May 2015

OFFICIAL PUBLICATION OF SDCMS MAY 2015

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MAY

CONTENTS

VOLUME 102, NUMBER 5

EDITOR: James Santiago Grisolía, MD MANAGING EDITOR: Kyle Lewis EDITORIAL BOARD: Sherry L. Franklin, MD, James Santiago Grisolía, MD, Theodore M. Mazer, MD, Robert E. Peters, PhD, MD, David M. Priver, MD MARKETING & PRODUCTION MANAGER: Jennifer Rohr SALES DIRECTOR: Dari Pebdani ART DIRECTOR: Lisa Williams COPY EDITOR: Adam Elder SDCMS BOARD OF DIRECTORS OFFICERS PRESIDENT: J. Steven Poceta, MD PRESIDENT-ELECT: William T-C Tseng, MD, MPH (CMA Trustee) TREASURER: Mihir Y. Parikh, MD SECRETARY: Mark W. Sornson, MD IMMEDIATE PAST PRESIDENT: Robert E. Peters, PhD, MD GEOGRAPHIC AND GEOGRAPHIC ALTERNATE DIRECTORS EAST COUNTY: Venu Prabaker, MD, Alexandra E. Page, MD, Jay P. Mongiardo, MD, Alt: Susan Kaweski, MD (CALPAC Treasurer) HILLCREST: Gregory M. Balourdas, MD, Thomas C. Lian, MD, Alt: Thomas J. Savides, MD KEARNY MESA: Sergio R. Flores, MD, John G. Lane, MD, Alt: Anthony E. Magit, MD, Alt: Eileen R. Quintela, MD LA JOLLA: Geva E. Mannor, MD, Marc M. Sedwitz, MD, Alt: Lawrence D. Goldberg, MD NORTH COUNTY: James H. Schultz, MD, Eileen S. Natuzzi, MD, Michael A. Lobatz, MD, Alt: Anthony H. Sacks, MD SOUTH BAY: Reno D. Tiangco, MD, Michael H. Verdolin, MD, Alt: Elizabeth Lozada-Pastorio, MD

feature

AT-LARGE DIRECTORS Lawrence S. Friedman, MD, Karrar H. Ali, MD, Kosala Samarasinghe, MD, David E.J. Bazzo, MD, Stephen R. Hayden, MD, Peter O. Raudaskoski, MD, Vimal Nanavati, MD (Board Representative), Holly B. Yang, MD

9

It’s Finally Over: The SGR Is Dead!

16 departments

OTHER VOTING MEMBERS COMMUNICATIONS CHAIR: Sherry L. Franklin, MD (CMA Trustee) YOUNG PHYSICIAN DIRECTOR: Edwin S. Chen, MD RESIDENT PHYSICIAN DIRECTOR: Jane Bugea, MD RETIRED PHYSICIAN DIRECTOR: Rosemarie M. Johnson, MD MEDICAL STUDENT DIRECTOR: Spencer D. Fuller

4

Briefly Noted: Calendar • Welcome New and Returning Members • Featured Member • Commercial Real Estate • And More …

12

Embracing Who We Are: A Win-Win for Everyone

10

o You Really Need a Compliance D Program?

BY HEIDI KOCHER, ESQ.

28

AT-LARGE ALTERNATE DIRECTORS Karl E. Steinberg, MD, Jeffrey O. Leach, MD, Toluwalase A. Ajayi, MD, Phil Kumar, MD, Wayne C. Sun, MD, Kyle P. Edmonds, MD, Carl A. Powell, DO, Marcella M. Wilson, MD

BY HELANE FRONEK, MD, FACP, FACPh

14

Up in the Cloud: Is It Safe to Store Protected Health Information on Remote Servers?

BY THE DOCTORS COMPANY

OTHER NONVOTING MEMBERS YOUNG PHYSICIAN ALTERNATE DIRECTOR: Daniel D. Klaristenfeld, MD RESIDENT PHYSICIAN ALTERNATE DIRECTOR: Diana C. Gomez, MD RETIRED PHYSICIAN ALTERNATE DIRECTOR: Mitsuo Tomita, MD SDCMS FOUNDATION PRESIDENT: Albert Ray, MD (CMA Trustee, AMA Delegate) CMA SPEAKER: Theodore M. Mazer, MD CMA PAST PRESIDENTS: James T. Hay, MD (AMA Delegate), Robert E. Hertzka, MD (Legislative Committee Chair, AMA Delegate), Ralph R. Ocampo, MD CMA TRUSTEES: Robert E. Wailes, MD, Erin L. Whitaker, MD CMA SSGPF DELEGATE: James W. Ochi, MD CMA SSGPF ALTERNATE DELEGATES: Dan I. Giurgiu, MD, Ritvik Mehta, MD AMA ALTERNATE DELEGATE: Lisa S. Miller, MD

16

One San Diego: Roneet Lev, MD, Interviews Nathan Painter, PharmD

26

Physician Marketplace: Classifieds

28

Infinitesimal Change

BY DANIEL J. BRESSLER, MD, FACP

2

MAY 2015

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.]

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/////////BRIEFLY /////////////////NOTED //////////////////////////////////////////////////////////////////////// San Diego Heart Failure Symposium JUN 6 at the Estancia La Jolla Hotel (cardiology. ucsd.edu/education/ Pages/symposia.aspx) Advances in Addiction JUN 6–7 at the Hyatt Regency in La Jolla at Aventine (www.sdpscme. com)

CALENDAR SDCMS Seminars & Webinars SDCMS.org

For further information or to register for any of the following SDCMS seminars, webinars, workshops, and courses, email Seminars@ SDCMS.org.

Social Media Update and Best Practices: Essentials for 2015 (webinar) MAY 28: 12:15pm–1:15pm Financial & Legal Life Skills Workshop for Physicians JUN 6: 8:00am– 12:00pm SDCMS White Coat Gala (event) JUN 13: 6:00pm– 11:00pm 2015 ICD-10-CM Code Set Boot Camp (course) JUN 25–26: 8:00am– 5:00pm 10 Ways to Improve Revenue Cycle Management (webinar) JUL 9: 12:15pm–1:15pm

“

The Leader’s Toolkit (workshop) JUL 11–12: 8:00am– 4:00pm & 8:00am– 12:00pm Taming Outlook Workshop for Physicians AUG 22: 8:00am– 12:00pm

Community Healthcare Calendar

To submit a community healthcare event for possible publication, email KLewis@SDCMS. org. Events should be physician-focused and should take place in or near San Diego County.

Free Public Screening of “The Invisible Threat” and “The Shot Felt ‘Round the World’” JUN 3 at the Ultra Star Cinema in Mission Valley – Hazard Center (screening followed by panel discussion) • (advance registration required: www. signupgenius.com/ go/5080b44a5ad2da64-invisible)

Family Medicine Update 2015 JUN 26–28 at Paradise Point Hotel, San Diego (www.sandiegoafp.org) Spine Injuries in Sport JUL 15 at Scripps Green Hospital (www.scripps. org/sparkle-assets/ documents/sports_ medicine_seminar_2015. pdf) Critical Care Summer Session 2015 JUL 23–25 at Paradise Point, San Diego (cme. ucsd.edu/criticalcare) Pan-Pacific Biomedical Informatics Training Camp AUG 3–13 at the UC San Diego Biomedical Research Facility II, La Jolla (cme.ucsd.edu/ bioinformatics) Advanced Therapeutic Interventions to Optimize Obesity and Diabetes Care SEP 25–26 at the San Diego Marriott La Jolla (www.scripps.org/events/ advanced-therapeuticinterventions-to-optimizeobesity-and-diabetescare-september-25-2015)

QUOTE OF THE MONTH

Thought is the blossom; language the bud; action the fruit behind it.

4

MAY 2015

”

— Ralph Waldo Emerson, American Essayist, Lecturer, and Poet (1803–1882)

SDCMS-CMA MEMBERSHIP

Welcome New and Returning SDCMS-CMA Members!

NEW MEMBERS Rafid B. Arabo, MD Internal Medicine La Mesa (888) 664-8297 Francis E. Attwill, DO Emergency Medicine Chula Vista (619) 482-5800 Bruce H. Friedberg, MD Emergency Medicine Escondido (858) 945-8899 John D. How, MD Emergency Medicine Escondido (760) 739-3300 Preeti Mehta, MD Internal Medicine La Jolla (858) 626-7780 Lewis H. Self, MD Internal Medicine Encinitas (858) 626-7780

RETURNING MEMBERS Douglas M. Crowley, MD Internal Medicine La Jolla (858) 626-7780 John D. Hill, MD, ABFP Family Medicine Solana Beach (858) 481-8808 Kamron Mirkarimi, MD Internal Medicine San Diego (858) 483-5570 Lakshmi Prathipati, MD Internal Medicine San Diego (619) 286-3222 Clark E. Smith, MD Addiction Psychiatry San Diego (858) 530-9112

AWARDS Al Ray, MD (far right), 23-year member of SDCMS-CMA, receiving the American Cancer Society 2014 Special Friend Partnership and Collaboration Award presented to SDCMS, Council of Community Clinics of San Diego, and California Colorectal Cancer Coalition, April 28, 2015.

/////////////////////////////////////////////////////////////////////////////////////////////////// FEATURED MEMBER

DR. STEVEN A. GREEN

Steven A. Green, MD, 27-year member of SDCMSCMA, was selected the California Academy of Family Physicians’ 2015 Family Physician of the Year. CAFP annually honors a family physician that represents the finest characteristics of the specialty. Winners of this award embody the finest characteristics of family medicine, are directly and effectively involved in public service and/or activities that enhance the quality of life in communities, and have been engaged with the CAFP. Dr. Green was recognized on April 25 during the 2015 Family Medicine Clinical Forum Celebration Lunch at the Westin St. Francis in San Francisco. Congratulations, Dr. Green!

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MAY 2015

By Chris Ross

Market Conditions and Trends: • Leasing activity is steady. Vacancy is gradually dropping. Rents and prices everywhere are up and will keep climbing. Investment property and owner-user demand is sky-high, but good opportunities are limited. Oncampus MOB and hospital construction is significant while off-campus development is limited to pre-leased buildings. That will change soon in some areas where market conditions are reaching the tipping point that justifies speculative development.

• Negotiating tables are relatively balanced between landlords and tenants in most submarkets, but landlords are gaining the upper hand in areas such as UTC and coastal North County.

Many of the county’s well-located buildings are 100% leased.

• Owner-user sale activity is at an all-time high. Sole practitioners, dentists, and medical groups of all sizes have flooded the market seeking opportunities to acquire real estate and control long-term costs.

• Currently under construction are the new 175,000-square-foot MOB on Scripps’ La Jolla campus and the 15,000-square-foot MOB at La Jolla Village Professional Center. Coming very soon are “Merge,” the mixed-use retail/office/medical development in Carmel Valley, and the new Sharp Rees-Stealy MOB in Rancho Bernardo.

Interesting Facts: • 18 existing Class B and 8 Class A MOBs in the county have more than 10,000 square feet of vacancy. The particularly tight Class A market is resulting in a surge of interest from developers interested in building more medical office.

• The new “high water mark” for medical office rent in San Diego County is $4.00 NNN — a lease recently signed in Carmel Valley. Highest-quality retail and shopping center rents have reached $5.00 NNN, even higher in some cases.

• In the past 12 months, several Class C medical buildings have been acquired by developers with plans to either redevelop or repurpose the properties for other uses such as multifamily, retail, mixed-use, and senior housing. Examples of this can be found in Hillcrest (Sixth Avenue Medical Center), La Jolla (former La Jolla Spa MD building on Fay Avenue), Mission Valley (Global Laser Vision building), Mission Bay (Kaiser Bunker Hill), and College Area (Campus Medical Dental building). Expect more of this over the next 18–24 months.

Mr. Ross is vice president of healthcare solutions for Jones Lang LaSalle.

He is a commercial real estate broker specializing exclusively in medical office and healthcare properties in San Diego County. To receive the complete Q1 2015 report, call Mr. Ross at (858) 410-6377 or email him at chris.ross@am.jll.com.

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APRIL 2015

SAN DIEGO PHYSICIAN.ORG

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SDCMS-CMA MEMBERSHIP

IT’S FINALLY OVER The SGR Is Dead!

AFTER A DECADE OF BATTLING, HR 2, the “Medicare Access and CHIP Reauthorization Act of 2015” — or “MACRA” — was passed by the U.S. House of Representatives on March 26 in a landslide vote of 392–37, by the Senate on April 14 in a vote of 92–8, and was signed into law on April 16, 2015.

This bipartisan legislation: • Permanently repeals the sustainable growth rate (SGR) formula, which was set to cut Medicare payments to physicians by 21% on April 15; • Stabilizes Medicare payments for physician services with positive updates from July 1, 2015, through the end of 2019, and again in 2026 and beyond; • Replaces Medicare’s multiple quality reporting programs with a new single Merit-based Incentive Payment System (MIPS) program that makes it easier for physicians to earn rewards for providing

high-quality, high-value healthcare; • Supports and rewards physicians for participating in new payment and delivery models to improve the efficiency of care; • Preserves fee-for-service as an option; and • Preserves the current 10-day and 90day global periods for more than 4,000 surgical service codes that Medicare had planned to unbundle.

SDCMS and CMA extend a sincere thank-you to all member physicians for the extraordinary campaign this last decade to end the SGR. Member physicians kept up the fight these past two years to hold Congress’s feet to the fire to develop a comprehensive bill to reform Medicare physician payments. The unity within organized medicine finally put this over the finish line. Moreover, 52 out of 54 members of the

California congressional delegation voted to support physicians — a direct result of longterm SDCMS and CMA advocacy.

While many will claim credit (JFK’s apocryphal comment “victory has 100 fathers while defeat is an orphan” comes to mind), let there be no doubt that SDCMS-CMA member physician dues dollars made this work. Combine this huge SGR win with the victories on Proposition 46, GPCI, arresting the Medi-Cal cuts for three years, preventing any Medi-Cal clawbacks, stopping scope of practice expansions … the list could go on … and the message could not be any clearer: Non-member physicians have received significant value from member dues.

NONMEMBER PHYSICIANS: Please join your fellow physicians who have contributed to these successes by becoming a member of SDCMS-CMA today at www.

SDCMS.org.

SAN DIEGO PHYSICIAN.ORG

9

P R AC T I C E M A N AG E M E N T

DO YOU REALLY NEED A COMPLIANCE PROGRAM?

by Heidi Kocher, Esq.

“My office manager went to a continuing education program, and she’s come back telling me we need a compliance program. I know I need to be in compliance with all those rules and regulations, but it seems to be complex and confusing. Do I really need one? How do I put a program into place without spending enormous sums? We’re a small practice, and we don’t have a lot of extra time and money to spend on compliance activities.”

10

MAY 2015

This is how my clients often approach me with questions about compliance programs — or they’ve been the recipient of an audit letter from either Medicare or a private insurer. Let’s face it: The requirements for compliance programs are here to stay.

Not only are compliance programs now required by the federal government for any provider who receives Medicare or Medicaid reimbursement (see section 6401 of the

Affordable Care Act), they are also required by many private insurance companies.

Within the last year, I have seen increasing numbers of network provider contracts from private insurance companies include a requirement that the provider have a compliance program. In other words, having a functional compliance program is no longer an option but a requirement. To that end, over the next year we will be exploring the basic elements of an effective compliance program, as well as topics related to a solid compliance program.

Let’s start with what a compliance program is and is not. A compliance program is not a document that’s placed in a binder on a high shelf in your office, to be dusted off only annually or when faced with scrutiny by insurance companies or, God forbid, state or federal regulators. Instead, a compliance program should become part of the fabric of doing business in your practice. When implemented correctly, a compliance program can help identify potential trouble spots in your practice and give you a framework for addressing those trouble spots. Of course, a functioning and effective compliance program can also help minimize fines and, if things go south, could keep a civil matter from turning into a criminal matter.

A compliance program is also not a muumuu — one size does NOT fit all. Just as there are differences between patients, there are differences between practices, the risks they face, and the best methods of addressing those risks. An effective compliance program recognizes that while the structure of most compliance programs is similar, it takes into account the practice’s size and sophistication, the medical specialty, and the patient population. For this reason, compliance programs in a box or purchased off the Internet really are not desirable and often cost a practice more money in customization and sometimes tears down the road. A perfect example is the recent settlement by Anchorage Community Mental Health Services in relation to a HIPAA breach, where the government noted the ineffectiveness of the “sample” compliance policies and documents the provider put forward as its compliance program.

The basic elements of an effective compliance program are not complicated.

They are: 1. Designating an individual to serve as compliance officer and creating a compliance committee, particularly for larger organizations

2. Implementing a standard of conduct and policies and procedures relevant to the practice’s operations 3. Conducting effective training and education 4. Instituting effective methods of communication 5. Conducting internal monitoring and auditing 6. Enforcing the policies and standards through well-publicized disciplinary guidelines 7. Responding promptly to violations and taking appropriate corrective action.

Each month we will explore each of these topics, discussing how to implement the element and sharing cost-effective means of doing so. Along the way, we will also discuss various forms of guidance available to practices in implementing their compliance programs. Let’s start with one right away: the federal government itself. The Office of Inspector General of the U.S. Department of Health and Human Services (“OIG”) has published a number of “Compliance Program Guidances” intended to help different provider types understand and implement compliance practices specific to and appropriate for their particular branch. One of the guidances — http://oig.hhs.gov/authorities/docs/physician.pdf — is specifically written for individual and small group physician practices and was published in October 2000. In fact, this document is so basic to a physician practice’s compliance program that I strongly recommend that every compliance program have this document printed, included among the compliance program documents, and readily available for staff member review. Although this document was published in 2000 (and therefore refers to CMS as HCFA and doesn’t make reference to the Affordable Care Act), it can be considered a bit like the U.S. Constitution, a document that creates the foundation for what comes after and points to a better future.

Next Month’s Topic: Selection of a Compliance Officer and Implementing a Compliance Committee Ms. Kocher is counsel with the law firm of Liles Parker. In addition to serving as a chief compliance officer and chief privacy officer, she has almost 20 years of experience advising and defending clients on legal and regulatory matters affecting providers of all sizes. Ms. Kocher can be reached at hkocher@lilesparker. com or (214) 952-5169.

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P E R S O N A L & P R O F E S S I O N A L D E V E LO P M E N T

What’s important is to understand ourselves, and the value we bring to our relationships, groups, and interactions.

EMBRACING WHO WE ARE A Win-Win for Everyone

by Helane Fronek, MD, FACP, FACPh

RECENTLY I WATCHED medical students practice communication skills as an actor played the part of a newly diagnosed diabetic. The students were tasked with explaining diabetes and negotiating a plan for further testing and lifestyle modifications.

Each student took a turn, picking up where the last student left off. It was striking how differently each student carried the discussion — some were quieter and listened intently, validating the concerns that the patient was experiencing; others were more animated, their contagious enthusiasm infusing the patient with hope that she could manage all that was before her. The actor provided each student with feedback and verified that each approach was effective and helpful in understanding her condition and gaining confidence that she could face what was ahead.

12

MAY 2015

The importance of different personality types is shown clearly by the Myers-Briggs Type Inventory, an assessment that identifies our preferences for what we pay attention to, how we like to take in information, the methods we use to process that information, and how we deal with the outside world. Some people pay more attention to the outside world; others focus on their internal thoughts. Some rely on information taken in through their senses; others favor what comes to them intuitively. Some people process information analytically; others decide on the basis of their values.

Some people feel more comfortable living in a structured, planned way; the attention of others is easily pulled in various, interesting directions.

While it can be frustrating to deal with those who are different from us, each type

offers something valuable to an interaction. What’s important is to understand ourselves, and the value we bring to our relationships, groups, and interactions. Otherwise, we risk withholding skills, talents and information, thinking that our way is not as valuable as someone else’s. Or, we aggressively try to dominate, believing that ours is the only relevant approach to a situation. While years were spent trying to “fix” people’s weaknesses, data shows that finding appropriate roles for our strengths is best for us, and our organizations.

It’s taken me years to understand and accept my own preferences. As a strong introvert, I opted for a wonderful conversation over a quiet dinner with a friend rather than the boisterous gala at a recent meeting. An extroverted colleague shared her delight with the evening of laughter and dancing. We each chose appropriately and emerged energized and ready for the morning sessions. I prefer to plan and follow an uninterrupted path toward my goals. My husband is happy to divert his attention to various interesting things along his path.

Because of my focus, most of our arrangements flow smoothly. But it’s his willingness to shift his attention that makes our life more interesting and fun.

In what ways are your preferences important in your relationships, activities, and work? How do those of others complement what you bring? By appreciating each person’s ideas and strengths, we make our own lives more enjoyable and enrich our workplaces and homes.

Dr. Fronek, SDCMS-CMA member since 2010, is assistant clinical professor of medicine at UC San Diego School of Medicine and a certified physician development coach who works with physicians to gain more power in their lives and create lives of greater joy. Read her blog at helanefronekmd.wordpress.com.

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R I S K M A N AG E M E N T

UP IN THE CLOUD Is It Safe to Store Protected Health Information on Remote Servers?

Contributed by SDCMS-endorsed The Doctors Company

For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

14

MAY 2015

R I S K M A N AG E M E N T

TrusT WHAT EXACTLY IS THE CLOUD? Cloud storage is a network of remote servers that allow for centralized data storage and online access to these resources. Your files are stored on a server connected to the Internet instead of being stored on your own computer’s hard drive. The cloud is convenient and cost-effective, providing a way to automatically back up your files and folders.

Despite these benefits, recent publicity around hacks of public cloud storage websites has raised concerns about whether it is appropriate for medical practices and facilities to store health records and information in the cloud.

Is cloud storage a safe way to store protected health information (PHI)? As with many new technologies, the safety level of the cloud, and whether it’s appropriate for use, depends on the vendor. There are several issues you will have to keep in mind: • Are the vendor’s security standards appropriate? You will have to research each vendor you choose. Make sure the company has a good reputation and solid security policies.

• How much data will you be storing? Ensure the vendor can handle the amount of data you would like to move to the cloud.

• Ensure your data is encrypted when being uploaded to or downloaded from the cloud.

This is also your responsibility. Make sure your browser or app requires an encrypted connection before you upload or download your data.

• Make sure your data is encrypted when stored in the cloud. Data

protected by law, such as medical information or personal identifiers, should never be stored in the cloud unless the storage solution is encrypted. Only selected members of your organization should be able to decrypt the data, and your organization should create policies detailing under what circumstances information can be decrypted.

• Understand how access is shared in your cloud folder. Many cloud storage providers allow you to share access to your online folders. Be familiar with the details on how that sharing works. Awareness of who has access and how is critical to monitoring activity within your stored data.

• Understand your options if the cloud provider is hacked or your data is lost. Virtually all cloud service providers require a user to sign an agreement that the user has very little, if any, remedy if a hack or a loss of data occurs.

Cloud storage can be a valuable asset to medical practices and facilities, but make sure you have absolute confidence in the service provider’s ability to keep the data safe and secure.

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SAN DIEGO PHYSICIAN.ORG

15

PRESCRIPTION DRUG ABUSE

ONE 16

MAY 2015

SAN DIEGO Interview Recorded March 10, 2015, Between Roneet Lev, MD, and Nathan Painter, PharmD

NOTE: The opinions expressed in this interview do not necessarily represent the opinions of the San Diego County Medical Society (SDCMS).

INTRODUCTION Lev: The Prescription Drug Abuse Medical Task Force hopes to bring together our entire medical community to a “One San Diego” message for safe prescribing of controlled medications. This was the theme of our March 11 symposium. One San Diego means a unified approach for all medical specialties with five principles: 1. One physician and one pharmacy for all controlled medications; 2. Appropriately using the CURES system; 3. Using medical agreements for patients who need three or more months of controlled medication; 4. Avoiding opioid and benzodiazepine combinations; and 5. Adhering to the emergency and urgent care safe prescribing principles.

We often practice in silos — primary care, emergency, orthopedic, psychiatry, urology, dentists, pharmacy — each one of us doing a great job within our own profession but not always working and coordinating optimally as a team. In this interview we hope to help prescribers and dispensers understand each other better so

we can provide better coordinated care.

Nathan, thank you so much for joining us today. Let’s start with some background about yourself.

Painter: Thank you for inviting me. I am a pharmacist and full-time faculty at UC San Diego Skaggs School of Pharmacy and Pharmaceutical Science. I have a clinical practice site at the family medicine clinics at UCSD, where I mainly do medication management for diabetes, hypertension, anticoagulation, and other chronic conditions. One of my areas of focus has been to educate physicians and students about prescription drug abuse, using CURES, and trying to tackle the issue from different fronts.

I have been a part of the San Diego and Imperial County Prescription Drug Abuse Medical Task Force for the last three and a half years. This task force has been the inspiration for the recently created Pharmacy Committee, which brings together representatives of different pharmacies throughout San Diego County, as well as representatives from the medical community, DEA, and County. I am very much looking forward to the interaction between

the Task Force and the Pharmacy Committee. We work together very well, but we each have our own specific issues. Together, I am sure we will work to improve safe prescribing in San Diego.

PHONE CALLS Lev: As physicians, our interaction with pharmacists is, unfortunately, often seen as an interruption of our day. We’re busy seeing patients, juggling different tasks, and the phone rings. A pharmacist on the phone, really? Can’t you read my handwriting? Can’t you just fill the prescription?

Nathan, can you tell us how often you really need to call physicians, and what are some of the red flags that make a pharmacist call a physician?

Painter: I know as pharmacists we understand the interruptions physicians experience, and we want to change the perception that we are just calling to validate prescriptions. We hope to convey that it’s sometimes a very necessary interruption.

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Pharmacists certainly are on the phone a lot more than physicians, dealing with insurance companies, dealing with patients calling in refills, and all those sorts of issues, so the phone is almost secondnature to pharmacists, whereas we definitely understand that it’s not on the priority list for physicians when they’re seeing patients.

It really depends on the pharmacy, the volume of the pharmacy, and even the individual pharmacist on how often they’re calling physicians. Probably, a typical pharmacy calls on a dozen prescriptions a day, and that’s a store that’s filling about three or four hundred prescriptions.

Some of the main reasons that we call would be for missing data on the prescription, such as strength, quantity, or refills.

Some prescriptions are illegible or not on a proper controlled prescription pad.

Sometime there is a suspicion of a fraudulent prescription. But certainly physicians shouldn’t be called more than once a day for a patient of their own.

In dealing with controlled substances, some pharmacies require a diagnosis on a controlled substance.

Roneet Lev, MD

Nathan Painter, PharmD

Lev: Do we really have to write a diagnosis on a prescription? It hasn’t been my practice. Some diagnoses are confidential … you really want to say gonorrhea on a script?

✺ One San Diego means a unified approach for all medical specialties.

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MAY 2015

Painter: Having a diagnosis on a prescription is not required by law; however, when dealing with controlled medications, it can become part of a verification process to make sure the prescription is appropriate. Also some insurances require a diagnosis if the prescription is written for a non-covered medication or if a prior authorization is required.

The decision to call is probably related to quantity and multiple red flags, which we’ll talk about in a minute. If your prescriptions look valid, the quantity looks appropriate coming out of the emergency department, name is consistent, and everything kind of checks out, then you shouldn’t get a phone call. But if you’re writing for higher-dose opioids, longterm opioids, or more than one controlled substance, then you’re going to add red flags to the prescription that might warrant a phone call.

But, absolutely, if you’re writing an antibiotic for a sensitive diagnosis, then I think it’s completely appropriate, especially if it’s an acute medication, not a chronic medicine, to not put the diagnosis on a prescription.

Lev: So the bottom line is that it’s not obligatory to include the diagnosis on a prescription, but it’s helpful for controlled medications with a chronic condition.

Painter: Correct.

RED FLAGS Lev: Physicians have red flags for questioning controlled medications. What are some of the pharmacy red flags?

Painter: One of the red flags is when a prescription looks fraudulent, such as irregularities on the face of the prescription, different colored inks, or numbers that just look off because of potential tamper. Certain patient behaviors are red flags, such as nervousness or a young patient with chronic pain. Other red flags include patients with multiple addresses, multiple prescribers, wanting to pay cash, not using insurance, and requesting early refills. In addition, pharmacists are on alert when they see prescriptions written for an unusually large quantity of pills or high doses of medications.

Medication therapy that does not make sense is another red flag. For example, duplicative drug therapy such as two fastacting opioids or two long-acting opioids could be a red flag. An initial prescription for a high-dose medication or a long distance from the patient to the pharmacy or the physician are other examples.

Irregularities in the prescriber’s qualifications may also be an alert, such as a pediatrician writing for a large quantity of opioids, or a dentist writing for stimulants. A prescription that has no logical connection to an illness or condition is a red flag, which is where a known diagnosis is useful.

Lev: Do pharmacists have a specific checklist on what is a red flag and when to call?

Painter: They have a general checklist but nothing specifically spelled out. Each pharmacy may publish its own warning list as well as encourage pharmacists to be on alert for suspicious prescriptions. It is not like one red flag they call or three red flags they call. It is always left up to the judgment of the pharmacist, and it will almost always come down to their familiarity with the patient and the physician and any potential mismatches that are found.

Lev: I have received pharmacy calls that ask, “Hey, this prescription is four months old, do you still want me to fill it?” Is there a rule or guideline about when prescriptions are too old to fill?

Painter: A C2, schedule II controlled substance, is only valid for six months. All other prescriptions are valid for two years, although insurance typically only pays for a prescription that is less than one year old.

However, it depends on the prescription. If you’re writing for acute pain, and the patient comes to the pharmacy three months later, or even one week later, then that is a mismatch and warrants a confirmation phone call. However, a chronic medication that presents with a delay in refilling a prescription would be acceptable. The pharmacist should be checking the refill history and making sure the dispensing is consistent.

Lev: As we move on to the next question, I hope physicians will see pharmacy phone calls as an opportunity to make a correction rather than a nuisance. It is similar to when a nurse comes to you and asks, “Did you really mean to write IM instead of IV or did you want Tramadol or Trazodone?”

These types of questions are an opportunity to think and take a second look at a potential error.

Painter: There’s a survey that demonstrates that pharmacists realize that communication with physicians is very important but are reticent to call physicians because they worry these phone calls and communications can be annoying, disruptive, and interfere with a positive relationship. I think at the end of the day we should understand that both physicians and pharmacists are trying to provide the best care for our patients.

CORRESPONDING RESPONSIBILITIES Lev: Physicians are often caught in a balance of providing pain relief, keeping people safe, and keeping our patient satisfaction scores up. And yet, our legal environment is that we’re sued if we prescribe, sued if we don’t prescribe, and people complain for too many prescriptions or too few prescriptions. The bottom line is that we just have to do the right thing regardless. What are the legal responsibilities for pharmacists?

Painter: That’s a good point. Obviously, pharmacists and physicians have a role when it comes to making sure that prescriptions are appropriate, and it’s the pharmacist’s responsibility to make sure that a prescription is valid and appropriate.

In 2013 the California Board of Pharmacy made a precedential decision regarding corresponding responsibility in the distribution of all controlled substances, but this particular case involved opioids (www. pharmacy.ca.gov/enforcement/fy1011/ ac103802.pdf). The physician and pharmacist were disciplined in this case. The Pharmacy Board has established a standard that requires a pharmacist to inquire whenever they believe that a prescription may not have been written for a legitimate medical purpose. So here we see the issue of diagnosis again. Pharmacists are required to make sure that a prescription is written for a legitimate medical purpose, but we don’t know if that’s the case unless we know the diagnosis. Furthermore, the pharmacist must not fill a prescription when the results of a reasonable inquiry indicate that a prescription is not written for a legitimate medical purpose. A pharmacist must do their due diligence by calling the prescriber, checking CURES, or doing whatever else they feel is necessary before filling a questionable controlled prescription. And the bottom line is that they must refuse to fill the prescription if they suspect it is not appropriate.

✺ It’s not obligatory to include the diagnosis on a prescription, but it’s helpful for controlled medications with a chronic condition.

San Diego and Imperial County Prescription Drug Abuse Medical Task Force The San Diego and Imperial County Prescription Drug Abuse Medical Task Force is a coalition of medical leaders who have joined efforts to reduce deaths and addiction due to prescription drugs. The numberone cause of unintentional deaths in San Diego County is from unintentional drugs deaths. Almost one person a day in our county dies from this preventable cause.

The Task Force includes pain specialists, internal medicine physicians, emergency physicians, psychiatrists, dentists, pharmacists, hospital administrators, health department administrators, and our local DEA. The Task Force also includes broad health partners, including Kaiser Permanente, Scripps Health, Sharp HealthCare, UC San Diego Health System, Palomar Health, and the Community Clinics.

The Task Force encourages all medical practitioners to use the materials provided to improve patient care. Visit www.SanDiegoSafePrescribing.org for further information.

To get involved in the Task Force or the Pharmacy Committee, contact Angela Goldberg at angelagoldberg@sbcglobal.net.

SAN DIEGO PHYSICIAN.ORG

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Lev: This is what’s called corresponding responsibility?

Painter: Yes, and, as you see, pharmacists are placed in a difficult position between dispensing and confirming legitimacy of the prescription.

✺ A prescription that has no logical connection to an illness or condition is a red flag, which is where a known diagnosis is useful.

Lev: Do you know what was the price tag of that lawsuit?

Painter: In that particular case, the pharmacy was fined $39,666 by the Board of Pharmacy. There are also cases in other states, and in July 2013 Walgreens paid $80 million for civil penalties for retail stores in Florida, Michigan, Colorado, New York, and investigations nationwide.

The stores received three times the state average for prescriptions such as oxycodone. They also filled prescriptions that they knew or should have known were not for legitimate medical uses. In April 2013 CVS paid out $11 million to settle civil penalty claims to the Controlled Substances Act. In 2012 $500,000 was paid by an Internet pharmacy case from DEA diversion investigation.

Lev: Do you have a story or an example of a red flag prescription? I see you brought examples of some.

Painter: Essentially, changing the quantity, changing the strength, or adding a different medication onto the prescription face itself are big red flags. Some of the other examples that I’ve heard patients doing are printing up their own controlled substance forms or stealing prescription pads from the physician’s office, but — I don’t know how they do this — they’ll put their own cell phone on the prescription so that when the pharmacist does call to verify it actually goes to the patient’s cell phone. These are all things that can be really difficult, and there are very sophisticated criminals out there that can make everybody’s life a little bit more difficult.

Lev: We have to show ID when we buy Sudafed from the supermarket. Do you ask for picture ID when people are filling a prescription? Are you allowed to take a picture of that ID and put it in a file?

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MAY 2015

Painter: There is no law requiring picture ID; however, many pharmacies developed their own protocols of asking for ID and taking pictures of ID. Many pharmacies note operational problems such as no good location to store a picture or a time delay of getting this information as a line forms when picking up prescriptions.

Some solutions have been to ask for ID when people drop off the prescription and to write the driver’s license number on the back of the prescription. At this point many pharmacies are not checking IDs. Lev: What are the best practices as far as checking IDs? Painter: My recommendation is that the ID should be checked for all new controlled prescriptions or new patients. This is important just like checking CURES and verifying that the prescription is going to the right person.

Lev: At the Pharmacy Committee, we heard stories from other pharmacies that when they encounter something suspicious, they simply say, “Can I see your ID, please?” and then people bolt right out of the store.

Painter: That is true, and it’s a good deterrent question that should be utilized.

Our Pharmacy Committee will be working on best practices and flow solutions such as this.

SAFE PRESCRIBING INITIATIVE Lev: The Prescription Drug Abuse Medical Task Force has a robust safe prescribing initiative that includes guidelines for emergency departments, urgent cares, medication agreements, and prescribing guidelines (www.SanDiegoSafePrescribing.org). Do you think that most pharmacies are aware of these guidelines?

Painter: At this time, most pharmacists are not aware of the guidelines. Our newly formed Pharmacy Committee will develop pharmacy education that will include the safe prescribing initiative and the One San Diego mission. This is important for emergency department prescriptions, chronic prescriptions, and all other parts of the guidelines. Pharmacists do not have to ask patients if they have a medication agreement. Pharmacists should understand that most patients on

controlled medications for three months or more should have an agreement, and that means using one pharmacy and one physician. It would be a red flag if we find a discrepancy.

DRUG INTERACTIONS Lev: Let’s talk about drug interaction.

One of the more useful pharmacy queries is alerting a physician about drug allergies or potential drug interactions. One of my patients that I won’t ever forget as an emergency physician was a nice elderly gentleman who was diagnosed with gout by his physician and placed on Cipro the day before. He was on Coumadin and presented with vomiting blood. Despite my best effort to reverse his coagulopathy, he bled to death in front of me. Do pharmacists routinely check medication interactions such as Cipro and Coumadin or other interactions? How do you handle medication interactions?

Lev: I would like to remind our physician community that we have a long and short version of medication agreements on our website at www.SanDiegoSafePrescribing.org. The agreements are available in English at a fifth-grade reading level and in Spanish. We recommend using them not just for opioids but for benzodiazepines and stimulants as well. One thing we have noticed is that some physicians and patients use medication agreements as “free tickets” to get medication refills.

Please don’t turn your brain off when using these agreements; you still have to verify each time a patient needs to continue the medication or can start a weaning process. Our CURES ZIP code study has shown that East County San Diego prescribed more opioids, benzodiazepines, and stimulants per capita than any other area of our county.

Painter: Every pharmacy I know of utilizes drug interaction checkers that are automated. This means that any time a medication is entered, a screen will pop up that will say which medications have an interaction, what the general severity of the interaction is, and what the overall impact of that

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interaction may be. Unfortunately, the Cipro and Warfarin is a good example of the pharmacist not always acting on the warning. A pharmacist may not immediately say the patient needs to go back to their doctor to get their INR checked and be monitored because sometimes Cipro may actually be the most appropriate drug for that patient at that time. But the important point is that pharmacists should be providing some education to the patient, and if possible calling the physician to get that medication changed. But drug interactions are being run all the time.

Lev: Every pharmacy has automatic drug interaction checkers; however, they won’t work when medications are filled at different pharmacies such as Costco, CVS, or Walgreens.

Painter: That is correct. Medication interactions can be checked only when using the same pharmacy or when the patient gives their current medication list to the pharmacist.

Lev: Do pharmacists ask, “What other medications are you taking?”

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21

Painter: Most pharmacists will ask about other medications taken.

Lev: How often do you see drug interactions and act upon them?

Painter: Unfortunately, pharmacists can suffer from “warning fatigue,” similar to physicians who get many alerts from the electronic medical records.

✺ The Pharmacy Board has established a standard that requires a pharmacist to inquire whenever they believe that a prescription may not have been written for a legitimate medical purpose.

Lev: What about benzodiazepines and opioids? Or the “holy trinity”: opioids, benzodiazepines, and Soma? We know from our study using San Diego medical examiner deaths in 2013 that over 50% of the people who have died have CURES reports that included opioid and benzodiazepine combinations, and 22% of deaths included the two medications. What do you do when you see that combination?

Painter: Opioid and benzodiazepines are a common and pervasive issue. We receive many alerts for this combination; often it is the same physician prescribing both medications, and currently we do not act upon this combination.

The “holy trinity” is another matter.

Many pharmacists will call and request an explanation of why the patient requires this combination of medication that is generally known to be problematic.

Lev: I see this combination often on the medication list of my emergency patients. I tell them that they have a medication interaction that they need to discuss with their doctor, and at the very least they should not take the two medications at the same time.

The CURES 2.0 system will include this combination in their alert system.

The VA system has stopped allowing the opioid/benzodiazepine combination, to the chagrin of psychiatrists. The Indian health clinics have stopped carrying Soma in their pharmacies. The medical community needs to do more about education, and the insurance industry can do more about paying for problematic medications. Given your explanation, I don’t think we can expect pharmacists to act upon all potential medication interactions.

PRESCRIPTION PADS Lev: We get a lot of phone calls about issues with prescription pads, especially if you use an institutional pad with lots of different physicians. One of the phone

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calls we received is about not having an NPI number on the prescription. However, with 20+ names and DEA numbers on a pad, the NPI number does not fit. Do we really have to have an NPI number on a prescription?

Painter: The tamper-resistant prescription forms must have the following security features: • Void protection to prevent duplication or chemical washing to alter prescriptions; • Watermark on the backside of the prescription with the text “California Security Prescription”; • Thermo-chromic ink that changes color when exposed to heat; • A description of the security features printed on each prescription form; • Quantity check-off boxes; and • The preprinted name, category of licensure, license number, and federal controlled substance registration number of the prescribing practitioner.

NPI is not required to fill a controlled substance, but insurance often requires it for billing purposes.

Lev: It does appear that the new physicians get the phone calls.

Painter: Exactly, because the pharmacy doesn’t have the new physician in the system, and they will need the NPI number for billing.

Lev: Is there a computer system where they can get the NPI number without calling the hospital?

Painter: NPI numbers are available on the Internet (https://nppes.cms.hhs. gov/NPPESRegistry/NPIRegistryHome. do); however, there are a few pharmacies where the Internet is blocked, so they may not be able to do the search.

Lev: Another prescription pad issue we have seen is using a blank prescription form where the physician name and DEA is handwritten or stamped on the top.

We have some pharmacies refuse these prescriptions. Is that appropriate?

Painter: A handwritten prescription on a controlled substance pad is allowed. In some large institutions, such as a hospital, the physician’s name can be handwritten, but the address must be pre-printed.

Lev: I have heard of some groups that print their own prescriptions on special paper? How does that work?

Painter: You can actually purchase special security paper that fits in an approved printer. This is often used in conjunction with an EMR system. At UCSD we have such a system, and the computer system recognizes that a controlled prescription is being written, and defaults to a controlled substance printer. The printer is located in an office that is normally locked unless someone is in the office.

This is used at our family medicine clinics and a few other places. Kaiser also uses this system.

Lev: Can a solo practitioner use this in their office? Is it cost-effective or is it cheaper to buy prescription pads?

One San Diego for Safe Prescribing

Painter: The cost of the paper ranges from $15 to $20 for 1,000 sheets. This does not include the cost of the printer, which has some additional security features, such as the ability to lock the paper drawer.

DOCTOR-SHOPPING Lev: Now we’ll change gears and talk about doctor-shoppers. The definition of a doctor-shopper is problematic. For research purposes I have used “4-4-12” or four pharmacies and four physicians in 12 months. I know the DEA uses a different definition for prosecution. However, we have seen patients who simply “double dip” — two doctors and two pharmacies each month — and they don’t meet the research definition of doctor-shopping.

It is better to discuss safety of prescriptions rather than accuse people of doctor shopping. We therefore like our “One San Diego” statement of one pharmacy and one physician for all controlled medications.

We understand that patients see different specialists, primary care, psychiatry, orthopedics. But one physician needs to be overseeing all the different prescriptions.

What do pharmacists do when they encounter doctor-shoppers, and how do you define doctor shopping?

Painter: Pharmacies do not have a specific definition of doctor-shopping. We will run a CURES report, and if a patient is using different pharmacies, but with the appropriate 30-day refill interval, this will not send a red flag. However, if there are multiple physicians or filling prescriptions before the 30-day expected timeframe, there will be a red flag. Multiple physicians within a month will be a red flag.

1

One physician and one pharmacy for all controlled medications.

Lev: Will pharmacists say, “I’m sorry, I’m not filling this,” without even calling the doctor?

Painter: Yes, absolutely. It does not happen often, but it does happen.

Lev: When you call a physician and ask, “Is this the right prescription?” or “Did you write this amount?” and the physician replies that the prescription is fraudulent, what do you do? Sometimes the doctor will say, “Call the police,” but we know that that is not the correct solution.

Painter: Pharmacists do not routinely call the police. I wish that there were a better and easier way to report these incidents.

Unfortunately, many such prescriptions go unreported, and there’s no real follow-up.

This is an issue that our committee could be addressing.

Lev: When the medical community met with the DEA, we also didn’t want to make a phone call that could be time-consuming, so we worked out an email solution. If we think a patient is doctor-shopping and should be investigated, or may benefit from court-mandated drug rehab, we can email the DEA with the patient’s name, birthdate, the location of the occurrence, and a description of the suspicion at deatipssandiego@usdoj.gov. The DEA does not need any medical information, and such information does not affect HIPAA. This tip line is available to both physicians and pharmacists.

2

Appropriately using the CURES system.

3

Using medical agreements for patients who need three or more months of controlled medication.

4

Avoiding opioid and benzodiazepine combinations. and

5

Adhering to the emergency and urgent care safe prescribing principles.

NALOXONE Lev: A new California ruling allows pharmacists to prescribe naloxone — this in response to the increase in heroin-related deaths from approximately 5,000 per year to 8,000 a year nationwide, and a desire by families of lost loved ones to see an increase in access to this reversal agent. Our website has some information for prescribers. Can you comment on how you see pharmacists prescribing naloxone?

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✺ Pharmacists should understand that most patients on controlled medications for three months or more should have an agreement, and that means using one pharmacy and one physician.

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MAY 2015

Painter: Increasing naloxone availability is important, and the pharmacy community is happy to play their part in this mission. The concept of prescribing rather than dispensing by pharmacists is new and will require an educational process at each pharmacy. The mechanism and documentation of giving the prescription will need to be established, but in general if a patient requests naloxone, they will be able to purchase it from behind the counter. It is available in injection form and nasal atomizer. Currently, the most readily available form is from a manufacturer called Evzio and is an auto-injector that gives audible directions and costs $600 for a package of two.

IF YOU HAD ONE REQUEST TO PRESCRIBERS …

Lev: If you had one request to prescribers from the pharmacy community, what would that be?

LIFE OF A PHARMACIST

Painter: I think we all need to have patience with each other, and try to understand a little bit about everybody else’s perspective. Pharmacists don’t necessarily assume that all physicians are prescribing improperly, just like I don’t think all prescribers assume that pharmacists are just pill pushers. Physicians should understand that pharmacists have a legal corresponding responsibility and, just like physicians, are liable for inappropriate prescriptions.

Lev: Tell us about your regular day as a pharmacist, what happens when you refuse to fill a script, what’s the hardest part of your job, and do you ever feel in danger?

SUMMARY

Painter: I’ve had pharmacists express the element of fear and danger if they refuse a prescription, especially if a patient is already agitated or very adamant about something. Being alone behind the pharmacy window can also make people feel vulnerable. One pharmacist will say, “I’m sorry, we’re out of stock of this medication,” and simply give the prescription back to the patient. This is unfortunate, and is passing the buck for someone else to deal with. A better way would be to copy the prescription before returning it and then contact the DEA. Another solution would be to ask for a driver’s license — just like the request for ID can send some customers out of the store without further inquiry. There are cases of murder and assault against pharmacists for drugs, and so there is a real reason to be fearful.

Lev: One of the things that is common to physicians and pharmacists is checking the CURES system. Pharmacists and physicians will not write a prescription without checking for allergies. Similarly, the gold standard would be not to refill controlled medications without checking CURES. CURES registration will be mandatory for physicians by 2016, and our San Diego public health office has been deputized to process the registration paperwork with notary.

Lev: Thank you very much for joining us today. Physicians and pharmacists have much in common in helping patients and preventing harm. We want to promote teamwork and our One San Diego message for dealing with the epidemic of prescription drug abuse for all our specialties, including pharmacies.

Painter: Thank you for this opportunity to speak and promote our collaboration in our professional work that is so important for the care of our patients.

Roneet Lev, MD, 22-year member of SDCMS-CMA, is a full-time emergency physician practicing at Scripps Mercy Hospital and serves as the director of operations for the emergency department. She chairs the San Diego and Imperial County Prescription Drug Abuse Medical Task Force. The Safe Prescribing program in the emergency departments won the 2014 National Association of Counties Award. Nathan Painter, PharmD, is an associate clinical professor and clinical pharmacist at UC San Diego Family Medicine Clinics. An active member of the San Diego and Imperial County Prescription Drug Abuse Medical Task Force, he received the 2015 Cardinal Health Generations Rx Champions Award from the American Pharmacist Association.

CLASSIFIEDS PHYSICIAN POSITIONS WANTED SHORT-TERM LOCUMS AVAILABLE!:D. (Doyle) Eugene Johnson, family physician with a wealth of experience, looking for short-term locums, preferably in North County. Have been a full-time practicing certified family physician for 50+ years and would like to continue seeing patients on a part-time basis. Had one of the largest solo family practices in San Diego for 25+ years. Excellent references! Continually certified in family practice, ACLS, BLS, regularly use computerized records.

Please email d.eugenejohnsonMD@gmail.com with particulars. [301] PHYSICIAN POSITIONS AVAILABLE INTERNAL MEDICINE PHYSICIAN WANTED — PRIVATE PRACTICE OPPORTUNITY IN BEAUTIFUL NORTH SAN DIEGO COUNTY: Unusual and exceptionally attractive outpatient IM opportunity newly available in North San Diego County.

This is a rare opportunity to experience the best of private practice with the added bonus of flexibility and simplicity. Work environment is a highly regarded single-specialty group with >30 years in the community. Office staff are exceptional, quality of patient care also exceptional, and office location is easily accessible from anywhere in the county. Multiple scheduling options available, allowing for optimal life-work balance. Seeking BC or BE applicants. Interested? Please email CV to portofino3@aol.com or call (619) 248-2324. [345] SEEKING PART-TIME PRIMARY CARE / URGENT CARE PHYSICIAN: For a busy, well-established primary care family practice / urgent care medical practice in Pacific Beach. This position could lead to an associate physician position of the practice for the right person. The candidate must be able to provide compassionate care in a fast-paced environment. Knowledge of musculoskeletal medicine and X-Ray is required. Must be able to suture and have experience with wound care. We have a state-of-the-art medical facility.

Please send your CV in confidence for consideration to pbyrnes@andersonmedicalcenter.com.

Compensation: Excellent Pay Rate [317] SEEKING IM PCP: Growing multi-specialty North County practice seeks internal medicine PCP. Please send CV and request for information to anon625@cox.net. [340] CLINICAL RESEARCH PHYSICIAN WANTED: Profil Institute for Clinical Research, Inc., is an early phase clinical research organization and innovator of research methodologies for diabetes and obesity. We are seeking a physician who will provide medical leadership, oversight, and management of human clinical trials while ensuring the integrity of the studies and the safety and wellbeing of human subjects. Must have current unrestricted license to practice medicine in the State of California and a current DEA license. Experience in clinical trials and/or drug development preferred. For more information and to apply, please visit our website at www.profilinstitute.com. [338] BE IN CHARGE OF YOUR OWN DESTINY! If you are a general internist interested in becoming your own boss, this may be the opportunity for you. Patients from a recently retired general internist on the campus of Scripps La Jolla need a new physician. Share an office and overhead with another general internist who is well established on the campus and will help you grow your practice,

as well as help in all the business aspects of private practice. Guaranteed salary for the first year, allowing you time to build up your panel. Great opportunity to practice medicine the way you want to. Interested? Email XimedMD@gmail.com. [337]

days (full or part time). No ER call or inpatient duties required. Transportation and personal assistant provided. Call Chris Hunt, MD, at (619) 9925330 or email CV to drhunt@thehousecalldocs. com. Visit www.thehousecalldocs.com. [037]

PHYSICIAN NEEDED: Seeking a Californialicensed physician to cover contrast injections at an imaging center in Imperial County, 2407 Marshall Ave., Suite A, Imperial, CA 92251. Please call (760) 730-3536 for more details, or fax (760) 720-4833. [335]

PHYSICIANS NEEDED: Internal medicine and family medicine physician positions currently open. Vista Community Clinic is a private, nonprofit, outpatient clinic serving the communities of North San Diego County with openings for fulltime, part-time, and per-diem positions. Current CA and DEA licenses required. Malpractice coverage provided. Bilingual English/Spanish preferred.

Forward resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. Visit our website at www. vistacommunityclinic.org. EEO Employer / Vet / Disabled / AA [912]

SEEKING FULL-TIME BC/BE EMERGENCY MEDICINE OR FAMILY MEDICINE PHYSICIANS: SHARP Rees-Stealy Medical Group, a 450+ physician multi-specialty group in San Diego, is seeking full-time BC/BE emergency medicine or family medicine physicians to join our urgent care staff. We offer a competitive compensation package, excellent benefits, and shareholder opportunity after two years.

Please send CV to SRSMG, Physician Services, 300 Fir Street, San Diego, CA 92101. FAX: (619) 233-4730.

EMAIL: lori.miller@sharp.com. [330] PHYSICIAN POSITIONS AVAILABLE AS WE CONTINUE TO GROW: Full, part-time, or per-diem flexible schedules available at locations throughout San Diego. A national leader among community health centers, Family Health Centers of San Diego is a private, nonprofit community clinic organization that is an integral part of San Diego’s healthcare safety net. We offer an excellent, comprehensive benefits package that includes malpractice coverage, NHSC loan repay eligibility, and much, much more! For more information, please call Anna Jameson at (619) 906-4591 or email ajameson@fhcsd.org. If you would like to fax your CV, fax it to (619) 876-4426. For more information and to apply, visit our website and apply online at www.fhcsd.org. [046a] SEEKING A FOOT/ANKLE SPECIALIST: Well-established, highly respected, four-physician group, private practice in San Diego seeking a foot/ankle specialist. Our group is expanding to meet high volume of cases and planned expansion. Potential opportunity for any established subspecialist looking for a permanent practice location. We have a broad-based primary care referral base, mature EHR, digital X-ray, ultrasound, and DME program. Interested parties, please email your CV in confidence to lisas@sdsm.net. [326] FULL-TIME PRIMARY CARE PHYSICIAN: For a busy, well-established pain management practice in Mission Valley. The candidate must be able to provide compassionate care in a fast-paced environment. Please send CV to alicjasteinermd@ hotmail.com. [322] URGENT CARE PHYSICIAN — PER DIEM BC/ BE: Arch Health Partners is an award-winning medical foundation affiliated with the Palomar Health System in North San Diego County. Hours: 9:00am–9:00pm. Send CV to catherine.jones@ archhealth.org or fax to (858) 618-5820. [312] SEEKING URGENT CARE PHYSICIAN: Busy practice in El Cajon, established in 1982, seeks a part-time physician. Good pay and working conditions along with the potential to become a fulltime position. Please send CV to jeff@eastcountyurgentcare.com. [306] PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com) is a fastgrowing group of house-call doctors. Great pay ($140–$220+K), flexible hours, choose your own

TO SUBMIT A CLASSIFIED AD, email Kyle Lewis at KLewis@SDCMS.org. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $150 (100-word limit) per ad per month of insertion.

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MAY 2015

OFFICE SPACE AVAILABLE OFFICE SUITE — APROXIMATELY 1,650 SQ. FT. IN OFFICE BUILDING ADJACENT TO SHARP CORONADO HOSPITAL: Large, newly refurbished waiting area, a business office and six exam /consultation rooms. The space is ideal for primary care physicians or a specialty group wishing to expand to Coronado. Pharmacy and parking are available on premises. The suite is largely furnished, and tenant improvements are available depending on the length of the lease. Part-time tenants are available to share lease expenses. Base rent $2.38 / sq. ft / mo, $1.28 / sq. ft. / mo operating expenses. Email John Kerley, MD, at kerjo100@gmail.com or call (619) 435-2060. [344] NEW MEDICAL OFFICE SPACE AVAILABLE FOR SUBLEASE IN KEARNY MESA: Brand new office suite located at 3750 Convoy Street with nine exam rooms and digital X-ray, hi-speed wireless, free parking for patients and staff, conference room in building. Several minutes from Sharp Memorial Hospital and Children’s Hospital.

Convenient freeway access to 163 and 805. Multiple half-day clinics available days, evenings, and weekends. Please contact Lisa Vaughn at (858) 278-8300, ext. 210, for more information. [343] PSYCHIATRIST WANTED TO SUBLEASE OFFICE in a 3700ft2 beautiful cardiology group practice office next to Tri-City Medical Center in Oceanside, CA. Consultation room available with access to a new BRAINSWAY DEEP TMS machine with H1 and H10 coils to be used for drug-refractory MDD, and chronic pain or MS syndromes.

Pease call Kenneth Carr, MD, at (760) 941-9440 or Yvonne Fraser, Esq., at (619) 368-2180. [339] WOMEN’S HEALTH / WELLNESS OFFICE HAS SPACE AVAILABLE FOR SUBLEASE: Exam room, office, and/or shared staff optional. Fully furnished exam rooms available and ready for use.

Location features onsite billing, reception, medical assistants, potential use of in-office procedure room, and a rooftop lounge. If you are interested, please reply with the heading “Space for Sublease” outlining the details of space and/or staff use desired, with your contact information, and we will contact you to set up a showing. Reply to Mrs. Kim at cvwh858@gmail.com. [288] MEDICAL OFFICE SPACE AVAILABLE FOR SUBLEASE/SHARE IN UTC/LA JOLLA AREA: Established orthopedic surgeon seeks tenant to share office space. 4675ft2 in Chancellor Park, near Scripps Memorial Hospital. Completely rebuilt in 2009. Six exam rooms, digital X-ray onsite. Beautiful finishings, spacious waiting room, conference room, break room. Ample space for support staff and a private office for physician.

Available immediately, full or part time. Ideal for primary or satellite office. Excellent freeway access (1-5 and 805), first-floor suite located off lobby near main building entrance. For further information, please contact Georgana Bradley at (858)

457-0050 or at gbradley@jpbamc.com. [334] CARLSBAD MEDICAL OFFICE FOR LEASE: • Space from 1,000–50,000 SF • Competitive lease rates and TI allowances • Existing tenants include imaging, pharmacy, orthodontics, urgent care, and pain management • Highly visible to over 43,000 vehicles per day along Palomar Airport Road • Interstate 5 is less than a mile away providing access to over 200,000 households within a 20-minute drive • North County’s most affluent demographic with average household income of $98,614 within a 5-mile radius. For further information, please contact: TRAVIS IVES, Cushman & Wakefield, (858) 334-4041, travis.ives@cushwake.com, Lic. # 1889097 [332] MEDICAL SPACE FOR RENT / LEASE: Approximately 2,000ft2. Available for lease, in best location of Imperial County. Negotiable. Please contact Dr. Maghsoudy at (760) 730-3536. [328] SUBLEASE PART-TIME SPACE ON SCRIPPS LA JOLLA CAMPUS: A beautiful office space is available a few times a week for someone looking for a part-time satellite office or someone who only has clinic a few times a week. We are located in HM Poole building on the campus of Scripps Memorial La Jolla, two-minute walk from the hospital. Office reception, two exam rooms, and a conference room/break room are available. Our staff use is negotiable. Rates will depend on the needs and usage. Please contact Olga at olgald@ sdneurosurgery.com for more information. [325]

and hardwood floors. Full Ultrasound lab with tech on site, doubles as procedure room. Will sublease partial suite, one or two exam rooms, half or full day. Will consider subleasing the entire suite, totally furnished, if there is a larger group interest. Plenty of free parking. For more information, call Irene at (619) 840-2400 or at (858) 452-0306. [153] POWAY OFFICE SPACE FOR SUBLEASE: Private exam room or rooms available for one day a week or more. Ideal for physician, chiropractor, massage therapist. Low rates. Email inquiries to kathysutton41@yahoo.com. [173] BUILD TO SUIT: 950SF office space on University Avenue in vibrant La Mesa / East San Diego, across from the Joan Kroc Center. Next door to busy pediatrics practice, ideal for medical, dental, optometry, lab, radiology, or ancillary services. Comes with six gated parking spaces, two entryways, restrooms, lighted tower sign space.

Build-out allowance to $10,000 for 4–5 year lease, rent $1,800 per month gross (no extras). Contact venk@cox.net or (619) 504-5830. [835] SHARE OFFICE SPACE IN LA MESA JUST OFF OF LA MESA BLVD: Two exam rooms and one minor OR room with potential to share other exam rooms in building. Medicare certified ambulatory surgery center next door. Minutes from Sharp Grossmont Hospital. Very reasonable rent.

Please email KLewis@SDCMS.org for more information. [867] NONPHYSICIAN POSITIONS AVAILABLE

NORTH COUNTY / LA COSTA-CARLSBAD OFFICE SPACE FOR SUBLEASE: Beautiful, new 2,300ft2 office space available for sublease. Minor procedure room, 5 exam rooms. Lasers available.

Located in Bressi Ranch off of El Camino Real. Perfect for dermatology, OB/GYN, wellness / weight loss. Perfect location for North County expansion.

Please call Melissa at (760) 707-5090. [318] ALISO VIEJO — 5 JOURNEY: Multi Tenant Medical Building with highly successful medical and dental practices. 2 ground floor medical spaces approx. 2,135, 2,225 & 1,742 rsf available for lease. $2.75 PSF NNN. Beautifully designed. Tenant Improvement Allowance to customize suite is available. For further information please contact Lucia Shamshoian @ 769-931-1134x13 or Shamshoian@ coveycommercial.com. [298] LA JOLLA (NEAR UTC) OFFICE FOR SUBLEASE OR TO SHARE: Scripps Memorial medical office building, 9834 Genesee Ave. — great location by the front of the main entrance of the hospital between I-5 and I-805. Multidisciplinary group. Excellent referral base in the office and on the hospital campus. Please call (858) 455-7535 or (858) 320-0525 and ask for the secretary, Sandy. [127] SCRIPPS XIMED MEDICAL CENTER BLDG, LA JOLLA — OFFICE SPACE TO SUBLEASE AVAILABLE: Vascular & General Surgeons have space available. One room consult office available, with one or two exam rooms, to a physician or team. Located on the campus of Scripps Memorial Hospital, The Scripps Ximed Medical Center is the office space location of choice for anyone seeking a presence in the La Jolla/UTC area. Reception and staff may be available. Complete ultrasound lab on site for scans or studies. Full-day or half-day timeslots. For more information, call Irene at (619) 840-2400. [154] NORTH COAST HEALTH CENTER, 477 EL CAMINO REAL, ENCINITAS, OFFICE SPACE TO SUBLEASE: Well-designed office space available, 2,100SF, at the 477-D Bldg. Occupied by Vascular & General Surgeons. Excellent and central location at this large medical center. Nice third-floor window views, all new exam tables, equipment, furniture,

SEEKING PA for well-established orthopaedic surgeon practice in San Diego. Orthopedic clinic experience. Prefer full-time, will consider parttime. Please contact Nancy at (619) 980-9801 or at nantowne@yahoo.com. [347] DENTIST: North County Health Services; Job Title: Dentist; Location: San Marcos, CA. An established, award-winning organization. A top place to work. A mission to serve. Come be awesome with us! We’re looking for people who support our mission and who want to be employed at NCHS — and not just for right now, but for the long term. We have a need for a talented dentist! Qualifications: CA DDS or DMD license; CPR, NRP; two years of experience. NCHS is proud to be an equal opportunity workplace and is an affirmative action employer. Contact Araceli Mercado at araceli.mercado@nchs-health.org or at (760) 736-6780. [341] CERTIFIED NURSE MIDWIFE: North County Health Services; Job Title: Certified Nurse Midwife; Location: San Marcos, CA. An established, award-winning organization. A top place to work.

A mission to serve. Come be awesome with us!

We’re looking for people who support our mission and who want to be employed at NCHS — and not just for right now, but for the long term. We have a need for a talented CNM! Qualifications: CA CNM license; CPR, NRP; two years of experience. NCHS is proud to be an equal opportunity workplace and is an affirmative action employer. Contact Araceli Mercado at araceli.mercado@nchs-health.org or at (760) 736-6780. [342] SEEKING PA/NP AND RN: Medical spa in the Del Mar / Solana Beach area is seeking PA/NP and RN. Should have experience with laser hair removal, IPL, CO2 laser, Botox and fillers, and sales. Positive attitude, ability to multitask, perform patient treatment, sales, consultations, effective communicator, work in a team environment, focused on client care, knowledge of lasers and laser theory, quick learner, self motivated. PA/NP will perform consultations and good-faith examinations. Minimum requirements: PA, NP, RN California license.

This is a part-time position, 1–2 days a week. Please email résumé / cover letter to synergyamasb@ gmail.com or fax to (858) 259-0864. [289]

RURAL HEALTH CLINIC MANAGER: Manager will provide management, planning, coordination, and expansion of southern California rural health clinics. Manager is responsible for supervision of clinic staff, billing procedures, patient services, and regulatory and reporting requirements, including compliance with State and CMS. Previous experience with management of rural health clinic is required. Full time with benefits. Must have at least three years experience in RHC clinic setting and/or BA. Resume to: P.O. Box 3632, El Centro, CA 92244. [333] FNP AND PA POSITIONS AVAILABLE AS WE CONTINUE TO GROW: Full, part-time, or per-diem flexible schedules available at locations throughout San Diego. A national leader among community health centers, Family Health Centers of San Diego is a private, nonprofit community clinic organization that is an integral part of San Diego’s healthcare safety net. We offer an excellent, comprehensive benefits package that includes malpractice coverage, NHSC loan repay eligibility, and much, much more! For more information, please call Anna Jameson at (619) 906-4591 or email ajameson@fhcsd.org. If you would like to fax your CV, fax it to (619) 876-4426. For more information and to apply, visit our website and apply online at www.fhcsd.org. [046b] SEEKING MEDICAL ASSISTANT: We are a private practice situated in Encinitas looking to hire a medical assistant. The medical assistant should be flexible and able to float from the front office (administrative area and reception) to the back office area (examination and treatment areas).

Some primary duties involve scheduling, registering and rooming patients, taking vital signs and blood tests, keeping the entire office and storage spaces organized, safe, and clean. Requirements include at least three years of work experience in this field with a high school diploma and medical assisting program certificate. Excellent computer knowledge as well as fluent written and verbal communication. Please email ktagdiri@gmail. com. [327] PART- OR FULL-TIME NURSE PRACTITIONER WANTED: Busy pain management practice in Mission Valley seeking a nurse practitioner to work with our growing practice. Please fax CV to (858) 756-9012. [323] PART- OR FULL-TIME PHYSICIAN ASSISTANT WANTED: Busy pain management practice in mission valley seeking a physician assistant to work with our growing practice. Please fax CV to (858) 756-9012. [324] SEEKING PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Seeking PA with experience in dermatology or wellness / weight loss to join busy cosmetic surgery practice in North County. Beautiful office and support staff. Full complement of cosmetic lasers. Please call Melissa at (760) 7075090. [319] NURSE PRACTITIONER: Needed for house-call physician in San Diego. Full-time, competitive benefits package and salary. Call (619) 992-5330 or email drhunt@thehousecalldocs.com. Visit www. thehousecalldocs.com. [152] PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Needed for house-call physician San Diego. Part-time, flexible days / hours. Competitive compensation. Call (619) 992-5330 or email drhunt@thehousecalldocs.com. Visit www.thehousecalldocs.com. [038]

SAN DIEGO PHYSICIAN.ORG

27

POETRY AND MEDICINE

INSENSIBLE LOSSES Moment to moment Hour to hour Time disappears Like dew from a flower

Where does the day go?

Our memory glosses

An evaporative loop

Of insensible losses

INFINITESIMAL CHANGE Introduction to Insensible Losses

by Daniel J. Bressler, MD, FACP

INTRODUCTION It’s difficult for the mind to grasp processes that occur at a very slow pace or on a very small scale. We use tricks like time-lapse photography to visualize the slow growth of a sprouting plant.

We use abstruse equations to represent quantities far below the experiences of everyday life.

Mathematics has a term called the infinitesimal. It has a long and controversial history dating back to the ancient Greeks. In the 17th century the infinitesimal was crucial in the development of calculus. It is often characterized as the smallest imaginable quantity that is not zero. Although tiny, a series of infinitesimals can be summed up to produce real numbers.

This process has proven to be extremely valuable in many applications in modern science.

In clinical medicine we have a term

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called insensible losses, which carries some of the same meaning as infinitesimals. It refers to the slow, obligate loss of fluid, principally from the moisture in our breath and evaporation from our skin. This water volume is difficult to detect and measure yet plays a crucial role in fluid and electrolyte balance, particularly during long surgeries, in other patients who are not taking oral food or liquid, and in those with neurologic disorders who have lost the ability to sense or communicate hunger or thirst.

In this poem, Insensible Losses, I use the term to represent all the slow, near-negligible processes to which our biology binds us. Most of these processes are features of our evolutionary heritage. Our insensible losses identify us as part of the tree of life. And, along with all parts of that tree, these losses mark us as mortal.

Dr. Bressler, SDCMS-CMA member since 1988, is chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and a longtime contributing writer to San Diego Physician.

Gravity pulls Energy launches Life hesitates Sitting back on its haunches

Breath follows breath

With organized pauses

Till the rhythm succumbs

To insensible losses How did we get here?

By what cosmic charter?

Water and air Serve biology’s barter

To live is to breathe

We’re bound by those clauses

Our existence is tied

To insensible losses How does the mind Emerge from this matter?

How do these thoughts Stand out from such clatter?

Consciousness gushes

The brain’s secret sauce, is

Yet doomed to run dry

From insensible losses We study the blood We research the heart We vanquish the plagues That once tore us apart

We intervene boldly

To know what the cause is

But must finally concede

To insensible losses We come to remember We come to place roses We dab our red eyes And blow our wet noses

We whisper our prayers

At gravestones and crosses

Where our someones lay stilled

From insensible losses.

Success.

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