive and active listener and to feel like they have an ally. We also have data that shows that adherence to treatment plans is dependent on how patients feel about their provider. One problem solved can build an ally for life. Primary care medicine is a relationship-based business. I don’t know how often that basic fact is overlooked or denied. Whether you are trying to get another person to alter their lifestyle, take expensive medicines according to inconvenient schedules, or even just trust and accept your diagnosis, you have to “earn” the right to do those things. Our titles and medical accouterments give us a foot in the door, but they don’t usually get us all the way into people’s inner circles of trusted advisers. In this age of corporate medicine, there is a belief that patients attach themselves to institutions and networks because of their trust in the organizations, and that therefore the connection with their individual providers is secondary. I think that is a factor mostly when someone is looking for sophisticated specialty interventions, often one-time-only, like, “Where’s the best place to go for high-risk cardiac surgery?” When looking for primary care, people still tend to ask, “Who’s a good doctor?” rather than “Which is the better primary care group — Uptown Medical Associates or Statewide Primary Care?” How do you, as a clinician in today’s restless and mobile society, earn trust and build therapeutic relationships in 15-minute visits with several visible and invisible intruders in the room — the computer and the insurance company, for starters? I have previously reflected on how to prepare yourself for beginning a clinical encounter. My ABCs are Attention, Behavior, and Connection. But where do you go from there, how do you continue, grow, and nurture a therapeutic relationship over time in the kind of environment most of us work within? Here are a few lessons I have learned myself:

Listen and Respond

How many times do we hear that patients don’t get to speak for even a minute before we interrupt them? If you hear something that immediately requires clarification, do what you would do in a social situation. Say that what the other person just said is important or interesting, reflect back what you think you understood and then be careful not to give them too many yes or no options, but invite them to continue their story. Imagine that you’re meeting an interesting person at a dinner party, not leading a legal interrogation.

Set an Agenda

Almost every time I ignore this little rule, I get burned. Patients may not reveal their real concerns when making an appointment, and their priorities may have changed since then. Going all in with what you think is their main issue and waiting to say, “Do you have any other concerns?” until the end of the visit is a recipe for disaster. That agenda-setting may need to be addressed right away or after hearing a little about the main concern. If you don’t ask what people need from you, how can you ever hope to fill your role as their provider?

Budget Time

Manage the Perception of Time

Don’t act frustrated about the reality that time is at a premium, and don’t declare that you have too little of it until you know how serious or urgent your patient’s concern is. The person with a seemingly trivial concern may need you to help them with the biggest or worst problem of their life, so invest your time and attention on listening and understanding early on in the visit. By acting unhurried at first, you are more likely to create an atmosphere of trust and caring; once you know your patient’s concern and their diagnosis or differential diagnosis, if they feel heard, you can move more quickly to wrap up the visit if you need to.

If I am running late, I often enter the exam room and demonstrably sit down, take a deep breath, and relax my posture as if I am finally arriving at the most important appointment I have all day. That slowing down gesture helps me to undo my patient’s fear that I’m going to be rushing them along. If they think I’m not going to meet their needs, their memory of the visit will likely be just that, even if I do a pretty good job technically for them.

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Don’t Be a Hero

My 2018 post “Be the Guide, Not the Hero” points out the fact that everyone is on their own journey in life, and we are at best guides in our patients’ pursuits. If we try to be the hero in their stories, we create unhealthy, dependent relationships that often lead to patient disappointment or even resentment. As guides instead of heroes, we also remind ourselves that we are not the ultimate experts on what is best for our patients. Since our patients are the heroes of their own stories, they must ultimately decide which piece of advice from which guide they will choose to follow.

Be True to Yourself

On the one hand, I believe we must adapt our demeanor to the situation — reassuring, motivating, inquisitive, or sometimes decisive — but we must stay within the range of our real selves. I can be jovial only to a point, or I will seem and feel like I am pretending, for example. People can usually sense falsehood a mile away.

Balance Disclosure

We cannot build therapeutic relationships as only technicians; we must engage as real people, and you can’t be real without showing emotion, genuine interest, engagement, and a good amount of humility. We have to be careful to show that we are fallible like everybody else but also that we ultimately have our act together. Nobody wants a self-absorbed, overconfident guide, but nobody wants a weak and 6

March 2020

insecure one either. If we say we never had tough choices to make or regrets we carry with us, how can we expect patients to allow us to be close enough to build trust? I tell people things they could relate to that I don’t think would come back to haunt me. I tell them how many miles I have on my car, but not how much money I spent on repairs. I tell them about my life lessons from being a Boy Scout or going through basic training in the Swedish army, the antics of the beagles I’ve had in my life, or the way my onetime vegetarian diet made me put on weight. I tell them I was homesick at my first scout camp, but I don’t talk about things that could distance patients from me; not that I am a golfer or a sailor, but pictures and magazines of such things will alienate as many patients as it might build a relationship with. My Arabian horses didn’t cost much money — they were adopted from a horse rescue and simply needed a home. Our relationship with animals, I believe, is more likely to show that we have the capacity for relationship building with humans, too.

Build Continuity

From one visit to the next, find a thread to follow. For some patients it is their chronic disease, for others their family or their hobby. Reconnecting about what you talked about last time is a powerful and quick way to reestablish the fact that you know each other and that you care about your patient. It brings you straight into a space where you are ready to do the work you do. Even if you have to pull up their last visit in the EMR (maybe even looking at the screen together), that quick reconnection that begins every visit helps make you seem better prepared; maybe you don’t remember the details of the last visit, but you do remember your patient very well.

Solicit Participation

When it’s time to formulate a treatment plan, don’t be too quick to lay it out as if there is only one way to do things.

Plan When and How to Reconnect

“Follow-up PRN” isn’t usually the best way to conclude a visit in your mind or the EMR. Friends don’t usually leave each other saying, “I’ll see you around” — that’s more for casual acquaintances. It’s important to agree on what to do after the test results come in, when the antibiotic runs out, if the rash doesn’t go away, or when to meet up if everything is going well. Not making such plans devalues the relationship and makes you look as if you don’t care about your patient. Dr. Duvefelt is a family physician who blogs at acountrydoctorwrites. This article originally appeared on MedPage Today.

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“First Republic handles the banking side of our business, allowing us to focus on taking the best care of our patients.” W E S T P O RTA L O R A L & FAC I A L S U R G E RY C E N T E R

Dean L. Duncan, D.D.S. (left); Eric M. Scharf, D.D.S. (right)

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MEMBER FDIC AND EQUAL HOUSING LENDER

SanDiegoPhysician.org 7

ars

Celebrating 150 Ye

women

The Key Role of in San Diego Medicine and SDCMS Over the Past 150 Years

San Diego, 1881 â&#x20AC;&#x201D; the first telephones were installed, gas lighting became available and the population was just over 6,700. There were approximately 65 female physicians in California and in January of that year, the first female MD physician placed an ad in The San Diego Union.

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The first female MD physician to practice in San Diego, Dr. Anna Longshore Potts, graduated as part of the first class of eight physicians from the Womanâ&#x20AC;&#x2122;s Medical College of Pennsylvania in 1851, and moved here in 1881. She actually graduated medical school before almost all of her San Diego male counterparts and colleagues! In addition to practicing medicine, she purchased a piece of land in Paradise Valley and began building the Potts Sanitarium. On Nov. 8, 1881, an article appeared in The San Diego Union reporting on the most recent Medical Society meeting and the question of admitting women physicians to the Medical Society. It was reported that none of the discussions said a word against the proposition and ultimately, by nearly unanimous vote, it was declared that regularly graduated women doctors should be admitted to the County Medical Society. When the decision was announced, there was a hearty round of applause. It is reasonable to suppose that the discussion in the Union article was regarding the admission of Dr. Anna Longshore Potts to the medical society, as she was the only regular female physician (MD) practicing in San Diego at this time! Unfortunately, there are no early records to review, due to destruction of SDCMS official membership registers in 1887 by a disgruntled Dr. Daniel McSwegan. By 1883, Dr. Potts had left San Diego and put her sister in law, Rebecca Longshore, MD, in charge of the Sanitarium project and began traveling the world to Australia,

HOLLY B. YANG, MD, AND SUE FLEDDERJOHN

March 2020

New Zealand, and Europe. Her medical lectures on anatomy, hygiene, temperance, rational dress (no corsets!) and exercise were legendary and packed the many venues she spoke in. She spoke at St. James Hall in London in front of 3,500 and the Sydney Exhibition Hall for a crowd of 4,500 people! Her lectures had allowed her the freedom to not only finance her sanitarium back home in San Diego, but to travel the world independently. The 30-bed Potts Sanitarium was completed in 1888. Unfortunately, due to a severe drought it was closed in 1895. Later, Paradise Valley Hospital was built on that same property. Arguably the most famous female San Diego physician of the time was Dr. Charlotte Le Breton Johnson Baker, who graduated from the University of Michigan Medical School in 1881. She and her husband, Dr. Fred Baker, relocated to San Diego in 1888. They were the first husband and wife physician couple to be admitted to the San Diego County Medical Society, and Charlotte is the first female physician for whom we have membership records. Two other women followed Dr. Charlotte Baker into SDCMS that year: Dr. Virginia Smiley and Dr. Lucia Lane. Dr. Smiley and Dr. Lane would go on to open a private hospital in San Diego in 1889. Dr. Charlotte Baker was a powerful change agent, and one of the founders of the Women’s Home Association and the Children’s Home Day Nursery (now the San Diego Center for Children). She was active in the Woman’s Christian Temperance Union, and spoke regularly about

health issues on campus of the State Normal School (which eventually became San Diego State Teachers College/SDSU). She was a leader in the woman’s suffrage movement, and became president of the San Diego Equal Suffrage Association in 1911. She was one of the founders of the San Diego YWCA (president in 1909), as well as the College Woman’s Club and the Purity League (later called the Suppression of Vice Society), a group that provided education about the health risks of risky sexual behavior and offered vocational training to help women leave prostitution. In her diaries, Dr. Charlotte Baker wrote about familiar themes: a woman who juggled her home and professional life, faced professional challenges that many female physicians may still face today, and worried about her patients and her family’s wellbeing. Yet she managed to carve out time for reading and sailing for her own welfare. In 1898, Dr. Charlotte Baker became the first female president of SDCMS. If that was not remarkable enough in an era where women could not vote in federal elections, that year there was an all-female sweep of medical society leadership. Dr. Lucia Latta was elected vice president, and Dr. Lois Nelson became treasurer and secretary of SDCMS. On April 2, 1898, The San Diego Union published an article about the previous night’s Medical Society

Top: Dr. Anna Longshore Potts. Center: Dr. Anna Longshore Potts wrote Discourses to Women on Medical Subjects, published in 1887. Bottom: Dr. Charlotte Baker uses a stethoscope on an unidentified woman.

SanDiegoPhysician.org 9

Helen M. Ranney, MD

meeting, which reported, “The gentlemen were defeated for every office, but allowed to remain as members.” It would be 89 years before another woman was elected president of the San Diego County Medical Society: Dr. Jacquelin Trestrail, in 1987. San Diego has had a number of firsts for women in medicine, like Dr. Anita Figueredo, who was the first female surgical oncologist in the United States. Dr. Figueredo graduated from Long Island College of Medicine in 1940, and was one of the first two women to train in surgery at Memorial Hospital (now Memorial Sloan Kettering). She began her practice in La Jolla in 1947 and in 1948 became the first female surgeon to earn hospital operating privileges at Scripps Memorial Hospital in La Jolla. She was reportedly so petite (4-foot-11) that she would stand on a step stool to reach her patients for surgery. She had nine children, and reportedly walked straight from the OR to the maternity ward, gave birth, and made rounds on her patients the next morning. She was known for her charitable work and was a founding board member for the San Diego College for Women (now University of San Diego). She saw patients in her office on Coast Boulevard in La Jolla until she was 80 years old. Her home and office is now a designated historical site. She died in 2010. Another renowned female San Diego physician was Dr. Helen Ranney, a hematologist who completed medical school at Columbia in 1947. Her research helped understand the genetic inheritance of sickle cell disease and a way to distinguish the

March 2020

normal hemoglobin structure from that of sickle cell anemia. She received the Dr. Martin Luther King Jr. Medical Achievement Award in 1972 for her important work. She was recruited to UC San Diego in 1973 to be the chair the Department of Medicine, and was the first woman to hold that position at a major university in the United States. She was elected to the membership of the National Academy of Sciences that same year. Dr. Ranny also served as the first woman to be president of the Association of American Physicians in 1984 and the first woman to be appointed Distinguished Physician of the Veterans Administration from 1986 to 1991. She also died in 2010. One more boundary-breaking woman was Dr. Doris Howell. She trained at McGill University Medical School, followed by residency training in pediatrics at Montreal Children’s Hospital and Duke University. She completed a fellowship in hematology/ oncology at Harvard. She became the first woman in the United States to hold a full-time pediatric department chair position when she took on that role at the Medical College of Pennsylvania. In 1974, Dr. Howell became chair of the UC San Diego Department of Community and Family Medicine. In 1977, she founded San Diego Hospice, which served both adult and pediatric patients, and trained physicians and other clinicians in hospice and palliative care from across the United States and around the world. After retiring, Dr. Howell focused on women’s healthcare advocacy through the Doris Howell Foundation for Women’s Health Research. She died in 2019.

These women’s stories are an important part of the history of medicine in San Diego. There are many, many more who have helped us to be the medical community we are today. While nationally women are now entering medical school at an equivalent or higher rate than men, there are still well-known inequities in pay, opportunities for advancement, and leadership positions. As a medical community, we have more work to do. In organized medicine there are still more men than women, but women are becoming more visible in positions of leadership and are powerfully engaged in advocacy and education for the benefit of our profession and our patients. It is incredibly inspiring that in 2019–20, the past president, president, and president-elect of the American Medical Association (AMA) are all women for the first time. In fact, the current AMA president, Dr. Patrice Harris, is the first African-American woman to hold the office. At the San Diego County Medical Society, women make up a valued and important part of our membership. It is our hope that as we enter our 150th year, physicians of all genders and diverse backgrounds feel welcome and help us to move our medical society forward. If you are a member, we hope you get involved and join us in our social events, physician wellness activities, advocacy work, committees, or volunteer for our foundation, Champions for Health. If you are not a member yet, we hope you will consider joining us to advocate for patients and physicians in San Diego County, California, and our nation. Check out our website, at www.sdcms.org, to learn more. We need all your voices. Dr. Yang is a hospice/palliative care specialist with Scripps Mercy Hospital and is president-elect of the San Diego County Medical Society. Sue Fledderjohn is executive assistant to SDCMS CEO Paul Hegyi and SDCMS’s in-house historian.

Twelfth Annual Course on Office and Urgent Care Orthopaedics: The Essentials of Musculoskeletal Care S AT U RDAY, MAY 2 , 20 2 0

A course for primary care, urgent care and emergency room physicians, nurse practitioners, physician assistants, physical and occupational therapists and all healthcare professionals who diagnose and treat orthopaedic injuries.

ALL NEW TOPICS AND EXPANDED HANDS-ON WORKSHOPS! COURSE DESCRIPTION

We will review the essentials of acute and chronic musculoskeletal care with focused lectures, case discussions and intensive hands-on workshops. The workshops will focus on the examination, differential, treatment options, injection techniques and red flags for each diagnosis. Seating for each workshop is limited COURSE DIRECTOR

Glenn Pfeffer, MD Director, Foot and Ankle Center Department of Orthopaedics Cedars-Sinai Medical Center

CONFERENCE LOCATION

Cedars-Sinai Medical CenterÂŽ Harvey Morse Auditorium 8701 Gracie Allen Drive Los Angeles, CA 90048

INFECTIOUS DISEASE

Coronavirus Transmission Clues: The Nose Knows VIRAL LOAD HIGHER IN THE NOSE VERSUS THROAT, RESEARCHERS REPORT By Molly Walker

NEW CLUES HAVE EMERGED ABOUT

how and when the novel SARS-CoV2 coronavirus transmits. Not only was viral load similar in an asymptomatic patient versus those with symptoms, but it was higher in the nose than in the throat, reports Jie Wu, PhD, of Guangdong Provincial Center for Disease Control and Prevention in Guangzhou, China, and colleagues. This suggests SARS-CoV2 has a shedding pattern closer to influenza, and one different than SARS, or SARS-CoV, they wrote in a Correspondence in The New England Journal of Medicine. They noted the differences to SARS, which was “associated with modest viral loads in the respiratory tract early in the illness, with viral loads peaking approximately 10 days after symptom onset.” Wu and colleagues examined SARSCoV2 viral load data from nine men and nine women (median age 59) in Zhuhai (adjacent to Macau in China’s south) in 12

March 2020

two family clusters. Four patients had secondary infections, including one who never had symptoms but was a close contact of an existing case. During Jan. 7–26, 14 of these individuals had recently returned from Wuhan with fever and were diagnosed with laboratory confirmed COVID-19, the disease caused by SARS-CoV2. Thirteen had evidence of pneumonia on CT scans, and three were admitted to ICUs, while the others had “mild-to-moderate illness.” Researchers examined 72 nasal swabs and 72 throat swabs from the 17 symptomatic patients. They found viral loads were highest soon after symptom onset, and more in the nose than the throat. Swabs were also collected from the asymptomatic patient, with a viral load in the same range as in those showing symptoms. The latter finding suggests “transmission may occur early in the course of infection,” Wu and colleagues concluded. “Identification of patients with few or

no symptoms and with modest levels of detectable viral RNA in the oropharynx for at least five days suggests that we need better data to determine transmission dynamics and screening practices,” they wrote. A Call for More Testing, Surveillance Marc Lipsitch, DPhil, of Harvard T.H. Chan School of Public Health in Boston, and two colleagues — one from Pfizer’s vaccine division and another from Merck — argued in an accompanying commentary that viral testing needs to be expanded from clinical into broader public health settings. “Although this approach may result in many negative test results and therefore appear ‘wasteful,’ such set-aside capacity will permit a far greater understanding of the spread of the epidemic and wiser use of resources to combat it,” they wrote. They discussed how increased testing in “unexplained clusters or severe cases of acute respiratory infection,” regardless of travel history, could detect transmission chains that have been missed. Lipsitch and colleagues pointed to the case of Singapore, which has been unable to link a number of its cases to either travel to China or known cases, despite having “one of the world’s best public health systems.” On a broader note, the commentary authors called for more studies, in particular to discover the full spectrum of disease severity; SARS-CoV2’s transmissibility; patient characteristics that affect risk for transmission; and the risk factors for severe illness and death. Tools used to gather this data include household studies, community studies, and case-control studies. Lipsitch and colleagues also advocate putting infrastructure into place for better surveillance, similar to that used in the 2009 influenza pandemic. This could involve “using existing surveillance systems or designing surveys to ascertain each week the number of persons with a highly sensitive but nonspecific syndrome ... and testing a subset of these persons for the novel coronavirus,” they said. “Electronic laboratory reporting will dramatically improve the efficiency of this and other public health studies involving viral testing,” they wrote. Molly Walker is associate editor of MedPage Today.

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SanDiegoPhysician.org 13

RISK TIP

How to Talk to Patients About Nutrition, Diet, and Preventing Heart Disease By Kerin Torpey Bashaw, MPH, RN NO MORE POWERFUL AN APPROACH

exists to preventing or even reversing heart disease than improving lifestyle, especially nutrition and diet. The challenge for physicians is finding an effective way to talk about nutrition with their patients, because the usual admonitions to eat better and exercise often do not work. The American Heart Association estimates that 46% of U.S. adults have hypertension and, on average, someone dies of cardiovascular disease every 38 seconds. A 2018 report by the Centers for Disease Control and Prevention (CDC) showed the average U.S. adult is nearly obese. A 2017 study revealed that about 45% of deaths from cardiometabolic conditions were due to dietary factors. Andrew M. Freeman, MD, FACC, co-chair of the Lifestyle and Nutrition Workgroup with the American College of Cardiology, explains that the drugs we use to treat heart disease can be wonderful tools, but they don’t really focus on a cure or reversal — they only control the disease. But drugs aren’t the only option. Stephen Devries, MD, executive director of the Gaples Institute for Integrative Cardiology, stresses the wealth of research focusing on lifestyle and nutrition as the key component for curing or reversing heart disease. The data suggest that a diet filled with vegetables, fruit, whole grains, and predominantly plant-sourced protein offers the best chance for both 14

March 2020

prevention and treatment of heart disease, as well as benefits for reducing the risk of certain cancers. Dr. Devries points to one landmark study, which found that a Mediterranean-style diet emphasizing more fish, vegetables, nuts, and whole grains yielded a 72% reduction in the occurrence of nonfatal myocardial infarction and death, compared to a control group. A more recent study of the Mediterranean-style diet found a 28% reduction in nonfatal myocardial infarction, cardiac death, and stroke, Dr. Devries notes. The results that are possible with changes in nutrition and other lifestyle improvements make every drug and procedure pale in comparison, Dr. Freeman says. The Dietary Approaches to Stop Hypertension (DASH) trial showed that a diet rich in vegetables, fruit, and low-fat dairy prompted a significant drop in blood pressure in only two weeks. Dr. Devries explains the compelling results of this research in a four-hour, self-paced CME program called Nutrition Science for Health and Longevity: What Every Physician Needs to Know, recommended by The Doctors Company. Dr. Freeman believes there is no doubt

we can significantly improve the quality of life for patients with heart disease through better nutrition, which promises benefits several magnitudes larger than nearly any medication. The science is solid, but applying it is the challenge, he says. Unfortunately, cardiologists have almost no training in lifestyle approaches to disease. A survey of 646 cardiologists revealed that cardiologists are unprepared to talk to patients about the effect of nutrition on heart disease, with 90% receiving no or minimal nutrition education during fellowship training, 59% receiving little or no nutrition education during internal medicine training, and 31% receiving no nutrition education in medical school. That means physicians face a significant challenge when trying to persuade patients to switch to a predominantly, if not totally, whole-food, plant-based diet. The switch is difficult for most patients, and physicians are not adequately prepared to talk about nutrition at all, much less such a daunting lifestyle change. Most physicians have only brief conversations in which they tell patients to change their diets, possibly with a few specific suggestions. So one of the keys to

making nutrition counseling work in a busy practice is making optimal use of the short period of time that physicians have available for nutrition counseling — a key component of the CME nutrition course. Even when patients are eager for nutritional advice, they may find it difficult to sort out competing messages from the media and may not know how to follow their physicians’ advice to improve nutrition. Effective communication requires a more interactive approach that uses data to back up the recommended changes. For example, Dr. Freeman asks patients what they had for lunch that day, what they had for dinner the night before, and how active they were in the past week for a snapshot assessment of nutrition and lifestyle. He then asks permission to be critical about the diet, which indicates whether the patient is receptive to the changes that are necessary to reverse the course of heart disease. Dr. Freeman also assesses readiness for change through a technique called moti-

vational interviewing, which helps identify what incentivizes a person to change behaviors. This approach recognizes how difficult it can be for some people to make lifestyle changes and helps them find successful strategies. This approach and further conversation may reveal, for example, that the patient has an unhealthy diet but is unhappy about how he or she feels on a daily basis and wants to be able to dance at a daughter’s upcoming wedding. Such circumstances and goals can become the basis for meaningful change, supported by resources such as recipes and online links to resources, as well as support groups that let patients meet people who have successfully transitioned to better nutrition. Clinical scenarios that provide tips for motivational interviewing are also included in the nutrition CME course. When patients are at least minimally receptive to the idea, the physician can show how research proves the value of improving their nutrition, comparing

their own nutrition to the ideal versions and discussing the incremental steps for improvement. Physicians also can support patients making healthy lifestyle changes through programs like Walk with a Doc, which encourages doctors and patients to take walks together. Dr. Freeman runs the regional program and regularly takes walks, and talks, and educates patients. Because the benefits of improved nutrition and lifestyle for heart disease are so compelling, clinicians must make a concerted effort to convey that information effectively and to work with patients to overcome any personal obstacles or hesitation. Simply telling patients to change their lifestyles does not work — a supporting hand through change is necessary. Kerin Torpey Bashaw is senior vice president of the Department of Patient Safety and Risk Management at The Doctors Company.

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An applicant must have, or open prior to closing, a checking or savings account with Bank of America. Applicants with an existing account with Merrill Edge®, Merrill Lynch® or U. S. Trust prior to application also satisfy this requirement. Eligible medical professionals include: (1) medical doctors who are actively practicing, (MD, DDS, DMD, OD, DPM, DO), (2) medical fellows and residents who are currently employed, in residency/fellowship, or (3) applicants who are medical students or doctors and are about to begin their new employment/residency or fellowship within 90 days of closing. Must be actively practicing in their field of expertise. Those employed in research or as professors are not eligible. For qualified borrowers with excellent credit. PITIA (Principal, Interest, Taxes, Insurance, Assessments) reserves of 4 – 6 months are required, depending on loan amount. 2 Minimum down payment requirements vary by property type and location; ask for details. 3 If applicant’s employment does not commence until after closing, in addition to the minimum cash reserves required, sufficient reserves to handle all debt obligations between closing and employment start date up to an additional 90 days must be verified. 4 Additional documentation is required. Credit and collateral are subject to approval. Terms and conditions apply. This is not a commitment to lend. Programs, rates, terms and conditions are subject to change without notice. Bank of America, N.A., Member FDIC. Equal Housing Lender. ©2019 Bank of America Corporation. AR7QN56V HL-230-AD 03-2019 1

Seeking FM/DO/IM/ Psychiatrist in San Diego County Position: Full-time and part-time. Full benefits package and malpractice coverage is provided by clinic. Requirements: California license, DEA license, CPR certification and board certified in family medicine. Bilingual English/Spanish preferred. Send resume to: hr@vistacommunityclinic.org or fax to 760-414-3702

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

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SanDiegoPhysician.org 15

PERSONAL & PROFESSIONAL DEVELOPMENT

What Do You Really Know? By Helane Fronek, MD, FACP, FACPh “KNOWING” IS AN INTERESTING WORD. RACHEL Remen, MD, creator of the Healer’s Art course, explains that there are many ways of knowing things: We can know something scientifically, cognitively, emotionally, esthetically, or experientially. When we look at something from one of these perspectives, we can forget that there are other ways to understand it. As physicians, we tend to overvalue the intellectual ways of knowing. We pride ourselves on our cognitive skills, fund of knowledge, and analytical ability. Easily tested, they form the proficiencies on which we are evaluated. Unfortunately, this emphasizes only one way of knowing things, undervaluing other sources of knowing. In fact, each of us repeatedly uses various ways of knowing to assess our patients. We walk into a room and immediately “know” if a patient is sick or not. We call it “clinical judgment” and so imbue it with value. It’s really intuition — a way of knowing something even when we can’t explain how we know it. As Malcolm Gladwell discusses in Blink, we all rely on intuition. Throughout our day, we take in information through our senses and recognize patterns we have seen before. These are processed 16

March 2020

on a subconscious level, creating physiologic changes in our bodies that form particular conclusions or drive certain actions. Great basketball players are said to have “court sense” and brilliant military generals are equipped by “coup d’oeil” — the “power of the glance.” Unfortunately, we are discouraged from believing things we know in less intellectual ways. “Show me the data,” we demand when people offer new ideas. While science forms an essential foundation for clinical decisions, our reliance on only one type of “knowing” should make us uneasy, as we’ve all witnessed the replacement of established “facts” by newer “facts.” One area in which we often ignore our inner knowing is in evaluating ourselves. Society can be critical of many aspects of our personalities, interests, and priorities, and our impressions of ourselves are often distorted by inaccu-

rate assessments as teachers, parents, friends, and others miss who we truly are. At times I have been labeled lazy, impatient, careless, and uncommitted — none of which reflects who I am. As a physician coach, I am thrilled and dazzled by the transformations I witness in my clients. Through our discussions, they grow to know who they are. Their confidence rises and they courageously cast off beliefs and limitations that don’t serve them. Reconnected with their true values, they venture into new territories in their lives, letting go of activities that no longer interest them and taking on exciting challenges they were afraid to try before. By knowing who they are, they feel happier and more settled in their lives. For many years I found this transformation inexplicable and somewhat magical. Now, I understand that, together, we connected them with what they already knew about themselves and gave them the confidence to believe it. What is it that you know about yourself but are afraid to believe? What would your life be like if you did? Dr. Fronek, SDCMS-CMA member since 2010, is an assistant clinical professor of medicine at UC San Diego School of Medicine and a certified physician development coach who works with physicians to gain more power in their lives and create lives of greater joy. Read her blog at helanefronekmd.com.

March Is Colorectal Cancer Awareness Month By Adama Dyoniziak COLORECTAL CANCER IS THE THIRD

most common cancer in the United States and the second leading cause of death from cancers that affect both men and women. More than 15,000 people in California will be diagnosed with colorectal cancer this year. It affects people in all racial and ethnic groups and is most common in people age 50 and older. With regular screenings, six out of 10 deaths from colorectal cancer could be prevented among people age 50 and older. “I was living on my last lifeline … had it not been for Project Access, I wouldn’t be here to tell my story.” Casildo was experiencing weight loss, anemia, and abnormal bowel movements, and had a positive FIT test. Dr. Dhruvil Gandhi conducted a colonoscopy at Tri-City Medical Center which confirmed advanced colorectal cancer. Surgery and chemotherapy was successful in getting Casildo’s survival rate to be 90% after treatment. “I got the great news from my cancer doctor (Dr. Darren Sigal, Scripps Health) last month that all of my labs and scans look great,” Casildo says. “I am so very grateful that Project Access supported me medically since I didn’t have any insurance, but also emotionally. Project Access Case Managers were there to support me … without a family this would have been very hard for me to get through. You became my family.” Casildo’s survival rate is still at 90% after his treatment. Dr. Gandhi has been volunteering with Project Access since 2015 doing colonoscopies and hernia repairs at both Tri-City Medical Center and Carlsbad Surgery Center. “I heard about Project Access by word of mouth from Dr Adam Fierer at the Carlsbad Surgery Center,” Dr. Gandhi says. “The best part about volunteering with Project Access is it has a fun team. The most gratifying part is to help a person by correcting something inside their body and see the person’s life turn around.” Dr.

Gandhi can understand personally how difficult it is for a person such as Casildo to be uninsured and deal with health issues. “My parents didn’t have health insurance until they were in their 40s and my dad got a job with health benefits,” he says. “I didn’t have health insurance until I was in medical school. You just hope you don’t get sick when you are uninsured.” Last year, Casildo participated in his first Undy Run/Walk 5K along with other Project Access colorectal cancer survivors and staff. “I couldn’t believe that I could complete the 3.1 miles,” Casildo says. “It was the first time in years that I was able to be that active.” This year Casildo is our team captain for the Undy Run/Walk hosted by the Colorectal Cancer Alliance on March 7 at De Anza Cove in Mission Bay Park. He is very enthusiastic to help organize other Project Access colorectal cancer survivors and their families to par-

CHAMPIONS FOR HEALTH

ticipate in an event that raises awareness for colorectal screening and prevention services in San Diego. “I feel very blessed to be able to help and to give of my time,” Casildo adds. The dedicated physician volunteers of the San Diego County Medical Society envisioned being of service to the community, so they created the Foundation, now named Champions for Health. Since 2008, Project Access has facilitated more than $20.45 million in pro bono care for more than 6,500 uninsured patients, including more than 1,500 surgeries and procedures (440 of these were colonoscopies and flexible sigmoidoscopies) and more than 16,000 specialty care appointments, and has prevented 57 deaths! For more information on how you can use your physician power to protect and heal our most vulnerable San Diegans, please contact Adama Dyoniziak at adama.dyoniziak@championsfh.org or call (858) 300-2780. Come join us at our second annual Champions Soirée: Waves of Wellness at the Birch Aquarium on March 28 to raise money for Project Access San Diego. www.championssoiree.org. Ms. Dyoniziak is executive director of Champions for Health.

Left: Casildo R. Bottom left: Dr. Dhruvil Gandhi and his team Below: Casildo R. and two Project Access cancer survivors at the Undy Run/Walk

SanDiegoPhysician.org 17

CLASSIFIEDS PRACTICE ANNOUNCEMENTS GRAND OPENING OF SAN DIEGO ENT AND UNITED MEDICAL DOCTORS OFFICE IN LA JOLLA: Connect with fellow physicians, tour the new office and enjoy hors d’oeuvres and beverages! We will have free giveaways, raffles and 50% off your choice of custom noise-reducing ear plugs or surfer’s ear plugs. Additionally, receive $7/unit Botox and $100 off filler syringes, which can be used at the time of the event or scheduled for a later date. Wednesday, March 11, 2020. 5:00pm-7:00pm 4150 Regents Park Row, Suite 345 La Jolla, CA 92037 Please RSVP at info@ sandiegoent.com. PHYSICIAN OPPORTUNITIES CHILD HEALTH OFFICER (MEDICAL DIRECTOR): The County of San Diego Health & Human Services Agency (HHSA), Medical Care Services (MCS), is seeking online applications and résumés from qualified individuals for Child Health Officer/Medical Director. This unclassified management position plays a key leadership role in our medical care system by supporting the planning, directing, and coordinating of all forensic and clinical functions specific to Medical Care Services. In accordance with Federal, state, and local policies and regulations, the Child Health Officer will have significant responsibility for monitoring and/ or evaluating medical assessments of child abuse and/ or neglect, pediatric care, and an array of services. Regular - Full time $240,000 - $250,000 Annually. Please visit the County of San Diego website for more information and to apply online. PEDIATRIC POSITION AVAILABLE: Grossmont Pediatrics, a private pediatrics practice with Commercial HMO, PPO, Tricare, Medi-Cal patients, provides family-focused individualized care in East San Diego. Clinical cases include ADHD, asthma, adolescent behavioral health. Average 2.5 clinic patients per hour, 1-in-3 light call & newborns at one hospital. With Epic HER, access real-time care at Rady’s and area hospitals. Working 24 or 28 hours weekly, you will earn $130-150,000 annual compensation, upto 3 weeks PTO plus holidays, and future share in practice. Direct professional expenses are paid, Health, Dental, 401K, etc. Contact venk@gpeds.sdcoxmail.com or (619) 5045830 with resume in .doc, .pdf or .txt. GENERAL FAMILY MEDICINE PHYSICIAN: to provide quality patient care to all ages of patient in a full-time traditional practice. The Physician will conduct medical diagnosis and treatment of patients using medical office procedures consistent with training including surgical assist, flexible sigmoidoscopy, and basic dermatology. The incumbent must hold a current California license and be board eligible. Bilingual Spanish/English preferred. Founded as a small family practice in Escondido 1932 by Dr. Martin B. Graybill, today we’re the region’s largest Independent Multi-specialty Medical Group. Our location is 277 Rancheros Dr., Suite 100, San Marcos, CA 92069. We are an equal opportunity employer and value diversity. Please contact Natalie Shields at (760) 291-6637 nshields@graybill.org. You may view our open positions at: https://jobs.graybill.org/ BOARD CERTIFIED OR BOARD-ELIGIBLE PHYSICIAN DERMATOLOGIST: Needed for busy, well-established East County San Diego (La Mesa) private Practice. We currently have an immediate part-time opening for a CA licensed Dermatologist to work 2-3 days per week with the potential for full-time covering for existing physicians, whenever needed. We are a full-service Dermatology office providing general, cosmetic and surgical services, including Mohs surgery and are seeking a candidate with a desire to provide general dermatology care to our patients, but willing to learn laser and cosmetics as well. If interested, please forward CV with salary expectation to patricia@ grossmontdermatology.com. PHYSICIAN CONSULTANT FULL-TIME: San DiegoImperial Counties Developmental Services, Inc. (San Diego Regional Center). Great opportunity to work in a

March 2020

multidisciplinary setting in a private non-profit agency that serves persons with developmental disabilities. Must be licensed to practice medicine in California and certified by specialty board such as Neurology, Neurodevelopmental Disabilities, Developmental Behavioral Pediatrics, Pediatrics or Internal Medicine. Experience in the field of developmental disabilities and administrative or supervisory experience required. Please visit our website at www.sdrc.org for more information and to submit an application. DEPUTY PUBLIC HEALTH OFFICER: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a California licensed or license eligible physician to work for County of San Diego Public Health Services, nationally accredited by the Public Health Accreditation Board. Regular - Full Time: $220,000 - $230,000 Annually. For more information and to apply: https:// www.governmentjobs.com/careers/sdcounty/ jobs/2359704/deputy-public-health-officer 19092204u?keywords=Deputy%20Public%20 health%20&pagetype=jobOpportunitiesJobs TEMPORARY EXPERT PROFESSIONAL (TEP) MEDICAL DOCTORS (MD’s) NEEDED: The County of San Diego Health and Human Services Agency is seeking numerous MD positions to work in a variety of areas including Tuberculosis Control, Maternal and Child Health, Epidemiology and Immunizations, HIV, STD & Hepatitis, and California Children’s Services. Applicants (MD or DO) must hold a current California medical license. Applicants must be proficient in either Opioid Abuse Prevention and Treatment Strategies, Communicable Diseases and/or Healthcare Systems, and willing to minimally work three days a week. Hourly rate is $103/hour. If interested, please e-mail CV to Anuj.Bhatia@sdcounty.ca.gov or call (619) 542-4008. BOARD CERTIFIED NEUROLOGIST POSITION AVAILABLE: Seeking a Board Certified Neurologist based in the San Diego region. Opportunities available on a part-time or full time basis for a prominent multi-specialty medical group practice. Candidates should have interest in management of traumatic brain injury, post-concussive symptoms, medical legal evaluations including IME, and EMG. Competitive salary. Please send letter of interest and CV to admin@ pacificmedicalllc.com. SAN DIEGO COUNTY EMPLOYMENT OPPORTUNITY: The County of San Diego has a current employment opportunity for M.D.- Chief, TB Control & Refugee Health (Public Health Medical Officer). Please see the link for more information: M.D.-Chief, TB Control & Refugee Health (Public Health Medical Officer-19412807UTB INTERNAL MEDICINE PHYSICIAN: Solvang, California – Established private internal medicine practice in the heart of wine country in the beautiful Santa Ynez Valley within Santa Barbara County seeks a BC/BE internist to join a busy practice within the lovely Danish town of Solvang. Competitive salary and benefits while living and working in a small community with excellent schools, short commutes, fine restaurants, entertainment and Mediterranean climate with no smog or traffic. Enjoy excellent quality of life while practicing medicine in a small clinic affiliated with the Cottage Health System. For more information please contact Office Administrator Amy Comer at (805) 688-2600. FAMILY PRACTICE MD/DO: Family Practice MD/ DO wanted for urgent care and family practice office in Carlsbad, CA. Flexible weekday and weekend shifts available for family practice physician at busy, wellestablished office. FAX or email CV to (760) 603-7719 or gcwakeman@sbcglobal.net. PART-TIME/FULL-TIIME RADIOLOGIST POSITION OPEN - IMPERIAL RADIOLOGY: MEDICAL DIRECTOR, CALIFORNIA CHILDREN’S SERVICES: The Our company is an outpatient diagnostic radiology facility in search of a part-time/ full time radiologist. All candidates must have an active

California Medical License. Please contact us via e-mail at info@carlsbadimaging.com with your resume if this position is of interest to you. Thank you. Job Type: Part-Time/Full Time. Pay: TBD. PRACTICE OPPORTUNITY: Internal Medicine and Family Practice. SharpCare Medical Group, a Sharp HealthCare-affiliated practice, is looking for physicians for our San Diego County practice sites. SharpCare is a primary care, foundation model (employed physicians) practice focused on local community referrals, the Patient Centered Medical Home model, and ease of access for patients. Competitive compensation and benefits package with quality incentives. Bilingual preferred but not required. Board certified or eligible requirement. For more info visit www.sharp.com/sharpcare/ or email interest and CV to glenn.chong@sharp.com DERMATOLOGIST NEEDED: Premier dermatology practice in beautiful San Diego seeking a full-time/ part-time BC or BE eligible Dermatologist to join our team. Existing practice taking over another busy practice and looking for a lead physician. This is a significant opportunity for a motivated physician to take over a thriving patient base. Work with two energetic dermatologists and a highly trained staff in a positive work environment. We care about our patients and treat our staff like family. Opportunity to do medical, cosmetic and surgical dermatology (including MOHs) in a medical office with state of the art tools and instruments. Please call Practice Administrator at (858) 761-7362 or email jmaas12@hotmail.com for more information. PHYSICIAN POSITIONS WANTED RESEARCH PHYSICIAN (NO CLINICAL PRACTICE) PHYSICIAN Provides medical leadership, oversight, and management of human clinical trails while ensuring the integrity of the studies and the safety and well-being of human subjects. Performs duties in accordance with company’s values, policies, and procedures. On call responsibilites: shares in rotation of weekly call schedule. Please email resumes to tabitha.alvarado@ prosciento.com PRACTICE FOR SALE PRACTICE FOR SALE IN ENCINITAS: A GYN-only practice for sale in Encinitas with a majority of the patients in North County. Insurance accepted are PPO, cash and some Medicare patients. Could be turnkey or just charts. Practicing is closing December 31st, 2019. Please call Mollie for more information at (760) 943-1011. CLINICAL RESEARCH SITE/MULTI-SITE SPECIALTY PHYSICIAN PRACTICE COMBO FOR SALE: Great opportunity for a Group Practice. Clinical Research offers a way for physicians to continue to practice medicine the way they like and provide an additional source of income that is compatible with their goal of providing great care and options for their patients. Patients will have the opportunity to participate in the research of new treatments. Current site has staff and facilities for research, physician suites, and X-Ray. Use as a primary location or as a satellite office with research site. Current physicians and staff willing to train and work alongside physicians new to research. Contact E-Mail: CL9636750@gmail.com PRACTICES WANTED PRIMARY OR URGENT CARE PRACTICE WANTED: Looking for independent primary or urgent care practices interested in joining or selling to a larger group. We could explore a purchase, partnership, and/ or other business relationship with you. We have a track record in creating attractive lifestyle options for our medical providers and will do our best to tailor a situation that addresses your need. Please call (858) 832-2007. PRIMARY CARE PRACTICE WANTED: I am looking for a retiring physician in an established Family

Medicine or Internal Medicine practice who wants to transfer the patient base. Please call (858) 257-7050.

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. OFFICE SPACE / REAL ESTATE AVAILABLE NORTH COUNTY MEDICAL SPACE AVAILABLE: 2023 W. Vista Way, Suite C, Vista, CA 92083. Newly renovated, large office space located in an upscale medical office with ample free parking. Furnishings, décor, and atmosphere are upscale and inviting. It is a great place to build your practice, network and clientele. Just a few blocks from Tri-City Medical Center and across from the urgent care. Includes: Digital X-ray suite, multiple exam rooms, access to a kitchenette/break room, two bathrooms, and spacious reception area all located on the property. Wi-Fi is NOT included. Contact Harish Hosalkar at hhorthomd@ gmail.com or call/text (858) 243-6883. MEDICAL OFFICE AVAILABLE FOR RENT: Furnished or unfurnished medical office for rent in central San Diego. Can rent partial or full, 5 exam rooms of various sizes, attached restroom. Easy freeway access and bus stop very close. Perfect for specialist looking for secondary locations. Call (858) 430-6656 or text (619) 417-1500. MEDICAL OFFICE SPACE FOR SUBLEASE: Medical office space available for sublease in La Jolla-9834 Genesee Avenue, Suite 400 (Poole Building). Steps away from Scripps Memorial Hospital La Jolla. Please contact Seth D. Bulow, M.D. at (858) 622-9076 if you are interested. AMBULATORY SURGICAL CENTER FOR RENT: Freestanding, single story, fully furnished & equipped licensed Ambulatory Surgical Center immediately available for Rent 7 days per week. Very flexible & reasonable terms available including hourly rental rates, if desired, plus an income producing opportunity is also available. The facility is centrally located to all of San Diego County near Sharp Memorial hospital with easy freeway access & free parking. The facility is suitable for all surgical specialties. If interested e-mail to infosandiego1@gmail.com or call (858) 715-1822 to view the facility or for further information & details. OFFICE SPACE FOR RENT: Recently renovated medical office space for rent. 1300 SFT which includes waiting room with a large closet, 3 exam rooms, an spacious office, a lab and plenty of closet space. $2,000 starting 12/15/19. Please email info@rheumsd.com LA JOLLA OFFICE FOR SUBLEASE OR TO SHARE: Scripps Memorial Medical office building at 9834 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) 3449024 or (858) 320-0525.

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

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.

LA JOLLA (NEAR UTC) OFFICE FOR SUBLEASE OR TO SHARE: Scripps Memorial medical office building, 9834 Genesee (Poole Bldg) between I-5 and I-805. Sublease full or part of office with 5 plus rooms, bathroom/shower. Excellent referral situation. (Interested in all specialties in particular, a Psychiatrist.) (If interested, may participate in multiple research projects) Call (858)344-9024 or (858) 320-0525.

MEDICAL EQUIPMENT / FURNITURE FOR SALE

MEDICAL/OFFICE SPACE AVAILABLE: Beautifully decorated, new office space 2,000 sqare feet located at 6125 Paseo Del Norte in Sunny Carlsbad, CA. This unique office offers great visibility off Interstate 5 and close to Carlsbad Outlet Mall. This medical office consists of 3 exam rooms, 1 big procedure room, and a large nurse’s station. To view the space, contact Katia at (760) 352-4103 or email: Feminacareo@gmail.com MEDICAL OFFICE SPACE SUBLET AVAILABLE SEPT 26 2019: San Diego Eye Professionals, 5965 Severin Dr. La Mesa, CA 91942. This office is close to Sharp Grossmont Hospital and Grossmont Out Patient Surgery Center. A newly renovated beautiful 2,000 sq. ft office space with 6 exams rooms and 3 exam rooms available for sublet. Office has 2 bathrooms, laboratory, large reception office area with brand new lighting and hard wood floors throughout the office, handicap-compliant office and reception with wheel chair access. Lots of free parking directly in front of office. Single story building. Optometrist/ Ophthalmologist practice but all practices OK. Please contact Dagmar or Tami at (619) 583-4295 or sandiegoeyeprofessionals@gmail.com SHARED OFFICE SPACE: Office Space, beautifully decorated, to share in Solana Beach with reception desk and 2 rooms. Ideal for a subspecialist. Please call (619) 606-3046. OFFICE SPACE/REAL ESTATE AVAILABLE: Scripps Encinitas Campus Office, 320 Santa Fe Drive, Suite LL4. It is a beautifully decorated, 1600 sq. ft. space with 2 consultations, 2 bathrooms, 5 exam rooms, minor surgery. Obgyn practice with ultrasound, but fine for other surgical specialties, family practice, internal medicine, aesthetics. Across the hall from imaging center: mammography, etc and also Scripps ambulatory surgery center. Across parking lot from Scripps Hospital with ER, OR’s, Labor and Delivery. It is located just off Interstate 5 at Santa Fe Drive, and a half-mile from Swami’s Beach. Contact Kristi or Myra (760) 753-8413. View Space on Website:www.eisenhauerobgyn.com. Looking for compatible practice types. OFFICE SPACE FOR RENT: Multiple exam rooms in newer, remodeled office near Alvarado Hospital and SDSU. Convenient freeway access and ample parking. Price based on usage. Contact Jo Turner (619) 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) 633-695

MEDICAL EQUIPMENT AVAILABLE FOR SALE/ FREE IN ENCINITAS: Orthopedic office relocating in UTC area and has medical equipment for sale or take away. Available equipment: exam tables (2), chart racks (6), Magazine Racks (4) Stools (3). Call Georgana for information at (858) 395-0693. MEDICAL EQUIPMENT AVAILABLE IN ENCINITAS: GYN-office closing in Encinitas and has medical equipment for sale or take away. Available equipment: exam tables, chart racks, autoclave, ultrasound machine, credenza for supplies, Berkley suction machine. Call Mollie for information at (760) 943-1011. NON-PHYSICIAN POSITIONS AVAILABLE FINANCE DIRECTOR: San Diego Sports Medicine and Family Health Center is hiring a full-time Financial Director to manage financial operations. Primary responsibilities include monitoring of income, expenses and cash flow, reconciling bank statements, supervision of accounts payable, oversee billing department, oversee accounts receivables, payments and adjustments, prepare contracts, analyze data, prepare financial reports, prepare budgets, advise on economic risks and provide input on decision making. MBA/Master’s and 5+ years relevant work experience preferred. Excellent references and background check required. Salary commensurate with skills and experience. To apply, please send resume to Jo Baxter, Director of Operations jobaxter@sdsm.com. PHYSICIAN ASSISTANT/NURSE PRACTIONER: Our growing Neurosurgery office in Chula Vista is looking for a part-time Nurse Practitioner/Physician Assistant. The job requires running clinic two days per week and possible hospital rounds/surgical assist in the future. We are looking for an efficient, hardworking team player with communication skills, caring and ability to adequately document is expected. Must have a current CA (PA or NP) license. We are willing to train the right candidate. For more information, fax resume to (619) 476-7963 Attn: Office Manager. NON-PHYSICIAN POSITIONS WANTED MEDICAL OFFICE MANAGER/CONTRACTS/ BILLING PERSON: MD specialist leaving group practice, looking to reestablish solo private practice. Need assistance reactivating payer contracts, including Medicare. If you have that skill, contact ljmedoffice@yahoo.com. I’m looking for a project bid. Be prepared to discuss prior experience, your hourly charge, estimated hours involved. May lead to additional work. PRODUCTS / SERVICES OFFERED DATA MANAGEMENT, ANALYTICS AND REPORTING: Rudolphia Consulting has many years of experience working with clinicians in the Healthcare industry to develop and implement processes required to meet the demanding quality standards in one of the most complex and regulated industries. Services include: Data management using advanced software tools, Use of advanced analytical tools to measure quality and process-related outcomes and establish benchmarks, and the production of automated reporting. (619) 913-7568 | info@rudolphia.consulting | www.rudolphia.consulting

SanDiegoPhysician.org 19

POETRY AND MEDICINE

Involuntary Enlightenment By Daniel J. Bressler, MD, FACP

PATIENTS OFTEN TELL me that “when the time comes” they want to “die with dignity.” Many explain that they imagine coming to terms with their achievements and failures, finalizing their spiritual beliefs, and saying heartfelt goodbyes. It turns out that this lofty goal, so widely shared, is hard to plan for. Even with the most sophisticated end-of-life conversations and Advance Directives, so many factors are determined by dumb luck. What is the terminal disease? Is pain control an issue? Is there mental decline or depression? How robust is the social support network? The answers to these questions often lie outside the control of the patient or the medical team. My father, Marty, retired from engineering in his 60s and spent the next 30 years diving deeply into a variety of topics that piqued his interests. His opinions were intensely held and vigorously prosecuted. People in his activity circles found him fascinating and fact-filled. Those 20

March 2020

of us in his family could add dogmatic and short-fused. He stayed physically and mentally active until about a year before his death from congestive heart failure in March of 2019. A few months before the end he had a period of relative calm. Unexplainably — one could say luckily — his anger gave way to sweetness. His intellectual faculties were disappearing but his emotional range expanded. He would kiss me hello and goodbye, something he’d never done before. I came to imagine that he had been granted spiritual compensations for a failing body. Perhaps this poem’s depiction is merely an act of wishful thinking. Perhaps it is true. Dr. Bressler, SDCMS-CMA member since 1988, is chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and a longtime contributing writer to San Diego Physician.

Involuntary Enlightenment For MB, Of Blessed Memory, 1924–2019 At the same kitchen table where you ranted For decades from your encyclopedic expertise And skewered anyone who might disagree Now, all that bluster drained by stroke, Replaced by a toddler’s blithe sweetness Your only demand for another cookie Your only slander for the saltless soup Your tirades transformed to puzzlement As a stranger guides your walker to your home hospital bed for a nap Between slow meals and urgent trips to the toilet You scan the words on the screen of your Kindle Oblivious to their context The lights of your high beam intellect blinked out. California coastal flowers, gone. Information theory, blank. Your obsession with tax-sheltered municipal bonds Replaced by the docile mystery of the present moment. Like the Buddhist Master dangling from a cliff’s vine Yet pausing to savor its sweet berry So you are only here, only now. The brain hemorrhage and heart failure have brought Along with the swollen legs and incontinence Involuntary Enlightenment. Beyond all judgment and calculation, You have glimpsed the Beatific Vision. Unable to grasp crossword puzzles or politics Your attention alights on Being itself. Preparing for your place at the next Kitchen Table Where all topics are discussed without rancor And where all viewpoints have the full consideration Of the Ultimate Authority.

SanDiegoPhysician.org 21

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