March 2021 by San Diego Physician

MARCH 2021

Official Publication of SDCMS

Celebrating 150 Years

OUTDOOR DINING

LOCKDOWNS AND VACCINES

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 Art Director: Lisa Williams Copy Editor: Adam Elder

VOLUME 108, NUMBER 3

OFFICERS President: Holly B. Yang, MD President-Elect: Sergio R. Flores, MD Secretary: Toluwalase (Lase) A. Ajayi, MD Treasurer: Nicholas J. Yphantides, MD Immediate Past President: James H. Schultz, MD GEOGRAPHIC DIRECTORS East County #1: Heidi M. Meyer, MD (Board Representative to the Executive Committee) East County #2: Rakesh R. Patel, MD Hillcrest #1: Kyle P. Edmonds, MD Hillcrest #2: Steve H. Koh, MD (Board Representative to the Executive Committee) Kearny Mesa #1: Anthony E. Magit, MD Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Preeti Mehta, MD La Jolla #2: David E.J. Bazzo, MD, FAAFP North County #1: Patrick A. Tellez, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Kelly C. Motadel, MD, MPH South Bay #2: Maria T. Carriedo, MD AT-LARGE DIRECTORS #1: Thomas J. Savides, MD #2: Paul J. Manos, DO #3: Irineo “Reno” D. Tiangco, MD #4: Miranda R. Sonneborn, MD #5: Stephen R. Hayden, MD (Delegation Chair) #6: Marcella (Marci) M. Wilson, MD #7: Karl E. Steinberg, MD #8: Alejandra Postlethwaite, MD ADDITIONAL VOTING DIRECTORS Young Physician Director: Brian Rebolledo, MD Retired Physician Director: Mitsuo Tomita, MD Resident Director: Nicole Herrick, MD Medical Student Director: Lauren Tronick

CMA TRUSTEES Robert E. Wailes, MD William T-C Tseng, MD, MPH Sergio R. Flores, MD

AMA DELEGATES AND ALTERNATE DELEGATES District 1 AMA Delegate: James T. Hay, MD District 1 AMA Alternate Delegate: Mihir Y. Parikh, MD At-large AMA Delegate: Albert Ray, MD At-large AMA Delegate: Theodore M. Mazer, MD At-large AMA Alternate Delegate: David E.J. Bazzo, MD, FAAFP At-large AMA Alternate Delegate: Kyle P. Edmonds, MD At-large AMA Alternate Delegate: Robert E. Hertzka, MD At-large AMA Alternate Delegate: Holly B. Yang, MD CMA DISTRICT I DELEGATES Karrar H. Ali, DO Steven L.W. Chen, MD, FACS, MBA Susan Kaweski, MD Franklin M. Martin, MD Vimal I. Nanavati, MD, FACC, FSCAI Peter O. Raudaskoski, MD Allen Rodriguez, MD Kosala Samarasinghe, MD Mark W. Sornson, MD Wayne C. Sun, MD

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

Features

SDCMS & COVID-19 By Paul Hegyi, MBA

A Recipe for Trouble? Reversal of California Outdoor Dining Ban Has Heads Spinning By Anna Almendrala

Op-Ed: Do ‘Lockdowns’ Work? If So, How Much? By Vinay Prasad, MD, MPH

80% of COVID-19 Patients May Have Lingering Symptoms, Signs By Judy George

Departments

The Strange Neurology of the Anonymizing Mask By James Santiago Grisolía, MD

Briefly Noted: Office Management • Vaccines

New Obesity Medicine Society Formed to Help Meet the Growing Obesity Crisis By Ken Fujioka, MD, Eduardo Grunvald, MD, Ray Plodkowski, MD, Michelle Look, MD and Mark Jabro, MD

The Gift of Sight By Adama Dyoniziak

Classifieds

Words Matter: The Responsibilities of Freedom By Helane Fronek, MD, FACP, FACPh SanDiegoPhysician.org 1

BRIEFLY NOTED 2

March 2021

OFFICE MANAGEMENT

Jazmin Miller Named Office Manager of the Year by SDCMS DR. TIMOTHY BAILEY WROTE THE following in nominating Jazmin Miller to be named the Office Manager of the Year by the San Diego County Medical Society: “Advanced Metabolic Care + Research is a growing independent single-specialty endocrinology practice located in North County San Diego. Six years ago we began our growth from a small two-physician single-specialty practice to nine endocrinologists plus two PA’s and three NP’s (a total of 14 prescribers total), making us the largest independent endocrinology group in California. “Jazmin Miller joined us just over three years ago to help us with our implementation of a LEAN production system. Shortly thereafter, she succeeded our previous medical office manager. Under her leadership our team has grown to 60 employees. As practice manager, she both exerts appropriate management controls and ensures high morale among our hardworking staff. “In 2020 she mentored and promoted from our ranks a total of four new departmental managers in order to manage our large staff more effectively. She has done this with great humility, integrity, resolve, thoughtfulness, and intelligence. Because of this she is highly respected and beloved by all staff. “Under her leadership, profits have increased and staff retention has been excellent — even during COVID-19. Jazmin has also been highly effective in growing business relationships with our customers by meeting with them and communicating our value to them. She has been instrumental in helping us negotiate our contracts. Contracts and reimbursements have significantly improved. During 2019–2020 we became clinically integrated (while remaining

independent as a business) with UC San Diego, and with this achieved significant additional compensation due to successful MIPS reporting. “When the pandemic hit in March 2020, Jazmin was instrumental to our survival. Through her efforts we were able to secure PPP funding and were able to keep 100% of our employees to provide uninterrupted services to our patients. We struggled to learn telehealth (within one week!) and were supported by Jazmin and her team. Also important in our success were weekly updates on how to code for these new telehealth services. Staff were remoted as much as possible and daily health screening was instituted. We have maintained adequate PPE and have a policy of universal masking (providing masks to patients who do not have one) to keep everyone safe.” Congratulations to Jazmin on her hard work and dedication to Advanced Metabolic Care + Research. SDCMS is thrilled to recognize Jazmin as the SDCMS Outstanding Office Manager of the year!

VACCINES

CMA President: The Importance of Physician Voices in the Effort to Vaccinate California CALIFORNIA MEDICAL ASSOCIATION President Peter N. Bretan Jr., MD, issued this statement on vaccination efforts in the Golden State in a letter to every physician member of CMA: The approval of two COVID vaccines in December 2020 has brought some much-needed positive news in the fight against COVID-19. But we know that many physicians are still struggling to find useful and reliable information to share with their patients about how and when vaccines are coming to their community. While supply continues to be an issue, CMA is engaged with the Newsom Administration to ensure the needs and voices of California physicians, and their patients, are heard. We have successfully pushed the Newsom Administration to relax the strict tier system for vaccine prioritization that was causing confusion and slowing down the vaccine distribution process and are now working to ensure our vast network of community physicians are deployed as a key part of the vaccination solution. We also argued that we needed a statewide, rather than a decentralized local strategy, to simplify navigating the system for both physicians and the general public. CMA has demonstrated its ability to reach community physicians and shown the state how it is possible to equip those who most directly serve the communities across the state. When California struggled to get personal protective equipment (PPE) in the hands of community practices, they turned to CMA. So far CMA, with help from our component medical societies, has distributed more than 100 million pieces of PPE to physician practices across California. CMA can help connect state administrators with community

physicians to build a robust vaccination network and help the state meet its goal of getting California vaccinated. Equity and speed are both vital components of any successful vaccination strategy. We must make sure we do not compromise one in the name of the other, and that we have a fast, effective, and fair distribution of vaccines statewide. That means getting the vaccine into the communities that need it most. We do not have to reinvent the wheel. We can simply stick with what has worked for other types of vaccinations. That means fully engaging community-based physicians so that people can be vaccinated in a place they are familiar with, under the care of a provider they trust. Millions of Californians receive care from an independent physician practice. This is the place where they get their routine vaccinations and annual flu shots. We must ensure, when supply allows, they can get their COVID vaccination the same way. Community physician practices have the capability to administer 4.5 million doses of COVID vaccines requiring refrigeration per month statewide, according to projections based on recent CMA survey results. These practices can reach patients who may not have the technological savvy to schedule an appointment through a new smartphone app or the ability to wait in line all day at a mass vaccination clinic. While smartphone apps and mass vaccination sites are an important part of the solution, they cannot be the entire solution. CMA is fighting to get the vaccine in the hands of communitybased physicians who can most easily and effectively reach Californians where they live — particularly those that are in lowincome communities and/or communities of color.

CMA leaders have made this case in hours of discussions with senior Newsom Administration officials, and collected some of these ideas in a recent letter to the governor’s office. Simplifying the eligibility framework and standardizing vaccine information and data on a statewide basis are necessary to connect our communities to vaccination in a timely way. These changes will accelerate the rate of vaccinations across California and improve the experience of both vaccine administrators and vaccine recipients. Meanwhile, we are also working to make it easier for the thousands of physicians who have reached out looking to help staff vaccine clinics in their communities and around the state. Last month, the governor signed an Executive Order that extends liability protections to physicians and other vaccine administrators — something that CMA had requested for months. We know that your patients want to know when they will be able to get the vaccine. The short answer is, we don’t know yet. But we are fighting to make sure the concerns of all of you, and your patients, are heard. Despite the frustrations, we are making progress, and will continue to advocate on your behalf, and keep you informed of our efforts. I encourage you to regularly visit CMA’s COVID-19 vaccine page for the latest information. SanDiegoPhysician.org 3

COVID-19 BY PAUL HEGYI, MBA

SDCMS & COVID-19 Left: Petco Park vaccination site. Center: SDCMS CEO Paul Hegyi volunteering. Right: SDCMS President Holly Yang, MD, volunteering at Petco Park site.

s we approach a year dealing with the COVID-19 pandemic, SDCMS continues to lead in helping our community respond. Since the approval of Pfizer’s emergency use authorization (quickly followed by Moderna), our focus has been on vaccinations. Initially, hospitals were the primary source of vaccinations, leaving many community physicians and even more of their staff in the wilderness. Hearing these concerns, SDCMS quickly worked with the County to expand community opportunities and ensure local health workers were protected as quickly as possible. In early January the first Vaccination Super Station was launched at Petco Park, made possible with a partnership between UC San Diego Health, the County of San Diego, the Padres organization, and the City of San Diego. This Super Station was the first of its kind in California, developing from an idea to a reality administering doses in a mere five days! It is now averaging 5,000 doses a day and passed 100,000 total vaccinations on Feb. 4. Petco has since been joined by four more Super Stations across the county and more than a dozen smaller county points of distribution (PODs). Many of you have volunteered through the County or UC San Diego to help with these efforts, and we can’t begin to express how much we appreciate it. Our own charity, Champions for Health, has entered the vaccination game as well, working on behalf of the County to train vaccinators and reach some of the most hard-to-get patients. The Champions team has trained more than 800 medical staff and vaccinated more than 1,100 seniors and healthcare workers (in just the first few weeks of this program). SDCMS is working on expanding vaccine access into more physician practices. While Super Stations are an important piece of vaccinating the community, many patients are looking to the physicians with which they have long relationships. This will be critical in dealing with the hesitancy many have expressed about these new vaccines — research has repeatedly shown that patients trust their physician when it comes to these issues. Another ongoing effort of the medical society has been the clinical town halls we host in conjunction with County Health and Human Services and the Hospital Association of San Diego & Imperial Counties. We are constantly 4

March 2021

adjusting topics and panelists to ensure the most relevant content for participants. Last summer SDCMS hosted a huge PPE Relief event in the parking lot of Jack Murphy Stadium, distributing nearly 800 cases of PPE material worth over $3 million to small and medium practices. Since then we have continued smaller efforts to help supply practices having difficulty filling PPE orders, with a new program currently in development. To learn more, reach out to membership@ sdcms.org. Finally, the policy side of this pandemic is something SDCMS has been actively involved in. Since the summer, when activists frustrated with social distancing orders and other non-pharmacological efforts were threatening public health officers across the state and country, we rallied around the public health officials here in San Diego and made clear that treatment would not be accepted. I think we made a real impact and your SDCMS team continues to attend every COVID-related County board meeting to ensure the voice of medicine is heard. We’re not out of the woods yet, but with more than 14% of our community vaccinated as of this writing (Feb. 8), we are much closer. Together we’ll beat back this outbreak and be able to return to some semblance of normality. Paul Hegyi is chief executive officer of the San Diego County Medical Society.

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COVID-19

A RECIPE FOR TROUBLE? Reversal of California Outdoor Dining Ban Has Heads Spinning BY ANNA ALMENDRALA 6

March 2021

utdoor dining is resuming in California under state and local orders issued in February — but with COVID cases, hospitalizations, and deaths still far higher than they were when the bans took effect, restaurant owners and workers are wary of reopening their patios and parking lots. Los Angeles County’s outdoor dining ban began Nov. 25, and a statewide ban, part of a broader stay-at-home order, took effect Dec. 5. No clear data from contact tracing could justify outdoor dining bans, public health officials acknowledged. New cases in California are down nearly 65% from last year’s peak on Dec. 15, but still high enough to prompt confusion about why Gov. Gavin Newsom allowed outdoor dining and other activities to resume. As has frequently been the case during the pandemic, messaging is mixed regarding the safe way to return to outdoor dining. When California Health and Human Services Secretary Mark Ghaly appeared in a video to explain the lifting of the ban, a slide alongside him said, “If you miss a friend, you can go out to eat outside at a restaurant together.” But L.A. County’s new rules for outdoor dining restrict tables to people within a single household. Some scientists think the policy whiplash erodes trust in health messaging. “The original decision to close was not data-driven, and therefore the decision to reopen wasn’t data-driven,” says Dr. Monica Gandhi, a professor of medicine and an infectious diseases doctor at the University of California San Francisco. “It looks like you’re not cleanly following numbers and making recommendations appropriately, and that can really confuse people.” Measuring the impact of outdoor dining on COVID transmission is difficult because the activity changes with the

seasons, and it coincides with other activities that move from indoors to outdoors in nicer weather, says Aaron Yelowitz, a professor of economics at the University of Kentucky, who co-authored a nationwide analysis that measured the effects of the earliest shutdown orders on COVID transmission. COVID transmission in L.A. decreased within two weeks of the outdoor dining ban, a data point suggesting that the stop played a role in curbing the spread of the coronavirus. With conditions no better, or even worse, than they were in November, the new order “doesn’t make sense,” said Billy Silverman, owner of Salazar, a Mexican barbecue restaurant in Los Angeles. The county department of health seemed to affirm Silverman’s observation on the first day L.A. restaurants could reopen for outdoor dining. “Although some restrictions were just lifted, we’re still in a very dangerous period in terms of cases, hospitalizations, and deaths,” said county health officer Dr. Muntu Davis. He noted that L.A. County had 7,112 new cases and 228 deaths, and that 5,855 people were hospitalized with the disease. While much lower than in mid-January, the COVID burden is far higher than it was on Nov. 22, the day the county announced the outdoor dining ban, when it reported a daily tally of 2,718 cases, nine deaths, and 1,401 hospitalizations. If the COVID numbers don’t improve in coming weeks, Silverman said, he can’t justify reopening his 120-seat, mostly outdoor restaurant. Though completely closed for more than half a year and then operating at 50% capacity in the fall, the business has managed to stay afloat with the help of a federal Paycheck Protection Program loan. Silverman tried to operate with only takeout and delivery when L.A. County instituted its outdoor dining ban, but he couldn’t break even on sales to cover

SanDiegoPhysician.org 7

the labor costs. Having laid off around 65 people in March, he furloughed his workers — a much smaller kitchen crew by then — a second time in early December. “I’ve talked to a lot of staff members, and they don’t feel comfortable rushing back to a potentially hazardous situation,” Silverman says. “I’m not going to do that to them.” Christian Albertson, co-owner of the Monk’s Kettle tavern in San Francisco, was also stunned by the reversal. “I can’t wrap my head around it, especially when the vaccine is so close,” Albertson says. “It just feels crazy. It is absolutely insane that we’re opening right now.” The slow, uneven vaccine distribution makes this a precarious moment, says Jennifer D. Roberts, an assistant professor at the University of Maryland school of

March 2021

public health. As the shots trickle out through the community, starting with the eldest and most vulnerable residents, younger service workers — many of whom live in multigenerational homes — could be put at risk if customers relax habits like mask-wearing and physical distancing, she said. Still, Albertson planned to resume outdoor dining in mid-February, to coincide with California Craft Beer Week. He’s confident in the protocols his restaurant developed last year to keep staffers and customers safe in a 30-seat patio area. Revenue in 2020 was down 55% compared with 2019 at Monk’s Kettle; the business is being kept afloat with governmental loan programs. “I’d much rather wait a month or more and then have everyone come back permanently,” he said. “Right now, it’s ‘Come back, and let’s see if we can get past

the first couple of weeks before cases start going up again.’” At the heart of the issue is the lack of data showing that outdoor restaurant dining has had a role in the spread of COVID. The strongest research to date includes a Centers for Disease Control and Prevention study that found COVIDpositive people were more than twice as likely to report eating at a restaurant two weeks before getting sick. A Stanford-led study found that restaurants operating at full capacity spread four times as many additional COVID cases as the next-worst venue, indoor gyms. Neither of these studies differentiated between indoor and outdoor seating. In the final few months of 2020, cases were rising rapidly in Los Angeles and throughout the state, however, and officials targeted outdoor dining in the absence of anything else they could regulate. With the state’s spotty contacttracing efforts insufficient to connect outdoor dining to disease transmission, officials gave different explanations for the ban. L.A. County’s Department of Public Health Director, Barbara Ferrer, said it was needed because outdoor dining required customers to take off their masks, raising the risk of transmission. Ghaly, the state official, said the ban had a broader aim. Transitioning to takeout and delivery “really has to do with the goal of trying to keep people at home, [and is] not a comment on the relative safety of outdoor dining,” he said Dec. 8. “That was the frustrating part for us — that it was like a hunch,” says Jot Condie, president and CEO of the California Restaurant Association, which represents about 22,000 restaurants in the state. “They had a hunch that this was probably not safe, and let’s just shut it down.” Condie’s association won a lawsuit against the county to overturn the ban, but by then the state’s regional orders

were in place. Since the orders restricted individuals from everything except work, essential errands, and exercise, the group didn’t escalate its suit to the state level, as restaurants weren’t being singled out. Restaurants, perhaps more than any other industry, have borne the brunt of back-and-forth pandemic restrictions. Up to 1 million Californian restaurant workers have been laid off or furloughed since the pandemic began, according to the California Restaurant Association, and 30% of the 396 restaurant owners the association surveyed said they were at risk of closing or downsizing. In December, California’s leisure and hospitality sector lost 117,000 jobs, the largest sector lost in the state, and most of these positions were in food services.

The loss of so many restaurant positions has made the job market extremely competitive for laid-off workers, adding pressure to job searches. Vincent Campillo, a 38-year-old bartender in Los Angeles, lost both his jobs at the beginning of the pandemic and has been living on unemployment benefits since. He began to pick up occasional fillin shifts toward the end of 2020. “It’s ridiculous that L.A. is opening right now,” Campillo says. “It blows my mind and I can’t understand it.” Newsom’s announcement seemed to divide the city into haves and have-nots, he said. Customers are cheering a return to outdoor restaurant dining, but Campillo is filled with dread. While young and healthy, he joked that he didn’t know if he

and COVID would “get along,” and didn’t want to find out. Yet Campillo said he would return to work if asked, to maintain the relationships and networks he needs to remain employed long term. He hopes to get a vaccine as soon as they are offered to food service workers. “I don’t know why I should be put in that place just so that someone can have a glass of natural wine and a charcuterie plate,” Campillo said. “People who are desperately in need of an income have to be the ones to serve them and put themselves in harm’s way.” Anna Almendrala is a correspondent for Kaiser Health News, where this article first appeared.

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COVID-19

OP-ED:

DO ‘LOCKDOWNS’ If So, How Much?

BY VINAY PRASAD, MD, MPH

n response to the COVID-19 pandemic, there have been thousands of specific policies instituted around the globe. At times, restrictions have been big and bold. Recently, the city of Perth, Australia, was placed in “lockdown” after a single case of SARS-CoV-2. Other restrictions have been focused: removing swings from playgrounds, capping the number of dining guests, or limiting the time for meals (90 minutes). One Toronto suburb closed outdoor ice-skating rinks, toboggan hills, and dog parks. The sheer variety of restrictions meant to curb the spread of SARS-CoV-2 raises important questions: Which ones work? And how big are their effects? I suspect that for many restrictions — perhaps even most restrictions — we will never know. We will never know, for instance, if removing the rim from a basketball hoop or closing a toboggan hill slowed SARS-CoV-2 where these strategies were deployed. For larger interventions — mandatory business closure and stay-at-home orders, colloquially called “lockdowns” — we may someday have a scientific consensus as to whether and to what degree this practice changes viral spread, but I believe that day is years away. Here I wish to highlight challenges with understanding these interventions.

March 2021

WORK?

Challenges With Identifying the Effect of Lockdowns

Already some studies have yielded mixed results. One analysis has found that mandatory business closure and stay-at-home orders were not associated with a reduction in infections. Another analysis did find a reduction. Both have limitations. Allow me to highlight some challenges that most research on this topic will face. First, lockdown is not expected to yield immediate results. One has to account for the typical lag before an effect can realistically show up, but this introduces analytic flexibility. Should we look for effects seven days later, or five, or 15? If we look too soon, we might get the wrong idea. An intervention that slows viral spread may appear to lead to viral spread because we deployed it on the upslope (reverse-causation). Alternatively, if we lag the analysis too much, we might see the impact of other interventions or the natural shape of the pandemic curve. Second, places often institute multiple restrictions concurrently, alongside powerful media messages to the public. In other words, was it the business closure that helped, the fact the nightly news scared people, or was it another restriction that occurred at the time of (or close to) the business closure that changed outcomes? Third, there are many ways to define “lockdown”; many regions, municipalities, or countries to include or exclude; many ways to model the data; and many investigators who will probe the dataset. Put together, the range of “answers” is certain to vary widely. A team from Edmonton, Alberta, defining lockdown as all business closures of more than three days, and looking at the county level data for 12 countries, might get a different “answer” than a group from Boston defining lockdown as any nonessential business closure, and looking at national data from 82 countries. Already we see a hint of the variety of answers that may be generated.

SanDiegoPhysician.org 11

In the long term, I am hopeful that somewhere in this sea of data, there may be a natural experiment that analysts can take advantage of to provide some clarity.

‘Lockdown’ Is Not Like an Aspirin

Fourth, restrictions might be even more complicated. A lockdown is not like an aspirin. It may not exert the same effect every time it is deployed. Lockdowns might have different effects based on the case rate. Lockdowns might help when cases are just a handful, as in Perth, in an effort to drive them to zero. Or lockdowns might only work when case rates are modest (1 case per 10,000 residents). Alternatively, lockdowns might work when case rates are brisk (1 per 1,000 residents). Perhaps lockdowns work in none of these cases, or just the first and second scenario. In other words, the effect of lockdowns may depend on the rate or absolute number of cases, or many other biologic factors (e.g., population density). Fifth, the same lockdown in the same location with the same enforcement

March 2021

may have diminishing effects. If people are feeling a sense of purpose and camaraderie, there may be a positive effect, but if those same people feel distrustful or fatigued, there may be a negative one. Lockdowns depend on the buy-in of the populace. The desire to isolate yourself wanes over time. What worked in April might not work in November. Sixth, lockdowns might have different effects based on the culture of the region, the practices of bordering nations, household density, or the political climate. What works in Norway might not work in the U.S. What works in New Zealand might not work in Canada. Seven, lockdowns depend on media coverage. Previously I alluded to the fact that it will be challenging to separate the effect of lockdown policies from the fact that the media coverage of COVID naturally encourages people to hunker down. Here, consider that lockdowns might work better when media coverage is lax, but less so when it is frenetic.

Because in the latter case, the additional people who change behavior due to the mandate may be few. Eight, lockdowns depend on specific behaviors that drive spread. In a region where daily interactions are driving spread, lockdowns may work. In a region where all spread occurs in a meat processing plant, the same lockdown may have no effect if the plant remains in operation. These considerations are just a few of the methodologic challenges with figuring out whether lockdowns work. And they do not even touch the harder question of: What are the complete effects of lockdown? What is the effect of restrictions on education, mental health, cardiovascular, and other societal outcomes? And when do these occur? Finally, I must mention that some may frame this entire discussion differently. They may start with the premise that the goal of policies is to separate people to prevent spread, and consider lockdowns alongside all other measures. I support

research efforts to examine the question in this manner as well. I wish this discussion captured all the complexity to lockdowns, but there is one more factor that must be considered. In cancer medicine, methotrexate is an effective drug, but you often have to give leucovorin to overcome the devastating side effects. Similarly, a lockdown might have one set of effects in a nation with a strong social safety net or strong unemployment insurance, and a different set of effects in a nation with a tattered safety net and no unemployment insurance. Resources are the antidote to lockdown, and resources are not evenly distributed or deployed. All studies of lockdowns should account for varying resources. This discussion has just been about one class of restriction or rule, but what about closing playgrounds, or removing swings, or closing ice rinks, or the many other specific policies implemented? For some of these interventions, I believe the plausibility is low. It is unlikely — on the face of it — that closing playgrounds will substantively curb viral spread, and these have met fierce opposition. A future society may look back critically on many of these policies. For many other policies, we may never know whether they helped or hurt.

Pundits Need Humility

When I think about the past year and the thousands of interventions we deployed to combat the coronavirus, I am saddened to know we will end with very little idea of which specific interventions helped, which hurt, and which were neutral. Imagine you ran a multi-trillion-dollar study and you didn’t get any answer at all. Going forward, we must be more thoughtful in applying restrictions. Municipalities should avoid throwing the kitchen sink at once. Implementing things in sequence, with time between policies, can help disentangle which policies help and which do not. Coordinated action can help. If 20 municipalities work together, and 10 try a set of some interventions and 10 others try different ones, we may start to learn which work, and to what degree.

Repeating this experiment is the path to knowledge. Next, with restrictions must come resources. Each policy meant to curb the spread of the virus may have harmful side effects. These harms must be measured and documented. Right now, we know little about how restrictions affect people, particularly poor and vulnerable ones. Resources can be applied to mitigate these harms. Folks concerned with the downsides of lockdown should not be demonized, ostracized, and marginalized. We must engage with them. Pundits must have humility. Each day on Twitter, I see doctors, epidemiologists, or policy experts definitively proclaim what we ought to do. These comments often prompt fierce backlash from folks equally confident that these interventions hurt. The truth is there is massive uncertainty, and being honest about that might make for more productive conversations and compromise. Lastly, policymakers must be upfront with the public as to the goals of intervention and under what circumstances the restrictions can be relaxed. Specific benchmarks for when and how policies are deployed and when they can be eased must be posted for public view in advance of deployment. Finally, we must not confuse matters of science with matters of morality. Most people want to minimize suffering and death, and disagreements are about how to do so, not the goal. Whether and to what degree restrictions work and under what circumstances is a set of scientific questions. Let me be the first to admit that I simply do not know the answers. Moreover, I believe the real answers will take years to emerge. As is often the case in life, distance brings wisdom. Dr. Prasad is a hematologist-oncologist and associate professor of medicine at the University of California San Francisco, and author of Malignant: How Bad Policy and Bad Evidence Harm People With Cancer. The views expressed above are his own, not his institution’s or of the San Diego County Medical Society. This column first appeared in MedPage Today.

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SanDiegoPhysician.org 13

ORGANIZED MEDICINE: OBESITY

New Obesity Medicine Society Formed to Help Meet the Growing Obesity Crisis By Ken Fujioka, MD, Eduardo Grunvald, MD, Ray Plodkowski, MD, Michelle Look, MD, and Mark Jabro, MD

T’S NO SURPRISE THAT THE

most common chronic medical disease affecting San Diego is obesity. If you are the lucky one-third of San Diegans who are normal weight, you can look to your left and you will see someone struggling with obesity; when you look to your right, you will see someone that is overweight. What might be surprising, but makes perfect sense, is that the fastest growing medical specialty is obesity medicine. In February of this year, close to 1,500 applicants will take the American Board of Obesity Medicine (ABOM) certification exam. More than 4,000 MDs or DOs have already passed this exam. This is truly remarkable when one considers the fact that the ABOM has been in existence for only the past 10 years. Another key piece in the explosion of healthcare providers (HCPs) interested

March 2021

in obesity medicine is the remarkable research that has mapped out the hormones that regulate weight. We now know the hormones, where they go, which receptors they engage and how they work. The pharmaceutical companies have copied all these hormones and they are in clinical trials as we speak. It is predicted that over the next five to 10 years HCPs will have the ability to control weight by giving a once a week injection of these exact hormones and physiologically control the set point. This is truly a great time to be in this field as patients will see rather impressive weight loss, and great improvements in their health and comorbidities. In the not too distant future, we will be able to manage obesity with a variety of classes of drugs in combination with evidence-based nutrition and lifestyle interventions — very similar to how we

treat other chronic conditions, such as diabetes and hypertension. Many HCPs in San Diego have taken and passed the ABOM exam. Now that there is a significant number of obesity medicine specialists in our region, a society has formed to foster the growth of this field. The group is known as the San Diego Obesity Medicine Society (SDOMS). The mission of SDOMS is to support the growth, recognition, and dissemination of obesity medicine in San Diego. SDOMS plans to accomplish this through education, collaboration, and scholarship. Education is the key, as many physicians can attest to patients asking questions about some crazy sounding diet or a “wonder berry” supplement that is guaranteed to produce 30 pounds of weight loss in just two weeks. SDOMS envisions helping both physicians and patients to separate good and safe weight-loss options from the massive amounts of misinformation. The vision of SDOMS is also along these lines. Basically put, SDOMS hopes to improve the lives of patients struggling with obesity. More importantly, SDOMS hopes to accomplish this through scientifically proven treatments; in other words, evidence-based medicine. 2021 looks to be a good year for the beginning of SDOMS. As of this writing it is a small, dedicated group that will be opening up to membership later this year. We hope to meet the needs of San Diego physicians and allied fields wanting knowledge, camaraderie, networking, and mentorship in obesity medicine. The authors are the founding members of the San Diego Obesity Medicine Society. Dr. Fujioka is at Scripps Weight Management and serves as president of the Society; Dr. Grunvald of the UC San Diego Bariatric and Metabolic Institute is president-elect; Dr. Plodkowski of Scripps Weight Management is vice president; Dr. Look of San Diego Sports Medicine & Family Health Center is secretary; and Dr. Jabro of Sharp Weight Management is treasurer.

INFECTIOUS DISEASE

80% of COVID-19 Patients May Have Lingering Symptoms, Signs More Than 50 Effects Persisted After Acute Infection, Meta-Analysis Shows By Judy George

IGHT OF 10 COVID-19

patients had lingering symptoms or signs 14 or more days after acute infection, a systematic review and meta-analysis showed. More than 50 symptoms tied to SARS-CoV-2 infection persisted, most commonly fatigue (58%), headache (44%), attention disorder (27%), hair loss (25%), dyspnea (24%), and anosmia (24%) were identified, according to Sonia Villapol, PhD, of Houston Methodist Research Institute in Texas, and colleagues. The findings were reported in a medRxiv preprint and have not undergone peer review. “We estimated that a total of 80% of the patients infected with SARSCoV-2 developed one or more long-term symptoms,” Villapol said. “Preventive measures, rehabilitation techniques, and clinical management strategies designed to address prevalent long-term effects of COVID-19 are urgently needed,” she told MedPage Today. To date, there’s no established diagnosis for the slow, persistent condition that people with lasting effects of COVID-19 experience; terms like “long COVID,” “long haulers,” and “post-acute COVID-19” have been used, Villapol and colleagues noted. In their review, they referred to lingering symptoms and signs as “long-term effects of COVID-19.” Last year, a widely-cited CDC survey showed 35% of COVID-19 patients had not returned to usual health two to three weeks after testing positive, but those were mild, outpatient cases. Early in 2021, a study in the Lancet showed that six months after illness onset, 76% of hospitalized COVID-19 patients in Wuhan, China, reported at least one

symptom that persisted, mostly fatigue or muscle weakness. In their meta-analysis, Villapol and colleagues included 47,910 people with a confirmed COVID-19 diagnosis in 15 studies that had evaluated symptoms, signs, or laboratory parameters two weeks or more post-viral infection. Each study had a minimum of 100 patients. Nine studies were from Great Britain or Europe; three were from the U.S. Six studies focused only on people hospitalized for COVID-19; the others included mild, moderate, and severe cases. Patients ranged from ages 17 to 87 years, and follow-up time ranged from 14 to 110 days. Fatigue was the most common symptom of both long and acute COVID-19, Villapol and colleagues noted: “It is present even after 100 days of the first symptom of acute COVID-19.” During follow-up, 34% of patients had an abnormal chest X-ray or CT. Elevated markers also were seen, including D-dimer (20%), NT-proBNP (11%), C-reactive protein (8%), serum ferritin (8%), procalcitonin (4%), and IL-6 (3%). Other lingering symptoms were pulmonary (cough, chest discomfort, reduced pulmonary diffusing capacity, sleep apnea, pulmonary fibrosis), cardiovascular (arrhythmias, myocarditis), or neurologic or psychiatric (memory loss, depression, anxiety, sleep disorders). All meta-analyses showed medium to high heterogeneity. “Future studies need to stratify by sex, age, previous comorbidities, severity of COVID-19 (ranging from asymptomatic to severe), and duration of each symptom,” the researchers wrote. From the clinical perspective, multidisciplinary teams with whole-pa-

tient perspectives are needed to address long COVID-19 care, they added. Limitations include possible selection or reporting bias, small sample sizes for some outcomes, and variation in how outcomes and markers were defined. “Another limitation is that, given that COVID-19 is a new disease, it is not possible to determine how long these effects will last,” Villapol and colleagues said. “To determine whether these long-term effects either complicate previous diseases or are a continuation of COVID-19, there is a need for prospective cohort studies,” they added. Measures like blood markers of genetic, inflammatory, immune, and metabolic function need to be standardized to compare studies, and open questions should be included. Judy George is a senior staff writer for MedPage Today, where this article first appeared.

Disclosures The research was supported by the National Institute for Neurological Disorders and Stroke and the Houston Methodist Research Institute. Villapol disclosed no relevant relationships with industry. A co-author is an employee of Novartis. Primary Source: medRxiv. Source Reference: Lopez-Leon S, et al “More than 50 Long-term effects of COVID-19: a systematic review and metaanalysis” medRxiv 2021; DOI: 10.1101/2021.01.27.21250617.

SanDiegoPhysician.org 15

PUBLIC HEALTH & POLICY

The Strange Neurology of the Anonymizing Mask Without Faces, We Work in a Sea of Muted Detachment By James Santiago Grisolía, MD

URING THE PANDEMIC, MASKING transformed my world, inside the hospital and out. A carnival profusion of masks blossomed outdoors in my safely distanced San Diego: outlaw bandannas, Khyber hoods, pets, skull mandibles, American flags, Mexican flags, secret service black — a street quilt of materials and prints. The most disturbing masks slightly distort the human face, seen sideways or zombie-colored. In the year that COVID-19 killed trick-or-treating, Halloween escaped its bonds and flooded our entire season. Inside the hospital, bland surgical masks and N95s prevail. Social smiles stay veiled, creating distance, impassivity, and disturbing flatness. Ghosts of eye crinkles provide the only clue to a hidden grin or snarl. Our hospital halls, now empty of visitors, enforce a new hush over nurses, therapists, and techs. Even the nursing stations lose their bustle as the masks and protective gowns muffle the usual clatter and chatter. Masking especially dampens the casual social interaction, the little smile at the elevator or when holding a door. Holding a door for someone so they don’t have to touch a potentially contaminated surface should garner more credit for gallantry, but masking somehow mutes both gesture and any gratitude. Acknowledging others becomes more subtle, a raised eyebrow or a quick nod. Without faces whole, many people just look past each other. Techs and custodians no longer meet my eyes; they stare into mid-distance, lost in their thoughts. Our brains hardwire facial recognition. It’s so important that newborns come programmed to lock onto faces, even two circles and a line if they’re set right. That newborn bundle must start bonding with caregivers to survive, and eye contact with faces starts the bonding. Soon babies can tell Mom from everyone else. Our right occipitotemporal cortex, in the fusiform gyrus, grows brain circuitry in two interlocking centers: one for identifying specific people and

March 2021

another for reading emotion through facial expression. We’re programmed to see faces everywhere, even in Viking photos of the surface of Mars. Masking blocks the gestalt system and forces our brains to break down individual features: eyes, brows, direction of gaze, body language. This less efficient system lets us recognize people who are already familiar, but not the nurse I barely know from another floor or the patient I see twice a year in the office. So, what are the positive aspects of masking? According to a Japanese survey, pre-COVID, wearing a mask made many women feel protected, less vulnerable. Some Muslim women say the same about wearing a veil. Another virtue for the Japanese women was getting by without makeup — certainly an advantage to anyone in a hurry or with sensitive skin. Outside the hospital, we can spin personal stories in a mask — sports fans, animal lovers, goths, music fans, foodies. Antimaskers can choose to undercut their own mask wearing with politics or irony. Certainly masking supports cosplay, especially among young people. “Plaguecore” embodies dressing like a medieval plague doctor, using the long-beaked mask and other regalia. With the pandemic, this once-arcane corner exploded in popularity, merging with trends in leather and in other period costumes. Of course, masked-singer contests spread rapidly from Korea to the U.S. and Europe, but an anonymous Milanese has been singing masked as Myss Keta for nearly a decade. Before, only her front-row fans wore masks; in the coronavirus era, she feels surrounded by fans everywhere. Masking can bring mystery and the thrill of fashioning a new self-creation. Yet wearing masks also stands for my solidarity with others, protecting other people from my potential infectivity while shielding myself. Ironically, the isolation of masking in turn masks a deeper connection, our unity before the virus. Truly we are together, alone. Dr. Grisolía is chief of staff-elect at Scripps Mercy Hospital in San Diego and a clinical neurologist. He is also editor of San Diego Physician. This article first appeared in MedPage Today.

CHAMPIONS FOR HEALTH

The Gift of Sight By Adama Dyoniziak

ll I saw was blobs and I couldn’t distinguish anything,” said Rosario, a 66-year-old Project Access patient with cataracts in both eyes. “I would be embarrassed because people would think that I was ignoring them, but really I couldn’t see them or didn’t know who they were.” Rosario always had health problems and when her vision began to worsen, she stopped leaving her house. She felt helpless — she was dependent on her husband and the Food Bank. She used to work for an agency that cleaned houses and offices. “With my cataracts, I couldn’t do anything,” she says. Then the COVID pandemic turned her isolation into hopelessness when her cataract operations had to be rescheduled. At one point Rosario said, “It’s OK if we aren’t able to schedule the surgery. At this point I just want to spend the rest of my years in my homeland [of Mexico] and die in peace.” Her husband, who is a farmworker, is the only family she has in San Diego. He is Rosario’s support system and they depend on each other. Project Access Care Manager Evelyn Penaloza was able to schedule the two cataract surgeries with Dr. Kelsi GreiderSideris and Dr. Maulik Zaveri of Greider Eye Associates. Penaloza coordinated medical interpreters and transportation while CSU San Marcos nursing students helped with surgery-day logistics. Now Rosario’s vision has greatly improved and she can do things on her own again. The two ophthalmologists were happy to volunteer their services. “I became a physician to improve the world on an individual level,” Dr. Greider-Sideris says. “Volunteering provides a lot of satisfaction. After surgery, a patient’s eyesight improves and they are happy again.” Dr. Zaveri agrees: “We see the smile and the look of joy on a patient’s “

Rosario and her husband

Dr. Maulik Zaveri

Dr. Zaveri with a patient

face. They finally see the world in a different way.” Rosario exclaims, “I had a great experience with both doctors from beginning to end. Everyone is so nice and I’m grateful to be able to see again. I can’t thank them enough.” Rosario has never gone to the beach and she wants to see the ocean. Most importantly, she looks forward to being reunited with her son and seeing her grandchildren. “With my vision restored, I can live a better life,” she says. Since 2008, Project Access has facilitated $21 million in care for more than 6,500 uninsured patients just like Rosario by providing free consultations and surgeries — all thanks to the dedication, time, and talent of our volunteer specialty healthcare physicians. Both Dr. Greider-Sideris and Dr. Zaveri expressed the power and

Dr. Kelsi Greider-Sideris

responsibility that physicians have to provide patients access to healthcare. “Connecting with people is the bottom line,” says Dr. Zaveri, “and Project Access is a wonderful program that allows us to connect with patients. It is incredibly rewarding to be a part of this process.” For every $1 spent on program expenses, we provide $10 in contributed healthcare services — a return on investment of 1,000%! Come join us at our second annual Champions Soirée — Waves of Wellness event at the Birch Aquarium on July 10 to raise money for Project Access San Diego. www.championssoiree. org. For more information about Champions for Health, please visit www. championsforhealth.org. Ms. Dyoniziak is executive director of Champions for Health. SanDiegoPhysician.org 17

CLASSIFIEDS CLINICAL TRIAL VOLUNTEERS NEEDED PARTICIPATION IN CLINICAL RESEARCH TRIALS: Physicians in the following specialties are needed for participation as Principal or Sub-Investigator in Pharmaceutical sponsored Clinical research trials involving COVID-19 vaccine, RSV vaccine, Flu vaccine, Migraine, Multiple sclerosis, Parkinson’s disease, Asthma, COPD, NASH, Diabetes studies. Prior Clinical Research Experience is preferred but not essential. Our team of Clinical Research Professionals will conduct the clinical trials under your supervision. Financial incentives and scientific publication opportunity. Will not take time away from your practice or increase liability. Primary care; Internal medicine; Pulmonology; Dermatology; Neurology; Gastroenterology. Please contact jsaleh@paradigm-research.com or anguyen@paradigm-research.com or Afalconer@ paradigm-research.com. PHYSICIAN OPPORTUNITIES FAMILY MEDICINE OR INTERNAL MEDICINE PHYSICIAN: TrueCare is more than just a place to work; it feels like home. Sound like a fit? We’d love to hear from you! Visit our website at www.truecare.org. Under the direction of the Chief Medical Officer and the Lead Physician, ensure the provision of effective quality medical service to the patients of the Health center. The physician is responsible for assuring clinical procedures are continually and systematically followed, patient flow is enhanced, and customer service is extended to all patients at all times. NEIGHBORHOOD HEALTHCARE MD, FAMILY PRACTICE AND INTERNISTS/HOSPITALISTS: Physicians wanted, beautiful Riverside County and San Diego County- High Quality Family Practice for a private-nonprofit outpatient clinic serving the communities of Riverside County and San Diego County. Work Full time schedule and receive paid family medical benefits. Malpractice coverage provided. Be part of a dynamic team voted ‘San Diego Top Docs’ by their peers. Please click the link to be directed to our website to learn more about our organization and view our careers page at www.Nhcare.org. PHYSICIAN WANTED: Samahan Health Centers is seeking a physician for their federally qualified community health centers that emerged over forty years ago. The agency serves low-income families and individuals in the County of San Diego in two (2) strategic areas with a high density population of Filipinos/Asian and other low-income, uninsured individuals — National City (Southern San Diego County) and Mira Mesa (North Central San Diego). The physician will report to the Medical Director and provide the full scope of primary care services, including but not limited to diagnosis, treatment, coordination of care, preventive care and health maintenance to patients. For more information and to apply, please contact Clara Rubio at (844) 200-2426 EXT 1046 or at crubio@samahanhealth.org. DEPUTY PUBLIC HEALTH OFFICER - COUNTY OF SAN DIEGO: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a California licensed or license eligible physician to work for County of San Diego Public Health Services, nationally accredited by the Public Health Accreditation Board. Salary: $220-230,000 annually and candidates may receive an additional 10% premium for Board Certification and 15% premium for Board Certification and Sub-specialty. For more information click here. PUBLIC HEALTH MEDICAL OFFICER - COUNTY OF SAN DIEGO: Under the direction of the Deputy Public Health Officer or designee, this position will be responsible for providing medical oversight of health programs and service delivery, and for performing administrative and operational duties that include the guidance and approval of policy

March 2021

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

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.

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

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

INTERVENTIONAL PHYSIATRY/PHYSICAL MEDICINE SPECIALIST POSITION AVAILABLE: Practice opportunity for part time interventional physiatry/physical medicine specialist with wellestablished orthopaedic practice. Position includes providing direct patient evaluation/care of spine and musculoskeletal cases, coordinating PMR services with all referring providers. Must have excellent interpersonal and communication skills. Office located near Alvarado Hospital. Onsite digital x-ray and emr. Interested parties, please email lisas@sdsm.net. CARDIOLOGIST WANTED: San Marcos cardiology office looking for a part-time cardiologist. If interested, send CV to evelynochoa2013@yahoo.com or via fax to (760) 510-1811. GENERAL FAMILY MEDICINE PHYSICIAN: to provide quality patient care to all ages of patient in a full-time traditional practice. The Physician will conduct medical diagnosis and treatment of patients using medical office procedures consistent with training including surgical assist, flexible sigmoidoscopy, and basic dermatology. The incumbent must hold a current California license and be board eligible. Bilingual Spanish/English preferred. Founded as a small family practice in Escondido 1932 by Dr. Martin B. Graybill, today we’re the region’s largest Independent Multi-specialty Medical Group. Our location is 277 Rancheros Dr., Suite 100, San Marcos, CA 92069. We are an equal opportunity employer and value diversity. Please contact Natalie Shields at (760) 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. DEPUTY PUBLIC HEALTH OFFICER: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a California licensed or license eligible physician to work for County of San Diego Public Health Services, nationally accredited by the Public Health Accreditation Board. Regular - Full Time: $220,000 - $230,000 Annually. For more information and to apply click here. TEMPORARY EXPERT PROFESSIONAL (TEP) MEDICAL DOCTORS (MD’s) NEEDED: The County of San Diego Health and Human Services Agency is seeking numerous MD positions to work in a variety of areas including Tuberculosis Control, Maternal and Child Health, Epidemiology and Immunizations, HIV, STD & Hepatitis, and California Children’s Services. Applicants (MD or DO) must hold a current

PHYSICIAN POSITIONS WANTED PAIN MANGEMENT POSITION WANTED: Pain Management Physician Position Wanted: Fellowshiptrained at MD Anderson Cancer Center, pain management with anesthesia background physician looking for a private practice, hospital, or academic position. Skilled in basic and advanced procedures, chronic pain and cancer pain management. Have CA, DEA, and Fluoro licenses. Please call/text (619) 9776300 or email Ngoc.B.Truong@dmu.edu. PRACTICE FOR SALE PRACTICE FOR SALE IN ENCINITAS: A GYN-only practice for sale in Encinitas with a majority of the patients in North County. Insurance accepted are PPO, cash and some Medicare patients. Could be turnkey or just charts. Practicing is closing December 31st, 2019. Please call Mollie for more information at (760) 943-1011. PRACTICES WANTED PRIMARY CARE PRACTICE WANTED: Looking for a retiring physician in an established Internal Medicine or Family Medicine practice who wants to transfer the patient base or sell the practice. Please call (858) 281-1588. PRIMARY OR URGENT CARE PRACTICE WANTED: Looking for independent primary or urgent care practices interested in joining or selling to a larger group. We could explore a purchase, partnership, and/ or other business relationship with you. We have a track record in creating attractive lifestyle options for our medical providers and will do our best to tailor a situation that addresses your need. Please call (858) 832-2007. PRIMARY CARE PRACTICE WANTED: I am looking for a retiring physician in an established Family Medicine or Internal Medicine practice who wants to transfer the patient base. Please call (858) 257-7050. OFFICE SPACE / REAL ESTATE AVAILABLE TURNKEY OFFICE SPACE FOR RENT NEAR ALVARADO HOSPITAL: Turnkey office space for rent. Modern, remodeled and clean. We have a little space available or a lot, depending on your needs. We are located near Alvarado hospital. Conference room, nurses station and many exam rooms, along with Doctors and Admin spaces. To inquire or to schedule a showing, please contact Jo Turner (619) 733-4068. OFFICE SPACE IN POWAY: Office in Poway. Centrally located. Close to Pomerado hospital. Radiology, pharmacy next door. Fully furnished, WiFi included. Three exam rooms, reception area, waiting room. Half days to full time available. Ideal for specialist who wants to expand. Call Dr. Luna if interested: (619) 472-1914.

KEARNY MESA OFFICE FOR SUBLEASE: Kearny Mesa area sublease in our orthopedic office which includes: onsite x-ray available, storage space, space for 1-2 employees and free parking. Can discuss internet, phones, fax line, access to printer/copier, and more. Please contact Kaye Spotz at kspotz@ synergysmg.com for more information. SAN DIEGO OFFICE NEAR SHARP FOR SUBLEASE OR TO SHARE: Rady Children’s Hospital medical office building at 7910 Frost Street. Central location near to both Rady Children’s Hospital and Sharp Memorial Hospital, between HWY 163 and I-805. Available to any specialty. The space available includes access to one office, two exam rooms and a nurse’s station / common area desk. Be close to excellent referral sources in the building and from the hospital campus. If you have an interest or would like more information, please call (858) 278-8300 x. 2210 or email nhughes@synergysmg.com REDUCED PRICE - EL CAJON MEDICAL OFFICE BUILDING FOR SALE OR LEASE: 3,700 square foot standalone medical building with 11 exam rooms & huge private parking lot available for sale or lease! Sink in all exam rooms, nurses station, break room, abundance of storage, etc. Building has been very well cared for and $200,000+ has gone into it since 2006. Prime location only three blocks from I-8 freeway exit right off of Broadway. Property also features oversized lot with 20+ parking spaces. Asking Sale: $950,000. Asking Lease: $5,500/month + NNN. Terms are negotiable. Seller financing is available. Please contact: Dillon.Myers@ TonyFrancoRealty.com | (619) 738-2318. MEDICAL SUITE AVAILABLE: Modern and luxurious medical suite located in the Scripps Ximed Building, on the campus of Scripps Memorial Hospital available for sublease/space sharing. The lobby is spacious, and there is a large doctor’s office, staff room and 4 exam rooms. Terms are flexible, available to share part-time, half days or full days 4 exam rooms. Rent depends on usage. For more information, call (858) 550-0330 EXT 106. ESCONDIDO MEDICAL OFFICE TO SHARE: Medical office space available at 1955 Citracado Parkway, Escondido. Close to Palomar Medical Center-West, Two to three furnished exam rooms, 2 bathrooms, comfortable waiting room, lab space, work area, conference room, kitchen. Radiology and Lab in the medical building. Ample free parking. Contact Jean at (858) 673-9991. MEDICAL OFFICE AVAILABLE FOR RENT: Furnished or unfurnished medical office for rent in central San Diego. Can rent partial or full, 5 exam rooms of various sizes, attached restroom. Easy freeway access and bus stop very close. Perfect for specialist looking for secondary locations. Call (858) 430-6656 or text (619) 417-1500. MEDICAL OFFICE SPACE FOR SUBLEASE: Medical office space available for sublease in La Jolla-9834 Genesee Avenue, Suite 400 (Poole Building). Steps away from Scripps Memorial Hospital La Jolla. Please contact Seth D. Bulow, M.D. at (858) 622-9076 if you are interested. SHARED OFFICE SPACE: Office Space, beautifully decorated, to share in Solana Beach with reception desk and 2 rooms. Ideal for a subspecialist. Please call (619) 606-3046. OFFICE SPACE/REAL ESTATE AVAILABLE: Scripps Encinitas Campus Office, 320 Santa Fe Drive, Suite LL4 It is a beautifully decorated, 1600 sq. ft. space with 2 consultations, 2 bathrooms, 5 exam rooms, minor surgery. Obgyn practice with ultrasound, but fine for other surgical specialties, family practice, internal medicine, aesthetics. Across the hall from imaging center: mammography, etc and also Scripps ambulatory surgery center. Across parking lot from Scripps Hospital with ER, OR’s, Labor

and Delivery. It is located just off Interstate 5 at Santa Fe Drive, and half a mile from Swami’s Beach. Contact Kristi or Myra (760) 753-8413. View Space on Website:www.eisenhauerobgyn.com. Looking for compatible practice types. OFFICE SPACE FOR RENT: Multiple exam rooms in newer, remodeled office near Alvarado Hospital and SDSU. Convenient freeway access and ample parking. Price based on usage. Contact Jo Turner (619) 7334068 or jo@siosd.com. OFFICE SPACE / REAL ESTATE WANTED MEDICAL OFFICE SUBLET DESIRED: Solo endocrinologist looking for updated bright office space in Encinitas or Carlsbad to share with another solo practitioner. Primary care, ENT, ob/gyn would be compatible fields. I would ideally have one consultation room and one small exam room but I am flexible. If the consultation room was large enough I could have an exam table in the same room and forgo the separate exam room. I have two staff members that will need a small space to answer phones and complete tasks. Please contact (858) 633-6959. MEDICAL OFFICE SPACE SUBLET DESIRED NEAR SCRIPPS MEMORIAL LA JOLLA: Specialist physician leaving group practice, reestablishing solo practice seeks office space Ximed building, Poole building, or nearby. Less than full-time. Need procedure room. Possible interest in using your existing billing, staff, equipment, or could be completely separate. If interested, please contact me at ljmedoffice@yahoo.com. MEDICAL EQUIPMENT / FURNITURE FOR SALE OBGYN RETIRING WITH OFFICE EQUIPMENT FOR DONATION: Retiring from practice and have the following office equipment for donation: speculums, biopsy equipment, lights, exam tables with electric outlets, etc. Please contact kristi.eisenhauermd@ yahoo.com or (760) 753-8413. MEDICAL EQUIPMENT FOR SALE: 2 Electric tables one midmark, 3 Ultrasounds including high resolution Samsung UG-HE60 with endovag and linear probes, STORTZ hysteroscopy equipment, 2 NOVASURE GENERATORS ,ENDOSEE OFFICE HYSTEROSCOPY EQUIPMENT : NEW MODEL, OLDER MODEL, Cynosure laser equipment: MONALISATOUCH (menopausal atrophy), TEMPSURE Vitalia RF (300 watts!) for incontinence, ENVI for face, Cynosure SculpSure with neck attachment for body contouring by warm sculpting. Please contact kristi.eisenhauermd@yahoo. com or 760-753-8413. FOR SALE: Nuclear medicine equipment including Ge Millennium MG system, hot lab, and sources Cs137. Rod Std 2. Cs-137. DCRS 3. Cs-137. Spot 4. Co-57. Flood sheet. Please contact us at (760) 730-3536 if interested in purchasing, pricing or have any questions. Thank you. NON-PHYSICIAN POSITIONS AVAILABLE PRACTICE MONITOR WANTED: Practice Monitor wanted for San Diego Practice. Practice Monitor required for reviewing percentage of charts and reporting to Medical Board Monthly. Monitor can be remote. Time involved one hour or less a month. Up to $500 hourly depending on Monitors judgement. Please email DrMegabucks1@gmail.com. PART-TIME BILLER POSITION AVAILABLE: Pain Management office looking for a part-time medical biller, will work directly with a variety of payors, healthcare providers and patients through the revenue cycle process to ensure claims are processed and paid in a timely manner, review EOB’s, verifying patient coverage, and assist with patient billing inquiries. Please email your resume to cestrada@ steinermd.com.

DIRECTOR OF NURSING - PUBLIC HEALTH SERVICES - COUNTY OF SAN DIEGO: The Director of Nursing in Public Health Services (PHS) will lead the clinical nursing enterprise of PHS, serving on the Executive Team of the PHS Department. This position will directly oversee clinical nurse management and all nursing personnel for six programmatic branches within PHS, as well as directly oversee all Public Health Nurse Managers or Leads in each branch. This position will work with Public Health Nurses in other Health and Human Services Agency (HHSA) departments such Aging and Independence Services, Child Welfare Services, and Regional Operations. Additionally, this position will have a dotted reporting line to HHSA’s Chief Nursing Officer and receive direction from the Chief Nursing Officer to HHSA-wide nursing practices. Salary: $124,092.80–$150,822.80 annually. For more information click here. PART-TIME BILLER POSITION AVAILABLE: Pain Management office looking for a part-time medical biller, will work directly with a variety of payors, healthcare providers and patients through the revenue cycle process to ensure claims are processed and paid in a timely manner, review EOB’s, verifying patient coverage, and assist with patient billing inquiries. Please email your resume to cestrada@steinermd.com. EXECUTIVE DIRECTOR, STUDENT HEALTH AND COUNSELING SERVICES: California State University San Marcos (CSUSM) has announced a national search for a visionary and collaborative leader to serve as Executive Director of Student Health and Counseling Services. Selected candidate will be appointed into an Administrator III OR Administrator IV. Appointment will be determined by education and experience. Selected candidate with an M.D. will be appointed as Administrator IV, and selected candidate without an M.D. will be appointed as Administrator III. For position specifications, benefits summary and to apply, please visit our website at https://apptrkr.com/1852486. FINANCE DIRECTOR: San Diego Sports Medicine and Family Health Center is hiring a full-time Financial Director to manage financial operations. Primary responsibilities include monitoring of income, expenses and cash flow, reconciling bank statements, supervision of accounts payable, oversee billing department, oversee accounts receivables, payments and adjustments, prepare contracts, analyze data, prepare financial reports, prepare budgets, advise on economic risks and provide input on decision making. MBA/Master’s and 5+ years relevant work experience preferred. Excellent references and background check required. Salary commensurate with skills and experience. To apply, please send resume to Jo Baxter, Director of Operations jobaxter@sdsm.com. NON-PHYSICIAN POSITIONS WANTED MEDICAL OFFICE MANAGER/CONTRACTS/ BILLING PERSON: MD specialist leaving group practice, looking to reestablish solo private practice. Need assistance reactivating payer contracts, including Medicare. If you have that skill, contact ljmedoffice@yahoo.com. I’m looking for a project bid. Be prepared to discuss prior experience, your hourly charge, estimated hours involved. May lead to additional work. PRODUCTS / SERVICES OFFERED DATA MANAGEMENT, ANALYTICS AND REPORTING: Rudolphia Consulting has many years of experience working with clinicians in the Healthcare industry to develop and implement processes required to meet the demanding quality standards in one of the most complex and regulated industries. Services include: Data management using advanced software tools, Use of advanced analytical tools to measure quality and processrelated outcomes and establish benchmarks, and the production of automated reporting. Please contact: (619) 913-7568 | info@rudolphia.consulting | www. rudolphia.consulting.

SanDiegoPhysician.org 19

PERSONAL AND PROFESSIONAL DEVELOPMENT

Words Matter: The Responsibilities of Freedom By Helane Fronek, MD, FACP, FACPh

E AMERICANS ARE PROUD OF AND

passionate about the freedoms we enjoy. It’s one issue that has been difficult during the pandemic, further dividing us. If my freedom impacts you in a way you don’t like, where does my freedom end? Our colleague Daniel Bressler wisely encouraged us to define how we, as a society, want to negotiate these conflicts so we might be better poised for our next public health emergency (San Diego Physician, January 2021). Another cherished freedom — freedom of speech — has also come under scrutiny within the last few months as we examine the insurrection at the Capitol. We hold dear and revel in our ability to say whatever we believe without fear that our government will arrest, jail, or execute us, as occurs in other countries. We might believe in this First Amendment right wholeheartedly — until someone says something about us that is untrue and hurtful or that compromises our liberties, opportunities, or livelihoods. While words may seem innocuous, simply an expression of what we believe, 20

March 2021

those words have impact, especially if we are in a position of authority. We are wise to consider what that impact might be, and whether those are words we want to speak. As physicians, we are often in the difficult position of informing patients of serious conditions or possibilities. How we say those things can make all the difference on our impact. As a resident, sleepdeprived and chronically overwhelmed, I announced matter-of-factly to a patient’s family that the mortality of his condition was 70%. I cringe when I think about my insensitive and utterly unskilled explanation, how I heightened their pain and squandered an opportunity to help them hold onto hope. In teaching medical students to discuss new diagnoses, we emphasize how medical jargon may be misinterpreted. When stating that our patient has

congestive heart failure, most patients will fixate on the words heart and failure — and panic. “If my heart is failing, am I going to die?” Recently, a friend who was reluctant to obtain medical care received the shocking diagnosis of metastatic cancer. While wanting to move ahead with the recommendations of his new oncologist, he was still reeling from the tectonic shift in his life and overwhelming concerns for his family. Not recognizing that he was still having difficulty accepting his diagnosis, the palliative care team decided to discuss what would happen when his “organs shut down.” While responsibly informing him of what might occur, they failed to honor their responsibility to appreciate his current mental state and what he actually needed from them: reassurance, hope, and more sensitive language surrounding some of the potential difficulties. Freedom of speech is the very first amendment for a reason. It is, and should be, our most cherished freedom. Yet with freedom comes responsibility. To avoid inadvertently causing problems we will regret, we can first consider the responsibility we hold for our speech and choose our words judiciously. What impact do we want to have? Words do matter. Helane Fronek is an assistant clinical professor of medicine at UC San Diego School of Medicine and a Certified Physician Development Coach.

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