April 2022 by San Diego Physician

Official Publication of SDCMS APRIL 2022

San Diego County Medical Society

2022–2023 INCOMING LEADERSHIP

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Contents APRIL

Editor: James Santiago Grisolia, MD Editorial Board: James Santiago Grisolia, MD; David E.J. Bazzo, MD; Robert E. Peters, MD, PhD; William T-C Tseng, MD Marketing & Production Manager: Jennifer Rohr Art Director: Lisa Williams Copy Editor: Adam Elder OFFICERS President: Sergio R. Flores, MD President–Elect: Toluwalase (Lase) A. Ajayi, MD Secretary: Nicholas (Dr. Nick) J. Yphantides, MD, MPH Immediate Past President: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM

VOLUME 109, NUMBER 4

GEOGRAPHIC DIRECTORS East County #1: Catherine A. Uchino, MD 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, MPH Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Preeti S. Mehta, MD (Board Representative to the Executive Committee) La Jolla #2: David E.J. Bazzo, MD, FAAFP La Jolla #3: Sonia L. Ramamoorthy, MD, FACS, FASCRS North County #1: Arlene J. Morales, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Nina Chaya, MD South Bay #1: Paul J. Manos, DO South Bay #2: Maria T. Carriedo-Ceniceros, MD AT–LARGE DIRECTORS #1: Thomas J. Savides, MD #2: Kelly C. Motadel, MD, MPH #3: Irineo (Reno) D. Tiangco, MD #4: Miranda R. Sonneborn, MD #5: Stephen R. Hayden, MD (Delegation Chair) #6: Marcella (Marci) M. Wilson, MD #7: Karl E. Steinberg, MD, FAAFP #8: Alejandra Postlethwaite, MD ADDITIONAL VOTING DIRECTORS Medical Student: Jimmy Yu Resident: Nicole L. Herrick, MD Young Physician: Brian J. Rebolledo, MD Retired Physician: Mitsuo Tomita, MD CMA OFFICERS AND TRUSTEES Robert E. Wailes, MD William T–C Tseng, MD, MPH Sergio R. Flores, MD Timothy Murphy, MD AMA DELEGATES AND ALTERNATE DELEGATES District I: Mihir Y. Parikh, MD District I Alternate: Sergio R. Flores At-Large: Albert Ray, MD At-Large: Robert E. Hertzka, MD At-Large: Theodore M. Mazer, MD At-Large: Kyle P. Edmonds, MD At-Large: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM At-Large Alternate: David E.J. Bazzo, MD, FAAFP CMA DELEGATES District I: Karrar H. Ali, DO, MPH District I: Steven L.W. Chen, MD, FACS, MBA District I: Franklin M. Martin, MD, FACS District I: Vimal I. Nanavati, MD, FACC, FSCAI District I: Peter O. Raudaskoski, MD District I: Kosala Samarasinghe, MD District I: James H. Schultz, MD, MBA, FAAFP, FAWM, DiMM District I: Mark W. Sornson, MD District I: Wynnshang (Wayne) C. Sun, MD District I: Patrick A. Tellez, MD, MHSA, MPH RFS: Rachel Buehler Van Hollebeke, MD

Features

Candidate Statements: 2022–23 SDCMS Board of Directors

Saying Kaddish at Christmas Dinner By Daniel J. Bressler, MD, FACP

Departments

Briefly Noted: Medi-Cal • CMA Medical Leadership • Practice Management

10 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.]

Managing Behavioral Symptoms in Individuals Living With Dementia By Daniel Sewell, MD

This Year’s Flu Shot Was a Bust, CDC Says By Zaina Hamza

COVID’s ‘Silver Lining’: Research Breakthroughs for Chronic Disease, Cancer, and the Common Flu By Liz Szabo

Champions for Health Soirée 2022: To Wellness and Beyond By Adama Dyoniziak

We Have More Choice Than We Think By Helane Fronek, MD, FACP, FACPh

Classifieds

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BRIEFLY NOTED 2

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MEDI-CAL

DHCS Temporarily Removes Prior Authorization Requirement for Psychostimulants/ Antidepressants . ON JAN. 1, 2022, THE CALIFORNIA Department of Health Care Services (DHCS) transitioned all Medi-Cal pharmacy services from managed care to fee-for-service (FFS). The Medi-Cal pharmacy benefits and services administered by DHCS in the FFS delivery system are collectively referred to as “Medi-Cal Rx.” On Feb. 6, 2022, DHCS revised the Medi-Cal RX prior authorization policy retroactive to Jan. 1, 2022, temporarily removing the prior authorization requirement for most drugs. Although the initial policy change did NOT apply to psychostimulants/antidepressants, DHCS announced today it would temporarily waive the prior authorization for that category of drugs. The only categories still requiring prior authorization are: 1. Opioid Analgesics 2. Ataractics/tranquillizers (including antipsychotics and benzodiazepines) 3. Certain excluded products and for children under the age of 21

For More Information The Medi-Cal Rx YouTube Channel offers training videos, including a video on the transition and the resources that directly impact pharmacy providers and prescribers. DHCS also offers live, instructor-led trainings and Office Hour Luncheon Sessions every Monday–Friday, noon to 1 p.m. (excluding holidays). CMA recommends that practices subscribe to the Medi-Cal Rx Subscription Service to stay up to date with the latest Medi-Cal Rx news. For questions, please contact the Medi-Cal Rx Customer Service Center at (800) 977-2273, available 24 hours a day, 365 days a year or email MediCalRxEducationOutreach@magellanhealth.com. CMA also recently co-hosted a webinar with DHCS on the Medi-Cal Rx transition. That webinar is available free to all interested parties and available for on-demand viewing. If your practice is experiencing problems billing for drugs under the Medi-Cal Rx program, please contact the California Medical Association at (800) 786-4262 or economicservices@ cmadocs.org.

CMA MEDICAL LEADERSHIP

CMA President’s Statement: Medical Professionals and Facilities Should Always Be Off Limits to Attack “CALIFORNIA MEDICAL ASSOCIATION President Robert E. Wailes, MD, issued the following statement in response to recent world events. “Physicians take our Hippocratic oath — ‘Do no harm’ — to heart. It is seared on our souls, and because of that, we commit our lives to healing patients, neighbors and communities. “Recent events demand that we reinforce the notion that nothing should be allowed to disrupt the physician-patient relationship and our

ability to mend broken bones, prevent disease, and cure ailments. And nowhere is this more critical than during times of war. “Medical professionals and facilities should always be off limits to attack, so they can remain what they are: places where we heal, mend, and repair survivors of the unthinkable. “Past is prologue, and it is time for us to finally learn valuable lessons from history. Restricting anyone’s access to essential health services is wrong.”

PRACTICE MANAGEMENT

Shirley Riedy Named Office Manager of the Year

THE SAN DIEGO COUNTY MEDICAL Society is proud to recognize Shirley Riedy, laboratory manager and office manager at San Diego Pathologists Medical Group, as the Outstanding Medical Office Manager of the Year in 2021. Dr. Carla Stayboldt, medical director at San Diego Pathologists, nominated Riedy for the recognition in a letter: “Shirley is one of the most incredible people I know. I admire her commitment, can-do attitude, leadership, operational expertise, people skills, professionalism, responsibility, courage, integrity, loyalty, and calmness under pressure. She can do the whole spectrum from mother to dragon-lady, depending on what’s needed in the moment. She has her finger on the pulse of the laboratory and is not afraid to roll up her sleeves and come in at 3 a.m. to work at the bench with lab staff during a highvolume night. “Shirley is able to get along with all physicians and can walk the tight rope gracefully when physician owners have differing opinions. She also builds and smooths relationships between physicians and our large office/laboratory staff. She connects with our employees as people who have families instead of just employees. During the initial COVID shutdown, she prepared care packages of hard-to-find toilet paper, disinfectants, and other goodies. We couldn’t have our annual Holiday Party in 2020, so instead she joyfully gave our

employees “The 12 Days of Christmas” with 12 days of gifts, gift cards, candies, and lunches to celebrate the holidays. “Over her career, Shirley expanded operations, negotiated cost savings in vendor contracts, built employee loyalty and encouraged a “family business” atmosphere. When we landed a multi-hospital contract, Shirley made it happen literally overnight without complaint. She was responsible for every other big account we obtained as she received the first phone call, developed the relationship, and brought new business to San Diego Pathologists Medical Group. Her first national account called Shirley when he needed a laboratory in his next job, landing a second national account. “When there have been accidents/ injuries in the lab (e.g. a seizure and chemical eye injury) she knew exactly what to do and did it, preventing further injury to the employee. “Shirley demonstrated her very essence when she saw two pit bulls attacking a small dog in her neighborhood before sunrise as she was driving to work. She stopped (most would have driven by) and went after the pit bulls armed only with two water bottles. She scared them off, awakened the dog’s owners so they could take their dog to the vet, and proceeded to drive to work — all in a day in the life of Shirley.” Congratulations Shirley Riedy on your recognition and hard work at the San Diego Pathologists Medical Group!

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CANDIDATE STATEMENTS 202 2 –2 3 SD CMS BOARD OF DIREC TORS

Note: • (inc.) After Name = Incumbent • Number in Parentheses (#) After Name = Term Length in Years OFFICERS Candidate for Presidentelect: Nicholas “Dr. Nick” J. Yphantides, MD, MPH (1) I am so grateful for your consideration, and support of my service to our Society as your next president-elect. For 12 years, I was so blessed with the strategic and impactful opportunity to be the first-ever chief medical officer (CMO) of the County of San Diego’s Health and Human Services Agency. During 4

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that time, I helped lead the regional COVID response, and provided leadership in response to the county’s hepatitis-A outbreak and the migrant caravan crisis. My role also included oversight over the regional Emergency Medical System, leadership of Medi-Cal’s Healthy San Diego, and as a public advocate for LiveWell San Diego. Since the end of my role at the

County in March of 2021, I have been supporting Palomar Health as a part-time executive clinical consultant and serving as a volunteer board member for a variety of charity and service-based organizations. My life’s passion is to be an advocate and catalyst to improve the health and wellbeing of our local population with a focus on those who need it the most. Prior to my service with the County, I served as the CMO of Neighborhood Health Care, was the publicly elected board chair of Palomar Health, and was the first CMO of the Council of Community Clinics. As your president-elect I look forward to supporting our soon-to-be president, Dr. Lase Ajayi, and advocating for our noble profession locally while working to strengthen our regional collective impact even further. Together we must continue to strive to improve the health and

SDCMS BOARD CANDIDATE STATEMENTS

wellness of our patients and their families. My greatest joy in life is being the full-time single father for my two teenage daughters and being an engaged resident of my Escondido community. Candidate for Secretary: Steve Koh, MD, MBA, MPH (1) Since residency, I consider my involvement in organized medicine to be a highlight of my medical career. I am honored to be serving on SDCMS’ Board of Directors and its Executive Committee. During these unprecedented times, I have seen the strength and impact of physician leaders who work tirelessly to champion our patients’ needs and health. With the San Diego Psychiatric Society and American Psychiatric Association, I have served in numerous leadership positions. From these experiences I have learned the value of united physician leadership in healthcare. It is critical for us to work together in a common house of medicine that supports our profession and patients. As an academic psychiatrist, I have significant interest in healthcare delivery models, workforce development, and public-sector population health. I believe that these academic interests align well with the goals and objectives of SDCMS. As physician leaders, we must continue to improve efficiencies in our care delivery, support enriching professional work environments, and champion quality healthcare for those underserved. It will be an honor and a privilege to serve as your SDCMS secretary and I ask for your support. Candidate for Treasurer: Preeti S. Mehta, MD (1) I am honored to be considered for the post of treasurer of the San Diego County Medical Society. I have certainly learned a lot over the last several years as a part of the Board of Directors and Executive Committee at SDCMS. I have come to know and work with several members closely and with their support, I feel confident and capable of running for this position. I have held several

leadership roles at Scripps Memorial Hospital, La Jolla: I am currently the chair of medicine. I am also the past president of the San Diego Association of Physicians of Indian origin. I plan to continue to work in the membership and physician wellness committees as a board member. Given my past experience, I feel prepared to take on the role of treasurer and make a positive impact on the community with my service. Thank you. GEOGRAPHIC DIRECTORS

Candidate for East County Director #1: Catherine A. Uchino, MD (inc.) (3) I am so grateful for the opportunity to continue to serve as East County director. As an obstetriciangynecologist I believe that advocacy is a deeply important aspect of patient care. I have been in San Diego since my residency at UC San Diego and currently practice with Kaiser

Permanente. These different practice models have given me exposure to the diverse needs of our patients across the county. My areas of special interest include equity in healthcare, women’s health, and engagement with the next generation of physicians. The San Diego County Medical Society plays a vital role in amplifying the voices of our patients and physicians, and in shaping the policies that in turn shape our community. Thank you for your consideration. Candidate for Hillcrest Director #1: Kyle P. Edmonds, MD (inc.) (3) I am director and section chief of palliative care at UC San Diego, where I work as an inpatient palliative medicine consultant and serve in multiple leadership roles across the institution. I have been an active member of SDCMS since I moved to San Diego for fellowship in 2012 and the Hillcrest director for three years. I’m honored to represent the neighborhood in which I work and nearby to where I live. I serve on the Council of Ethical, Legal, and Judicial Affairs and the Council on Membership and Governance for the California Medical Association and am a CMA delegate to the American Medical Association, where I also represent the American Academy of Hospice and Palliative Medicine in the Young Physician Section. For the AAHPM, I am the chair of the Advocacy and Awareness Strategic Coordinating Committee, overseeing its health policy and government relations work for my field. I’ve been active in organized medicine since medical school and am honored to be nominated to continue as a board member of SDCMS. I look forward to continuing to serve as one of your representatives. Candidate for Hillcrest Director #2: Stephen R. Hayden, MD (3) For most of my career in the fields of emergency medicine and hyperbaric medicine at UC San Diego, I have been involved in national academic affairs and have advocated for

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SDCMS BOARD CANDIDATE STATEMENTS

the practicing emergency physician in various capacities in our specialty societies. Ultimately, I decided to focus more on local San Diego and California issues and so, in addition to serving on the Medical Society’s Board of Directors, I have the privilege of being the District 1 delegation chair to the CMA. It has been a great experience to participate in the annual House of Delegates, and to help determine the major topics CMA will address each year. With the landscape changing so quickly in healthcare, I believe it is as important as ever for community physicians and academic physicians to partner and face the current challenges in medicine together. For more than 20 years, I have been directly involved in national specialty societies and the American Board of Emergency Medicine, and these experiences will allow me to contribute to SDCMS’ advocacy efforts. After a tour of duty as senior flight surgeon for the Naval Strike Warfare Center NAS Fallon, Nevada, I completed my emergency medicine residency at the University Medical Center at Stony Brook, New York, where I served as chief resident. I am the previous associate dean for graduate medical education at UC San Diego, after serving as the program director of the emergency medicine residency. I am a past president of the national Council of Emergency Medicine Residency Directors, and, in 2006, I was selected as the editor-in-chief of The Journal of Emergency Medicine. I am a primary author/editor for a major textbook in emergency medicine, The Five-Minute Emergency Medicine Consult, as well as numerous textbook chapters, peer-reviewed publications, and numerous invited national and international speaking engagements. I have endeavored to use my experience to represent all of the physicians in San Diego with both SDCMS and CMA. My main clinical practice is in the emergency department, and the hyperbaric chamber at the UC San Diego Hillcrest medical center. I am passionate about teaching, assisting the underserved in our community every shift I work, healthcare advocacy, and advancing clinical research in emergency medicine. If reelected, I would consider it a privilege to continue to serve the San Diego County Medical Society and its members.

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level. SDCMS has been, and will continue to be, a leader in California healthcare policy. I relish the chance to continue to contribute. Thank you for your consideration. AT-LARGE DIRECTORS Candidate for North County Director #2: Christopher M. Bergeron, MD, FACS (inc.) (3) I am honored to be considered again for a position on the SDCMS Board of Directors. I am a rhinologist / otolaryngologist practicing at Scripps Clinic in La Jolla, Rancho Bernardo, and now Oceanside. Prior to joining Scripps Clinic, I was a member of the full-time faculty at UC San Diego. I am also the immediate past president of the San Diego Academy of Otolaryngology. During my 14-plus years in the San Diego area, I have seen the impacts of increased governmental regulation on physicians and patients alike. The challenges of the pandemic have also taken their toll on all of us. It is of vital importance that physicians play a major role in the shaping of current and future healthcare policy at the local, state, and national

Candidate for At-large Director #3: Irineo “Reno” Tiangco, MD (inc.) (3) No Statement Candidate for At-large Director #5: Daniel D. Klaristenfeld, MD, FACS (3) It is an honor to be nominated for the SDCMS Board of Directors. I have been a general and colorectal surgeon at Kaiser Permanente San Diego for the past 11 years. In that time, I have served on various professional staff committees and I am currently the president of the professional staff at our hospital. I am a voluntary faculty member at UC San Diego and at the Uniformed Services University of Health Sciences coordinating general surgery resident learning at our institution. Nationally, I have served on committees for the American College of Surgeons and the American Society of Colon and Rectal Surgeons. I have seen the profound impact that physicians can have when we are organized and coordinated. I am excited to meet and work with colleagues from around the region. Thank you so much for this opportunity. YPS DIRECTOR Candidate for YPS Director: Emily A. Nagler, MD (1) I am honored to be considered for the Young Physician Section director position for SDCMS. I have been a member of SDCMS since 2016, when I was completing my internal medicine training, meeting other physicians at SDCMS networking events, and watching my mentors and friends

SDCMS BOARD CANDIDATE STATEMENTS

involved in leadership within the group and the California Medical Association. These experiences made me realize how much of an impact we have on public health policy and how important it is for physicians to have these connections with each other. Since that time I have been privileged to remain in SDCMS as I completed my hematology and oncology fellowship and am now a practicing hematologist and oncologist in San Diego. I have had the honor of being a delegate for YPS in the California Medical Association since 2021, and I am grateful for this opportunity to become increasingly aware of the importance of our voices in politics and public policy, especially at such a critical time in medicine. It would be a privilege to continue to serve my community and offer mentorship to future physicians starting their journey. CMA DISTRICT I DELEGATES Candidate for CMA District I Delegate: Steven Chen, MD, FACS, MBA (inc.) (3) It is an honor to be considered for reelection to a position as a delegate for SDCMS. As a surgical oncologist in independent practice with offices in Mira Mesa and Encinitas, I hold privileges in the Scripps, Sharp, and Palomar systems, allowing me to get a broad overview of county issues. Prior to my current practice, I have been an academic physician at UC Davis while serving as chief of breast surgery and an employed physician at City of Hope in Los Angeles. Through these different places, I have developed experience in multiple practice modes and will ensure that our policies and positions take all modes of practice into account. My experience in organized medicine has spanned serving on the board of the Los Angeles County Medical Association and the Sierra Sacramento Valley Medical Society as well as nationally, including being a past president of the American Society of Breast Surgeons, as well as prior service on the governing councils of the Young Physicians Section of the AMA and the Young Fellows Association of the American College of Surgeons. I continue to serve on the legislative or health policy committees of the American College of Surgeons and the American Society of

Breast Surgeons and thus stay up to date on the issues facing the professional practice of surgery and medicine, while also serving as a delegate in the AMA House of Delegates, giving me a broader view of the needs of other specialties. I fully believe that if we do not defend our profession and act as professionals, we will lose the right to be a profession. SDCMS and organized medicine are key links to ensuring that being a physician continues to mean being a professional. I ask for your support to allow me to help represent you and your concerns.

Candidate for CMA District I Delegate: Mark W. Sornson, MD, PhD (inc.) (3) It has been my privilege to have served as a pastpresident of SDCMS, and multiple other roles within SDCMS and CMA, representing the physicians of San

Diego. Taking part in the presidency, Executive Committee, Board, Finance and Legislative Committees has reinforced my conviction that when we speak with a unified voice and build relationships, we can make a difference. We have an upcoming serious issue of another attempt to eviscerate MICRA, and we need strong advocacy to highlight our physicians’ efforts against the continuing COVID-19 pandemic. Decisions made today on our key issues will greatly affect our futures. As a board member I will continue to be a voice for reasoned discussion, representing all physicians. I’ve greatly enjoyed my service on behalf of SDCMS and CMA, and I am honored to ask for your vote to continue my service as a member of the Board. CMA RFS DELEGATE Candidate for CMA RFS Delegate: Rachel B. Van Hollebeke, MD (inc.) (1) I was born and raised in San Diego and returned home for medical school at UC San Diego. I am currently completing my family medicine residency at Scripps Mercy Hospital in Chula Vista. It was an honor to serve as a resident delegate last year, and I’m very excited about the possibility of serving in that role again. I enjoyed learning more about health policy and giving back to the San Diego community that I care so deeply about. As a former member of the U.S. women’s national soccer team and two-time Olympic gold medalist, I hope to continue to share my passion for healthy living and utilize the leadership skills I have developed in both my soccer and medical careers. Thank you for considering me for this role.

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GRATITUDE

Saying Kaddish at Christmas Dinner BY DANIEL J. BRESSLER, MD, FACP

UR STAFF, ALONG WITH

their friends and family, met for a holiday dinner in early January of this year at an Italian place in Mission Hills not far from Scripps Mercy. It was the first time we had gathered socially since the pandemic lockdown began. There was a palpable sense of joy and relief that the world might be getting back to some kind of normal. Once we were seated, and after orders had been taken but before dinner was served, I ceremoniously tapped on my wine glass to get everyone’s attention. We then performed a pre-planned ritual 8

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that allowed us to intermix our holiday celebration with some reflection as a way to both deepen and elevate the occasion. Earlier that week, the staff and I had assembled a list of the patients that we had lost in 2020 and 2021. In the hush after the tapped glass and sitting in the deliberate privacy of a corner table, we began. Sensitive not to cross the boundaries of “privileged health information,” we stage-whispered the first name of a patient (we, the staff, all knew who was being referred to but our guests did not) and then with that same whisper preceded to share memories about the person that had moved or touched us. We shared

vignettes about their quirks and their talents, their bugs and their features. We said nothing about their medical condition — we spoke only about their human condition. The stories included: a cheerful raconteur’s long devotion to his serious spouse, who forever complained that she didn’t get his jokes; a widowed matriarch whose frail condition did not weaken her command and control of family matters for her grown children; a decorated but dissatisfied architect who was forever looking for an even grander award-winning project; an amateur clarinetist and musicologist who, in his day, had sat in with some of the great names in jazz; an intense yoga practitioner who was lovingly attended in her final days by a clutch of yoga friends; a laconic physician who could never bring himself to talk of his adored wife in the five years between her passing and his; an ex-nun who, after leaving the convent, became a New Age healer and spiritual guide with an international following; a devout and big-hearted Southern Baptist with the deepest hugs imaginable who returned to her Tennessee hometown for palliative treatment only to call monthly till the end to let us know that she “was doing just fine.”

None were under 70. Most were in their 80s and a few in their 90s. In that sense, the deaths were not “tragic,” although each was sad, as a loss always is. We reviewed together a roll call of the dead that mixed that sadness with whimsy, and mixed grief with admiration. It was a spoken memorial to people we had cared for and who were now taken from us. It was, on this Christmastime dinner, a way of “saying Kaddish.” Kaddish, or, more specifically, the Mourner’s Kaddish, is a prayer from the Jewish liturgy said for the recently deceased. It is recited at the funeral and is also said by family members every Sabbath for a year after a death in the family. It is a way of commemorating the deceased by saying their name in the context of a prayer which honors the holiness and greatness of God. In a longstanding longitudinal primary care practice, such as mine, we lose patients every year. Even in the best of circumstances, we humans have unavoid-

able “expiration dates” as the defects of aging accumulate. In other regrettable circumstances, it is preventable trauma or infection that takes us down suddenly. There is the special irony that the medical care team often gets to know patients best toward the end, when their medical needs intensify. The nurses and receptionist come to easily recognize the sound of their voice on the phone before they say their name. We learn better than ever the names of family members, pets, and pet peeves. And when the patient dies, all that connection-based knowledge is lost along with their life. Families grieve, of course, and one of my goals for the survivors is to help frame the death in a way that allows the grief to be as gentle and complete as possible. But we (the staff and I) grieve, too. With each death we lose someone we have taken into our circle of responsibility and into our hearts. “Saying Kaddish” is for the commemoration of the dead, but as importantly for the benefit of the living. The grief

PLACE YOUR AD HERE FEBRUARY 2020

that comes to survivors from loss needs to be incorporated into an ongoing life. Although out of sight, it is emotionally damaging to simply put the deceased out of mind. How much healthier to recall them deliberately as a way to say goodbye again, gently. It elevates the way we hold their memories by intentionally calling out their uniqueness, their irreplaceable and essential qualities. This practice naturally produces a knowing nod to balance the lump in the throat. And so, at a Christmas dinner, as 2021 became 2022, and as a horrible pandemic year became less horrible, we read the names and recalled the virtues of some people that we had had the privilege of caring for, and in so doing blessed their memory and helped to heal ourselves. Dr. Bressler, SDCMS-CMA member since 1988, is a former chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and a longtime contributing writer to San Diego Physician.

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Contact Jennifer Rohr

Vista Community Clinic is a federally qualified, not-for-profit healthcare clinic with more than 800 employees and nine state-ofthe-art clinics treating more than 69,000 patients every year. We provide healthcare throughout the Southern California regions of North San Diego, Orange and Riverside Counties. Our compensation and benefits program includes: Competitive compensation, sign-on bonus, relocation bonus, health, dental, vision, company-paid life, longterm disability, flexible spending accounts , 403(b) retirement plan, malpractice coverage, NHSC loan repayment eligible organization, CME allowance, and no oncall hours For more information visit www.vcc.org or email hr@vcc.org EEO

858.437.3476 • Jennifer.Rohr@SDCMS.org

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DEMENTIA

Managing Behavioral Symptoms in Individuals Living With Dementia BY DANIEL SEWELL, MD

EMENTIA ILLNESSES

inflict tremendous costs on individuals and society in terms of diminished quality of life for those living with dementia and those who care for them, increased rates of medical morbidity and mortality among family caregivers, compassion fatigue among both family and professional caregivers, and financial burden associated with the costs of care, lost wages, and diminished productivity. The Rand Corporation found that the annual financial cost of dementia in the U.S. surpasses the cost associated with either heart disease or cancer. Additional research by The Rand Corporation determined that nursing home care and

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costs associated with care at home are responsible for 75%–84% of dementia costs. In 2017, a group of researchers in Great Britain found that poorer cognition and behavioral and psychological problems associated with dementia illnesses were consistently associated with an increased risk of nursing home placement. Clearly, there is a lot to be gained from improved treatment of the cognitive, behavioral, and psychological symptoms experienced by individuals living with dementia. Although the statistics cited above are sobering, there are reasons to be optimistic about the future of dementia treatment and reducing the toll dementia illnesses are exacting on individuals

and society. Recent developments in the ongoing effort to find disease preventing and disease modifying medications are heartening. Whether aducanumab ultimately becomes the first medication in this category, and becomes easily accessible, remains an unanswered question. Its existence, however, suggests that we have come tantalizingly close to this long hoped for development. Meanwhile, the algorithm to treat the many behavioral and psychological symptoms of dementia (BPSD) is neither complicated to learn nor expensive to implement. Although this algorithm has been developed and refined by dementia experts, it is an approach that any primary care provider can quickly learn and

There are reasons to be optimistic about the future of dementia treatment and reducing the toll dementia illnesses are exacting on individuals and society.

implement. One of the main goals of the trail-blazing San Diego County Alzheimer’s Project (SDCAP) has been to develop and make widely available information and tools to aid primary care providers in the assessment and treatment of BPSD. The remainder of this article provides an overview of a BPSD assessment algorithm and provides information on how to access additional guidance provided through SDCAP. Dementia experts led by Helen Kales, MD, have created the DICE algorithm to help clinicians learn and remember the key steps to follow when a patient presents with BPSD. DICE stands for Describe, Investigate, Create, and Evaluate. When confronted with BPSD, the

clinician should be careful not to jump to the conclusion that the BPSD symptoms are exclusively and intrinsically an expected outcome of dementia illness. When patients with BPSD are optimally evaluated, a third or more have been found to be experiencing common medical or psychiatric problems — some of which may be new, while others may be exacerbations of preexisting problems. Sometimes difficulties associated with medication administration may be the cause of exacerbations (e.g. levothyroxine on an empty stomach at 6 a.m.). The process of identifying, DESCRIBING, and documenting the specific behavioral symptoms often reveals their underlying cause and the associated corrective action or actions. A careful history often identifies temporal associations between changes in a patient’s behavior patterns or environment (e.g., insomnia, travel across time zones, new additions to the caregiving team, or alterations in the medication regimen) that subsequently prove to be a clue to the cause (e.g., urinary frequency due to infection), a contributing cause, or the sole cause of the problematic BPSD. Even if a nonmedical factor, like a change the noise level of the patient’s environment, is thought to be the cause of the BPSD, while steps are being taken to confirm this, consideration of contributing medical factors is remains essential. The next step in the DICE model is to INVESTIGATE. As with the assessment of any chief complaint, the history obtained will often inspire additional history

gathering, like questions to identify a recurrent episode of major depressive disorder, an abdominal exam to assess for constipation or a joint inspection to detect painful arthritis, or laboratory tests like a urinalysis to confirm a urinary tract infection (UTI). The third step in the DICE model is to CREATE and implement a plan to correct the problem or problems believed to be the cause of the BPSD. If a psychiatric or medical problem is identified, provision of the appropriate treatment may completely resolve the BPSD. After an appropriate interval of intervention, such as the removal of a suspected environmental trigger, the completion of a medical course of treatment like antibiotic for a UTI, or the correction of one or more forms of suboptimal prescribing like polypharmacy, the last step in the DICE model is to EVALUATE whether the patient’s BPSD has improved. If the BPSD has not completely resolved or has only partially resolved, then the DICE algorithm should be repeated in order to look for additional potential causes that may have been overlooked or which may have appeared since the algorithm’s first use. Following each application of the algorithm, RE-EVALUATION of the patient’s BPSD symptoms is required. If the correction of all identified contributing causes or triggers does not lead to improvement, then consultation with a specialist, such as a psychiatrist, is indicated. If the BPSD symptoms are placing the patient or those around the patient in danger, then emergent use of psychiatric medication may be needed, followed by prompt transport to an emergency department. Additional information about BPSD and other aspects of dementia diagnosis and treatment, along with information on assessing for pharmacologic management of symptoms, are available at championsforhealth.org/alzheimers. Dr. Sewell is a geriatric psychiatrist who recently retired as head of UC San Diego’s geriatric psychiatry inpatient unit, and is a professor emeritus at UC San Diego. He has been an active member of CMA-SDCMS.

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INFECTIOUS DISEASE

This Year’s Flu Shot Was a Bust, CDC Says Study Finds Non-significant Effectiveness of 16% Against Predominant Strain BY ZAINA HAMZA

HIS YEAR’S SEASONAL FLU

shot performed abysmally for reducing medical visits for influenza, according to CDC data. For the 2021–2022 season, vaccine effectiveness against medical visits for acute respiratory infections (ARIs) related to the predominant influenza strain, A(H3N2), landed at a non-significant 16% (95% CI -16 to 39), reported Jessie Chung, MPH, of the CDC in Atlanta, and colleagues. “These VE [vaccine effectiveness] estimates underscore the need for ongoing diagnostic testing for influenza, influenza antiviral treatment and prophylaxis when indicated, and everyday preventive measures,” the authors wrote in the Morbidity and Mortality Weekly Report. 12

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“While flu seasons are always unpredictable, flu activity so far this season has been lower than in flu seasons before the COVID-19 pandemic,” Chung told MedPage Today. But Chung noted that “there is a growing body of research suggesting vaccination can prevent serious outcomes even when it does not prevent infection,” and the CDC continues to recommend the vaccine during the flu season to reduce the risk of such outcomes, even when it shows lower effectiveness against a particular strain. For their interim report for the 2021– 2022 season, the researchers examined data on 3,636 children and adults seeking care for ARIs enrolled in the U.S Influenza Vaccine Effectiveness Network from

Oct. 4, 2021 to Feb. 12, 2022. The analysis adjusted for study site, age, month of illness, and days from symptom onset to enrollment. Participants were prospectively enrolled from seven sites — in California, Pennsylvania, Michigan, Tennessee, Texas, Wisconsin, and Washington — and included those 6 months of age and older seeking outpatient medical care or SARS-CoV-2 testing for their ARIs (along with fever, cough, or loss of taste or smell) within 10 days of their symptoms. Those who already were treated with influenza antivirals such as baloxavir (Xofluza) or oseltamivir (Tamiflu) were excluded. Overall, 5% tested positive for the flu (influenza A) on RT-PCR. None tested positive for influenza B. Of 178 influenza A viruses that were subtyped, 177 were A(H3N2), while only one was the 2009 pandemic A(H1N1). Eleven tested positive for both influenza A and SARS-CoV-2 infections. Among the positive tests, 41% had received the 2021–2022 influenza vaccine, versus 50% of those who tested negative. Documented flu vaccinations among the participants ranged from 31% to 64% across the seven sites, and mostly relied on self-reporting. “Influenza activity is difficult to predict, and strategies to prevent influenza illness remain important to reduce strain on healthcare services,” wrote Chung and coauthors. “Clinicians should be aware that influenza activity might continue or increase, and influenza should be considered as a possible diagnosis in all patients with ARI.” The authors acknowledged several limitations to the data. Because of insufficient enrollment, vaccine effectiveness could not be stratified by age or vaccine type. Healthcare seeking behavior has also been reported to have changed during the pandemic, which may have influenced the results. Zaina Hamza is a staff writer for MedPage Today, where this article first appeared. She covers gastroenterology and infectious disease.

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COVID-19 MEDICAL RESEARCH

COVID’S ‘SILVER LINING’ Research Breakthroughs for Chronic Disease, Cancer, and the Common Flu BY LIZ SZABO

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HE BILLIONS OF DOLLARS

invested in COVID vaccines and COVID-19 research so far are expected to yield medical and scientific dividends for decades, helping doctors battle influenza, cancer, cystic fibrosis, and many more diseases. “This is just the start,” says Dr. Judith James, vice president of clinical affairs for the Oklahoma Medical Research Foundation. “We won’t see these dividends in their full glory for years.” Building on the success of mRNA vaccines for COVID, scientists hope to create mRNA-based vaccines against a host of pathogens, including influenza, Zika, rabies, HIV, and respiratory syncytial virus, or RSV, which hospitalizes 3 million children under age 5 each year worldwide. Researchers see promise in mRNA to treat cancer, cystic fibrosis, and rare, inherited metabolic disorders, although potential therapies are still many years away. Pfizer and Moderna worked on mRNA vaccines for cancer long before they developed COVID shots. Researchers are now running dozens of clinical trials of therapeutic mRNA vaccines for pancreatic cancer, colorectal cancer, and melanoma, which frequently responds well to immunotherapy. Companies looking to use mRNA to treat cystic fibrosis include ReCode Therapeutics, Arcturus Therapeutics, and Moderna and Vertex Pharmaceuticals, which are collaborating. The companies’ goal is to correct a fundamental defect in cystic fibrosis, a mutated protein. Rather than replace the protein itself, scientists plan to deliver mRNA that would instruct the body to make the normal, healthy version of the protein, says David Lockhart, ReCode’s president and chief science officer. None of these drugs is in clinical trials yet. That leaves patients such as Nicholas Kelly waiting for better treatment options. Kelly, 35, was diagnosed with cystic fibrosis as an infant and has never been healthy enough to work full time. He was recently hospitalized for 2 and a half months due to a lung infection, a common complication for the 30,000 Americans with the disease. Although

novel medications have transformed the lives of most people with CF, they don’t work in 10% of patients. About a third of patients who don’t benefit from the new medications are Black and/or Hispanic, according to JP Clancy, vice president of clinical research for the Cystic Fibrosis Foundation. “Nobody wants to be hospitalized,” says Kelly, who lives in Cleveland. “If something could decrease my symptoms even 10%, I would try it.” Predicting Which COVID Patients Are Most Likely to Die Ambitious scientific endeavors have provided technological windfalls for consumers in the past; the race to land on the moon in the 1960s led to the development of CT scanners and MRI machines, freeze-dried food, wireless headphones, water purification systems, and the computer mouse. Likewise, funding for AIDS research has benefited patients with a variety of diseases, says Dr. Carlos del Rio, a professor of infectious diseases at Emory University School of Medicine. Studies of HIV led to the development of better drugs for hepatitis C and cytomegalovirus, or CMV; paved the way for successful immunotherapies in cancer; and speeded the development of COVID vaccines. Over the past two years, medical researchers have generated more than 230,000 medical journal articles, documenting studies of vaccines, antivirals, and other drugs, as well as basic research into the structure of the virus and how it evades the immune system. Dr. Michelle Monje, a professor of neurology at Stanford University, has found similarities in the cognitive side effects caused by COVID and a side effect of cancer therapy often called “chemo brain.” Learning more about the root causes of these memory problems, Dr. Monje says, could help scientists eventually find ways to prevent or treat them. Dr. James hopes that computer technology used to detect COVID will improve the treatment of other diseases. For example, researchers have shown that cellphone apps can help detect potential COVID cases by monitoring patients’ self-reported symptoms. Dr. James said she wonders

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COVID-19 MEDICAL RESEARCH

if the same technology could predict flareups of autoimmune diseases. “We never dreamed we could have a PCR test that could be done anywhere but a lab,” Dr. James says. “Now we can do them at a patient’s bedside in rural Oklahoma. That could help us with rapid testing for other diseases.” One of the most important pandemic breakthroughs was the discovery that 15% to 20% of patients over 70 who die of COVID have rogue antibodies that disable a key part of the immune system. Although antibodies normally protect us from infection, these “autoantibodies” attack a protein called interferon that acts as a first line of defense against viruses. By disabling key immune fighters, autoantibodies against interferon allow the coronavirus to multiply wildly. The massive infection that results can lead the rest of the immune system to go into hyperdrive, causing a life-threatening “cytokine storm,” says Dr. Paul Bastard, a researcher at Rockefeller University. The discovery of interferon-targeting antibodies “certainly changed my way of thinking at a broad level,” says E. John Wherry, director of the University of Pennsylvania’s Institute for Immunology, who was not involved in the studies. “This is a paradigm shift in immunology and in COVID.” 16

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Antibodies that disable interferon may explain why a fraction of patients succumb to viral diseases, such as influenza, while most recover, says Dr. Gary Michelson, founder and co-chair of Michelson Philanthropies, a nonprofit that funds medical research and recently gave Dr. Bastard its inaugural award in immunology. The discovery “goes far beyond the impact of COVID-19,” Dr. Michelson says. “These findings may have implications in treating patients with other infectious diseases” such as the flu. Dr. Bastard and colleagues have also found that one-third of patients with dangerous reactions to yellow fever have autoantibodies against interferon. International research teams are now looking for such autoantibodies in patients hospitalized by other viral infections, including chickenpox, influenza, measles, respiratory syncytial virus, and others. Overturning Dogma For decades, public health officials created policies based on the assumption that viruses spread in one of two ways: either through the air, like measles and tuberculosis, or through heavy, wet droplets that spray from our mouths and noses, then quickly fall to the ground, like influenza.

For the first 17 months of the COVID pandemic, the World Health Organization and the Centers for Disease Control and Prevention said the coronavirus spread through droplets and advised people to wash their hands, stand 6 feet apart, and wear face coverings. As the crisis wore on and evidence accumulated, researchers began to debate whether the coronavirus might also be airborne. Today it’s clear that the coronavirus — and all respiratory viruses — spread through a combination of droplets and aerosols, according to Dr. Michael Klompas, a professor at Harvard Medical School and infectious disease doctor. “It’s not either/or,” Dr. Klompas says. “We’ve created this artificial dichotomy about how we think about these viruses. But we always put out a mixture of both” when we breathe, cough, and sneeze. Knowing that respiratory viruses commonly spread through the air is important because it can help health agencies protect the public. For example, high-quality masks, such as N95 respirators, offer much better protection against airborne viruses than cloth masks or surgical masks. Improving ventilation so that the air in a room is completely replaced at least four to six times an hour is another important way to control airborne viruses. Still, Dr. Klompas says, there’s no guarantee that the country will handle the next outbreak any better than this one. “Will we do a better job fighting influenza because of what we’ve learned?” Dr. Klompas says. “I hope so, but I’m not holding my breath.” Fighting Chronic Disease Lauren Nichols, 32, remembers exactly when she developed her first COVID symptoms: March 10, 2020. It was the beginning of an illness that has plagued her for nearly two years, with no end in sight. Although Nichols was healthy before developing what has become known as “long COVID,” she deals with dizziness, headaches, and debilitating fatigue, which gets markedly worse after exercise. She has had shingles — a painful rash caused by the reactivation of the chickenpox virus — four times since her COVID infection. Six months after testing positive for

COVID, Nichols was diagnosed with chronic fatigue syndrome, also known as myalgic encephalomyelitis, or ME/ CFS, which affects more than 1 million Americans and causes many of the same symptoms as COVID. There are few effective treatments for either condition. In fact, research suggests that “the two conditions are one and the same,” says Dr. Avindra Nath, clinical director of the National Institute of Neurological Disorders and Stroke, part of the National Institutes of Health. The main difference is that people with long COVID know which virus caused their illness, while the precise virus behind most cases of chronic fatigue is unknown, Dr. Nath says. Advocates of patients with long COVID want to ensure that future research — including $1.15 billion in targeted funding from the NIH — benefits all patients with chronic, post-viral diseases. “Anything that shows promise in long

COVID will be immediately trialed in ME/ CFS,” says Jarred Younger, director of the Neuroinflammation, Pain and Fatigue Laboratory at the University of AlabamaBirmingham. Patients with chronic fatigue syndrome have felt a kinship with long COVID patients, and vice versa — not just because they experience the same baffling symptoms, but also because both have struggled to obtain compassionate, appropriate care, says Nichols, who’s vice president of Body Politic, an advocacy group for people with long COVID and other chronic or disabling conditions. “There is a lot of frustration about being written off by the medical community, being told that it’s all in one’s head, that they just need to see a psychiatrist or go to the gym,” says Dr. David Systrom, a pulmonary and critical care physician at Brigham and Women’s Hospital in Boston. That sort of ignorance seems to be

IS IT TIME TO EXAMINE

declining, largely because of increasing awareness about long COVID, according to Emily Taylor, vice president of advocacy and engagement at Solve M.E., an advocacy group for people with post-infectious chronic illnesses. Although some doctors still refuse to believe long COVID is a real disease, “they’re being drowned out by the patient voices,” Taylor says. A new study from the National Institutes of Health, called RECOVER (Researching COVID to Enhance Recovery), is enrolling 15,000 people with long COVID and a comparison group of nearly 3,000 others who haven’t had COVID. “In a very dark cloud,” Nichols says, “a silver lining coming out of long COVID is that we’ve been forced to acknowledge how real and serious these conditions are.” Liz Szabo is a senior correspondent and enterprise reporter for Kaiser Health News, where this article first appeared.

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SOIRÉE 2022

A BY A DA M A DYO NIZ I A K

Adama Dyoniziak and Dr. Nikolas London

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HUGE THANK-YOU TO everyone who supported the Champions for Health 2022 Soirée: To Wellness and Beyond, which helps us raise critical funds for our flagship program, Project Access San Diego. We are very grateful to our sponsors for their contribution to an incredible evening: AMR, San Diego County Medical Society, Community Health Group, Point Loma Nazarene University, TrueCare, Aldrich Advisors, San Ysidro Health, Pacific ENT Medical Group, Neighborhood HealthCare, Preferred Employer Insurance Group, and Cooperative of American Physicians. This year’s theme was “To Wellness and Beyond,” and our butterflies symbolized the transformative change of specialty care interventions for our Project Access patients from pain and great health difficulties over many years to renewed energy and reengagement with family and life itself. This was movingly described by Lilia M., a Project Access patient. This soirée was a celebration of our many volunteer physicians and medical partners, who were presented with awards for their contributions to Project Access. Honorees included: Medical Interpreter of the Year: Delilah Calderon was the awardee for not only removing language as a barrier to healthcare, but creating a vital bridge in the relationship and trust that is cultivated often in a manner of minutes between a

patient and his or her provider. Physician of the Year: Dr. Sunil Bhoyrul’s experience working alongside inspirational mentors helped him to dedicate his life to closing the health-equity and access-to-care gap, one patient at a time. His philosophy is to deliver patient care with excellence, humility, and respect. Partner of the Year: Neighborhood Healthcare possesses the resources and culture necessary to provide quality, compassionate, and whole-person care regardless of the person’s circumstances. Their partnership extends to their medical and referral staff, ensuring that patients with the greatest need are offered the opportunity to receive pro bono specialty services through Project Access. Our synergy transforms patients’ lives. Medical Group of the Year: ASMG has provided more than 1,000 Project Access patients with anesthesia services for the past 14 years. Project Access and our volunteer specialists literally could not perform the medically necessary outpatient surgeries without ASMG. Civic Health Leader of the Year: Dr. Wilma Wooten’s strong interest in health disparities and health equity is a bedrock of her daily work. This common thread of bringing down the barriers to access by collaborating closely with medical and community leaders includes supporting Champions for Health’s mission and Project Access patients. Champion of the Year: Dr. Nikolas Lon-

Dr. Jim Schultz

don has been a Project Access volunteer since the beginning, providing consultations and procedures to 110 patients and counting. He treasures the relationships with his patients and goes above and beyond to make a difference in their lives. President’s Award: Since 2010, Scripps Health hospitals have hosted 70% of the total Project Access outpatient surgeries and procedures through Scripps Charity Care. Project Access patients would surely have manifested dire consequences had Scripps Health not been a Project Access partner. Access to care for all is the mission of Champions for Health — it shouldn’t be a dream that is out of reach. The physicians of the San Diego County Medical Society made a promise to the vulnerable populations of San Diego when they formed Champions for Health, and Project Access was a twinkle in their eye, just a dream that is now a reality. We are grateful that so many of you so generously supported — and continue to support — Champions for Health. Our volunteers are generous with their time and talent to create the safety net to your neighbors who are most in need of procedures and surgeries. You can be a part of these butterfly transformations by donating at www.championsforhealth. org/donate..

Dr. Wendy Buchi and Dr. Tom Savides

Carol Jean and Dr. Stony Anderson

Dr. Sergio Flores testing out a space capsule

Adama Dyoniziak is executive director of Champions for Health.

Dr. Sergio Flores, Christina Flores, Emily Flores, and Steve Coker

Dr. Mihir Parikh and Dr. Keerti Gurushanthaiah

Celene Salazar, Dr. Jim Schultz, Evelyn Penaloza, and Mimi Herrera

Paul Hegyi, Marty and Jen Ohmstede, Angela Shiau and Dr. Will Tseng

Josh Mbugua and Trinity Lewis

Project Access patients

Dr. Wilma Wooten and Dale Fleming

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PERSONAL AND PROFESSIONAL DEVELOPMENT

We Have More Choice Than We Think BY HELANE FRONEK, MD, FACP, FACPH

IFE IS FULL OF CHOICES.

Julia Louis-Dreyfus once commented, “I’ve never met a moment when I didn’t have a choice.” Too often, though, we live as if we have no choice at all. “That’s just the way it is,” people explain when complaining about an undesired situation. After pointing out that others respond differently to the same situation, I’m usually met with blank stares. They are too entrenched in their belief to see that it is actually their habitual way of dealing with the situation that is “just the way it is,” not the situation itself. 20

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What contributes to this apparent lack of choice? Through our life experiences, we adopt a set of beliefs that usually operate beneath consciousness. These often begin with “I must … ” or “I cannot … ” or “If I do/don’t do X, then Y will happen.” It’s why some physicians spend hours completing detailed notes while others write very little and happily move on to other activities each evening. Until we become aware of our operating principles, we are trapped by our belief that “it’s just the way it is.” For most of my life, I was a compulsive volunteer. While many activities I par-

ticipated in were enjoyable and congruent with my values, some were not. One cringeworthy experience involved teaching myself to juggle at midnight (the only time available) so I could teach a group of Cub Scouts the following day. While this sounds silly (it was), I honestly felt I had to do this — I had no choice. After many similar experiences, I discovered the belief underlying these misguided decisions: Everything I’m asked to do immediately becomes my responsibility. While the irrationality of this idea is obvious, it came directly from the role I played in my family and caused my plate to be perennially overloaded. Fortunately, beliefs can be changed — we routinely change beliefs as new information becomes available. Byron Katie (thework.com) offers questions to help us find a belief that’s at least as true as the one we’re holding on to; once we do, choices appear that we didn’t see before. We must then be willing to experience the discomfort of doing things a different way. Discovering and changing my rule took time. To mitigate the discomfort of change, I learned to say, “That sounds like an interesting idea. Let me think about it and get back to you.” By creating space away from the person who was asking, I could examine my thoughts, feelings, personal values, and commitments, and the right choice became clear. While initially uncomfortable, “no” became a more frequent word in my vocabulary and my life became less stressful and more joyful. Whenever we believe we have no choice, we’re wise to ask ourselves what rule we’re following. Where did it come from? Do we still want it running our life? What might we believe instead? What choices would appear if we did? Dr. Fronek is an assistant clinical professor of medicine at UC San Diego School of Medicine and a Certified Physician Development Coach.

CLASSIFIEDS VOLUNTEER OPPORTUNITIES

PHYSICIANS: HELP US HELP IMPROVE THE HEALTH LITERACY OF OUR SAN DIEGO COUNTY COMMUNITIES by giving a brief presentation (30–45 minutes) to area children, adults, seniors, or employees on a topic that impassions you. Be a part of Champions for Health’s Live Well San Diego Speakers Bureau and help improve the health literacy of those with limited access to care. For further details on how you can get involved, please email Andrew.Gonzalez@ChampionsFH.org. CHAMPIONS FOR HEALTH PROJECT ACCESS: Volunteer physicians are needed for the following specialties: endocrinology, ENT or head and neck, general surgery, GI, gynecology, neurology, ophthalmology, orthopedics, pulmonology, rheumatology, and urology. We are seeking these specialists throughout all regions of San Diego to support those that are uninsured and not eligible for Medi-Cal receive short term specialty care. Commitment can vary by practice. The mission of the Champions for Health’s Project Access is to improve community health, access to care for all, and wellness for patients and physicians through engaged volunteerism. Will you be a health CHAMPION today? For more information, contact Andrew Gonzalez at (858) 300-2787 or at Andrew.Gonzalez@ChampionsFH. org, or visit www.ChampionsforHealth.org.

PHYSICIAN OPPORTUNITIES CARDIOLOGIST POSITION AVAILABLE: Cardiology office in San Marcos seeking part-time cardiologist. Please send resume to albertochaviramd@yahoo.com. DERMATOLOGIST NEEDED: Premier dermatology practice in La Jolla seeking a part-time BC or BE dermatologist to join our team. Busy practice with significant opportunity for a motivated, entrepreneurial physician. Work with three energetic dermatologists and a highly trained staff in a positive work environment. We care about our patients and treat our staff like family. Opportunity to do medical/surgical and cosmetic dermatology in an updated medical office with state-ofthe art tools and instruments. Incentive plan will be a percentage based on production. If you are interested in finding out more information, please forward your C.V. to jmaas12@hotmail.com RADY CHILDREN’S HOSPITAL - PEDIATRICIAN POSITIONS: Rady Children’s Hospital of San Diego seeking board-certified/eligible pediatricians or family practice physicians to join the Division of Emergency Medicine in the Department of Urgent Care (UC). Candidate will work at any of our six UC sites in San Diego and Riverside Counties. The position can be any amount of FTE (full-time equivalent) equal to or above 0.51 FTE. Must have an MD/DO or equivalent and must be board certified/eligible, have a California medical license or equivalent, PALS certification, and have a current DEA license. Contact Dr. Langley glangley@ rchsd.org and Dr. Mishra smishra@rchsd.org. PER DIEM OBGYN LABORIST POSITION AVAILABLE: IGO Medical Group is seeking a per diem laborist to cover Labor and Delivery and emergency calls at Scripps Memorial Hospital in La Jolla. 70 deliveries/ month. 24-hour shifts preferred but negotiable. Please send inquiries by email to IGO@IGOMED.com. MEDICAL CONSULTANT – SAN DIEGO COUNTY: The County of San Diego, Health and Human Services Agency’s Public Health Services is looking for a Board Certified Family Practice or Internal Medicine physician for the Epidemiology and Communicable Disease Division. Under general direction, incumbents perform a variety of duties necessary for the identification, diagnosis, and control of communicable diseases within the population. This position works closely with the medical and labora-

tory community, institutional settings, or hospital control practitioners. Learn more here: https://www.governmentjobs.com/careers/sdcounty?keywords=21416207 KAISER PERMANENTE SAN DIEGO - PER DIEM PHYSIATRIST: Southern California Permanente Medical Group is an organization with strong values, which provides our physicians with the resources and support systems to ensure they can focus on practicing medicine, connecting with one another, and providing the best possible care to their patients. For consideration or to apply, visit https://scpmgphysiciancareers.com/specialty/physical-medicine-rehabilitation. For questions or additional information, please contact Michelle Johnson at 866-503-1860 or Michelle.S1.Johnson@kp.org. We are an AAP/EEO employer.

PRIMARY CARE PHYSICIAN POSITION: San Diego Family Care is seeking a Primary Care Physician (MD/DO) at its Linda Vista location to provide direct outpatient care for acute and chronic conditions to a diverse adult population. San Diego Family Care is a federally qualified, culturally competent and affordable health center in San Diego, CA. Job duties include providing complete, high quality primary care, and participation in supporting quality assurance programs. Benefits include flexible schedules, no call requirements, a robust benefits package, and competitive salary. If interested, please email CV to sdfcinfo@sdfamilycare.org or call us at (858) 810- 8700. FAMILY MEDICINE OR INTERNAL MEDICINE PHYSICIAN: TrueCare is more than just a place to work; it feels like home. Sound like a fit? We’d love to hear from you! Visit our website at www.truecare.org. Under the direction of the Chief Medical Officer and the Lead Physician, ensure the provision of effective quality medical service to the patients of the Health center. The physician is responsible for assuring clinical procedures are continually and systematically followed, patient flow is enhanced, and customer service is extended to all patients at all times.

to patients. For more information and to apply, please contact Clara Rubio at (844) 200-2426 EXT 1046 or at crubio@samahanhealth.org.

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

OFFICE SPACE / REAL ESTATE AVAILABLE CHULA VISTA MEDICAL OFFICE: Ready with 8 patient rooms, 2000sf, excellent parking ratios, Lease $4000/ mo. No need to spend a penny. Call Dr. Vin, 619-4056307 vsnnk@yahoo.com OFFICE SPACE AVAILABLE – BANKERS HILL: Approximately 500 square-foot suite available to lease, includes private bathroom. Located in beautiful Bankers Hill. For more details, please call Claudia at (619) 501-4758. OFFICE AVAILABLE IN MISSION HILLS, UPTOWN SAN DIEGO: Close to Scripps Mercy and UCSD Hillcrest. Comfortable Arts and Crafts style home in upscale Mission Hills neighborhood. Converted and in use as medical/surgical office. Good for 1-2 practitioners with large waiting and reception area. 3 examination rooms, 2 physician offices and a small kitchen area. 1,700 sq. ft. Available for full occupancy in March 2022. Contact by Dr. Balourdas at greg@thehanddoctor.com.

PUBLIC HEALTH LABORATORY DIRECTOR: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a qualified individual to work for a Level 3 Public Health Laboratory. The Public Health Services department, part of the County’s Health and Human Services Agency, is a local health department nationally accredited by the Public Health Accreditation Board and first of the urban health departments to be accredited. Public Health Laboratory Director21226701UPH

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

NEIGHBORHOOD HEALTHCARE MD, FAMILY PRACTICE AND INTERNISTS/HOSPITALISTS: Physicians wanted, beautiful Riverside County and San Diego County- High Quality Family Practice for a privatenonprofit 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.

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.

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 lowincome, 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

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

OFFICE SPACE / REAL ESTATE WANTED

NON-PHYSICIAN POSITIONS AVAILABLE

SA NDIEGOPH YSICI A N.ORG

$5.95 | www.SanDiegoPhysician.org

PRSRT STD U.S. POSTAGE

San Diego County Medical Society 8690 Aero Drive, Suite 115-220 San Diego, CA 92123

PAID DENVER, CO PERMIT NO. 5377

[ Return Service Requested ]

ReNDEZVOUS AN EVENING CELEBRATING 152 YEARS OF HEALING

Friday, JUNE 3, 2022 6:00 PM-10:00 PM THE ABBEY ON FIFTH

Please join the San Diego County Medical Society for a celebration as we welcome Toluwalase (Lase) A. Ajayi, MD as SDCMS President for 2022-2023 and thank Sergio R. Flores, MD 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/2022Rendezvous