May/June 2020 by San Diego Physician

MAY/JUNE 2020

Official Publication of SDCMS

Celebrating 150 Years

THE AGE OF

COVID-19

150th ANNIVERSARY

ReNDEZ ReNDEZVOUS VOUS Friday, SEPTEMBER 18, 2020 6:00 PM-10:00 PM THE ABBEY ON FIFTH

Please join the San Diego County Medical Society in celebrating our 150th Anniversary, welcoming Holly B. Yang, MD, MSHPEd, FACP, FAAHPM as SDCMS President for 2020-2021 and thanking James H. Schultz, MD, MBA, FAAFP for his service as Immediate Past President.

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

May/June 2020

Contents MAY/JUNE

Editor: James Santiago Grisolia, MD Editorial Board: James Santiago Grisolia, MD; David E.J. Bazzo, MD; Robert E. Peters, MD, PhD; William T-C Tseng, MD Marketing & Production Manager: Jennifer Rohr Sales Director: Dari Pebdani Art Director: Lisa Williams Copy Editor: Adam Elder

VOLUME 107, NUMBER 5

OFFICERS President: Holly B. Yang, MD President-Elect: Sergio R. Flores, MD Secretary: Toluwalase (Lase) A. Ajayi, MD Treasurer: Nicholas J. Yphantides, MD Immediate Past President: James H. Schultz, MD GEOGRAPHIC DIRECTORS East County #1: Heidi M. Meyer, MD (Board Representative to the Executive Committee) East County #2: Rakesh R. Patel, MD Hillcrest #1: Kyle P. Edmonds, MD Hillcrest #2: Steve H. Koh, MD (Board Representative to the Executive Committee) Kearny Mesa #1: Anthony E. Magit, MD Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Preeti Mehta, MD La Jolla #2: David E.J. Bazzo, MD, FAAFP North County #1: Patrick A. Tellez, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Kelly C. Motadel, MD, MPH South Bay #2: Maria T. Carriedo, MD

features:

Our Humbling Plague

AT-LARGE DIRECTORS #1: Thomas J. Savides, MD #2: Paul J. Manos, DO #3: Irineo “Reno” D. Tiangco, MD #4: Miranda R. Sonneborn, MD #5: Stephen R. Hayden, MD (Delegation Chair) #6: Marcella (Marci) M. Wilson, MD #7: Karl E. Steinberg, MD #8: Alejandra Postlethwaite, MD

by Daniel J. Bressler, MD, FACP

Individual and Institutional Ethics During the COVID-19 Pandemic

ADDITIONAL VOTING DIRECTORS Young Physician Director: Brian Rebolledo, MD Retired Physician Director: Mitsuo Tomita, MD Resident Director: Nicole Herrick, MD Medical Student Director: Lauren Tronick

by Nayana M. Trivedi, MD

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

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

Departments

Briefly Noted: Federal Issues • Personnel

Anti-Vaccine Activists Latch onto Coronavirus to Bolster Their Movement By Liz Szabo

Safety Concerns Affirmed with HCQ in COVID-19 By Nicole Lou

Top 10 Tips for Reopening Your Office During COVID-19 By Kerin Torpey Bashaw, MPH, RN, and Debbie K. Hill, MBA, RN

Zooming into COVID-19 By Adama Dyoniziak

Physician Classifieds

Nurturing Physician Wellness in the Age of COVID-19 By Helane Fronek, MD, FACP, FACPh SanDiegoPhysician.org 1

BRIEFLY NOTED 2

May/June 2020

FEDERAL ISSUES

CMS Announces Additional Temporary Regulatory Flexibilities ON APRIL 30, THE CENTERS FOR Medicare and Medicaid Services (CMS) released an interim final rule that establishes new regulatory flexibilities in addition to the policies CMS previously announced at the end of March. Key policy changes include: • Payment Parity for Telephone Codes: CMS is increasing reimbursement of telephone (audio-only) codes to match office/outpatient evaluation and management (E/M) code values. While CMS had already allowed healthcare professionals to bill for telephone visits during the pandemic, the values of these codes were originally much lower than the values of the office and outpatient E/M codes. • GME Payments: To ensure that graduate medical education payments to hospitals are not adversely affected because of the response to the COVID-19 pandemic, CMS will not reduce Medicare payments for teaching hospitals that shift their residents to other hospitals to meet COVID-related needs, or penalize hospitals without teaching programs that accept these residents. This change removes barriers so teaching hospitals can lend available medical staff support to other hospitals. • Teaching Physician Oversight of Medical Residents: CMS is expanding the flexibilities available under the current “primary care exception” to the physician oversight rules. Specifically, CMS is allowing teaching physicians to not only direct the care furnished by residents, but also to review the services provided with the resident, during or immediately after the visit, remotely via telehealth. • Medicare Shared Savings Program for ACOs: CMS is making numerous changes to the Medicare Shared Savings Program for Accountable Care Organizations (ACOs). CMS is adjusting the financial methodology for calculating spending to account for the pandemic and not penalize ACOs that may have higher costs. While new ACOs usually come into the program every year, CMS will not be accepting new applications in 2021. CMS is also giving ACOs whose participation is set to

•

end this year the option to extend for another year. Finally, CMS is giving ACOs that were supposed to take on more financial risk next year the opportunity to maintain their current level of risk. Point of Care Testing: CMS has made changes to allow Medicare patients to get tested at other locations including “parking lot” test sites operated by pharmacies and other entities consistent with state requirements. Such pointof-care sites are a key component in expanding COVID-19 testing capacity. To that end: » New E/M Code for Point of Care Testing: CMS is establishing a new E/M code solely to support COVID-19 testing when specimens are collected outside of a laboratory. This code helps to address the resource requirements hospitals and clinics face in establishing broad community diagnostic testing for COVID-19, including the significant specimen collection necessary to conduct that testing. » Who Can Order Tests: During the public health emergency, COVID-19 tests may be ordered by any healthcare professional authorized to do so under state law. Pharmacists also can perform certain COVID-19 tests if they are enrolled in Medicare as a laboratory, in accordance with a pharmacist’s scope of practice and state law. Coverage for Serology (Antibody) Tests: To facilitate expanded testing, Medicare and Medicaid are covering certain serology tests, which may aid in determining whether a person may have developed an immune response and may not be at immediate risk for COVID-19 reinfection. Home Health Workforce Expansion: CMS is allowing nurse practitioners, clinical nurse specialists, and physician assistants to provide home health services. Ambulatory Surgery Centers: CMS is waiving requirements for ambulatory surgery centers to reappraise medical staff privileges during the COVID-19 emergency so that physicians whose privileges are expiring can continue caring for patients.

PERSONNEL

Governor’s Order Makes It Easier to Receive Workers’ Comp for COVID-19 Claims Gov. Gavin Newsom on Wednesday signed an executive order to ensure that employees who contract COVID-19 during the course of their employment can receive workers’ compensation benefits. The order establishes a “rebuttable presumption” that any workers infected with COVID-19 contracted the virus on the job. Gov. Newsom spoke about the issue in the context of reopening the economy, stating that it can only happen if we properly protect workers. He also mentioned that previous state and federal employee benefit requirements made thus far during the pandemic did not

specifically include healthcare workers and first responders. Therefore, Newsom’s order will extend workers’ compensation benefits to that sector, and across all industries. Employers will still be able to contest the presumption and paid sick leave benefits must first be exhausted before additional benefits can be received. The order applies to all workers’ compensation insurance carriers and employers that carry their own risk, including the State of California. To be eligible for workers’ compensation benefits, the employee must test positive for COVID-19 within 14 days of working at their place of employment at the employer’s direction. The change is retroactive and will include dates of injury on or after March 19, 2020, and will be effective for 60 days from the date of the order. The Department of Industrial Relations will be releasing additional guidance in the coming days.

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SDCMS Reschedules 150th Anniversary Gala The San Diego County Medical Society has rescheduled its 150th Anniversary “Rendezvous” Gala & Presidential Installation at The Abbey on 5th Avenue in San Diego from June 19 to Sept. 18, 2020. It will be at the same location and same time, from 6 to 10:30 p.m.

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Official Publication of SDCMS

NOVEMBER/DECEMBER 2019 Official Publication of SDCMS

Celebrating 150 Years

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SanDiegoPhysician.org 3

OUR HUMBLING PLAGUE

FROM ALBERT CAMUS’ 1947 NOVEL THE PLAGUE:

BY DANIEL J. BRESSLER, MD, FACP 4

May/June 2020

“But what does it mean, the plague? It’s life, that’s all.” The word “plague” comes from the Greek word plaga, meaning a “strike” or “blow.” By the 14th century, it had come to acquire its current meaning of pestilence or calamity. By the 16th century it came to be associated with what we now call the bubonic plague, the highly contagious and highly lethal disease caused by Yersinia pestis, a gram-negative coccobacillus. The word “bubonic” refers to the fact that most sufferers develop “bubos” or swollen inguinal lymph nodes, with bubo being the Greek word for “groin.” Bubonic plague is a zoonotic infection of wild and domestic animals, with humans considered so-called “incidental hosts” in that they do not participate in the disease’s natural life cycle. The vector species is the rat flea and most human cases come from the bite of those fleas. Bubonic plague has been with humans for several thousand years. Yersinia pestis DNA has been isolated from the teeth of human skeletons from Europe and Asia dating back 5,000 years. Molecular clock estimates suggest that the bacteria acquired the genetic changes that allowed it to become highly virulent about 3,000 years ago. The consequences of plague pandemics have dramatically changed the course of human history. The Plague of Justinian in the 6th century is thought to have played a major role in weakening the Byzantine Empire. Bubonic plague of the 14th century (known as The Black Death) is estimated to have killed 30–50% of the European population. Earlier plagues have been associated with the decline of Classical Greece and disruptions in Roman rule. The

third and last plague pandemic started in 1866 in China, eventually killing more than 12 million people worldwide — most of them in India. The disease remains endemic but with a low incidence worldwide, including in the U.S. Southwest. In 1947 the French-Algerian writer Albert Camus published The Plague about Oran, a fictional town in North Africa that was overwhelmed by an infection whose description matches that of bubonic plague. The book, considered one of several masterpieces that won for Camus the Nobel Prize in literature in 1957, takes us on the town’s descent into lockdown, loss, and surreality, a journey seen through the eyes of the physician protagonist, Dr. Rieux. He notes the various approaches that his fellow townspeople use to respond to the progressive devastation: denial, sensual indulgence, religious immersion, and numbness. The hardest thing for the citizens of Oran to deal with, besides the immediate threat of illness and the grief, was the disorientation caused by a loss of any sense of the future. “How hard it must be to live only with what one knows and what one remembers, cut off from what one hopes for,” reflects Rieux. After many months, the lockdowns and injections work, the plague recedes, and the town comes back to life, celebrating and grieving. Rieux’s closest friend, Tarrou, who finally perishes from the disease, proposes that, even more important than heroism, the goal of a life well lived is to use what strength you have to be a healer and to never lose your compassion for your fellow human beings whatever their foibles and follies. “After a short silence the doctor raised himself a little in his chair and asked if Tarrou had an idea of the path to follow for attaining peace. ‘Yes,’ he replied. ‘The path of sympathy.’” During my internal medicine residency in the early ’80s, the subspecialty of Infectious Diseases was relatively unpopular as a professional aspiration. Most ID consults were rote and, from a practical perspective, the field seemed to offer few job prospects outside of academia. The idea that infectious diseases would be increasingly controlled and eliminated — just as smallpox had been in 1977 — was not far-fetched. How silly and hubristic such a view seems in retrospect. Toward the end of my residency, we first began admitting young men with Pneumocystis carinii (now called jirovecii) pneumonia, esophageal candidiasis, and Kaposi’s sarcoma. The arrival of the disease we now know as AIDS was a

stark reminder of microbial opportunism. Since that time, the medical and social world have been rocked by one infection-related crisis after another. Widespread aggressive use of antibiotics has led to MDROS (multiple drug resistant organisms) even at our best hospitals. Rumors and disinformation have led to declining vaccination rates and increases in vaccine-preventable diseases in both rich and poor countries. Resurgent rates of drugresistant TB, syphilis, and gonorrhea have followed in tracks laid down by poverty, sexual exploitation, and injectable drug use. And influenza pandemics have continued to wash over the world, with the most recent version, the H1N1/09 (“swine flu”), causing an estimated 280,000 deaths worldwide and “only” 12,000 in the U.S. In The Mirage of Health published in 1959, microbiologist Rene Dubos warned against utopian medical imagination that proposed a future society free from disease and distress. From his study of both soil microbes and his later attention to psychosocial factors in health, Dubos anticipated much of the subsequent research regarding the interplay between human health and built environment. Among other cautions, he advised us to acknowledge the ongoing ecological relationship between human health and the non-human natural world. Nature, along with many other traits, was opportunistic and fickle. For this reason, his fundamental thesis as captured in the title was that freedom from disease is a pleasant but deceiving mirage. “All our moves toward progress have necessary but sometimes unpredictable downsides … [and] wherever human beings are concerned, trend is not destiny,” he writes. This current pandemic has taught us that in spades. It turns out that human progress is not a missile nor even a ratchet moving monotonically toward better and better outcomes. Rather, it is most accurately imagined as a scatter diagram with the best fit line that is up and to the right, but with many individual data points well off the trend. Optimistic, technology-focused futurists have failed to take into account nature’s own say in the matter. Whatever brilliant new techniques we bring to the game, nature always bats last. As I’m writing this in late April 2020, the bubonic plague caused by Y. pestis seems like a quaint historic relic in light of the zoonotic viral pandemic that has so wracked our society and our planet over the past four

SanDiegoPhysician.org 5

months. COVID-19, caused by another zoonotic organism, the novel coronavirus SARS-CoV-2, appears to be endemic and non-pathogenic in bats. As we’ve learned, the disease is transmitted principally human-to-human by droplets, is mostly asymptomatic but in a minority of infected patients causes a unique irreversible systemic illness and death. As has been said, the disease doesn’t choose who to infect but does choose who to kill, with vulnerability principally related to age, as well as cardiometabolic and immune factors. Without effective prophylactic or therapeutic medications, societies have resorted to some version of the travel and physical restrictions that are in many ways modern adaptations of those used by our ancestors when plague struck. COVID-19 — both despite and because of our modern inventions and conveniences, our travel, our dense cities, our science, our efficient supply chains, and our experimental virology — is our humbling plague. I live and practice medicine in the middle of San Diego County, which is 3,000 miles and 12,000 COVID deaths away from New York City. None of my primary care patients have been hospitalized or had documented symptomatic infections. But I don’t mean to be serving up happy talk. Although there have only been 124 documented COVID-19 deaths in San Diego County as of April 30, the impact of the virus on our local colleagues, hospitals, and economy has been immeasurable. Our vaunted medical and economic machine has been brought to its knees. Our supply chains have not been able to provide front-line healthcare workers with essential equipment. Our medical experts have not been able to give clear advice on either prevention or treatment. Our government mouthpieces have given us contradictory and chaotic guidance. I am humbled because I know I could have done no better had I been controlling simultaneously the gears of business, medicine, or government. The information we were all getting was confusing and the best way forward unknown. I am humbled just as I am thinking about my patients with pain syndromes caught between limited therapeutic options and government

May/June 2020

bureaucracy; or counseling my patients with end-stage cancer or heart disease when they are offered yet another expensive pill or procedure by yet another specialist; or when picturing anyone in our society who is poor, depressed, and desperate — virus or no virus. I have no doubt that we will eventually control COVID-19 using the tools of modern biology and medicine. I am left to wonder, though, if after the recovery will we aim no higher than to get back to some version of “business as usual.” I hope not. Paul Romer, the 2018 Nobel Laureate in economics, famously quipped, “A crisis is a terrible thing to waste.” Will the tens of thousands of American lives and hundreds of thousands of human lives merely be a stepping stone to more advanced diagnostics, antivirals, vaccines, and virtual office visits? I hope it will be that and much more. I hope it will be a true humbling also in the spiritual sense: a loss that leads toward a confrontation with purpose and meaning. I hope this humbling plague reminds all of us of our mortality, fragility, and fellowship. For it is only from that place of humility and connection that we can ask fundamental questions about what we want from our medical care system and our government. I hope that we will be inspired by this humbling tragedy to take up the great task of using our Promethean powers to do more than simply accelerate the technological juggernaut that emphasizes means over ends, billable procedures over therapeutic conversations, and profits over kindness. We can ask ourselves the spiritual question of what we want to do during our brief stay on Earth and act to create a healthcare system, as Camus’ Dr. Rieux would direct us, based on healing and sympathy. In this way, we can transform the human and economic tragedy of our humbling COVID-19 plague into an opportunity to embrace and protect our common humanity. 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.

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COVID-19 “ … To cure disease, to serve the sick, to promote health and to do no harm … ”

Individual and Institutional

ETHICS During the COVID-19 Pandemic

BY NAYANA M. TRIVEDI, MD 8

May/June 2020

or more than 2,000 years, the Hippocratic oath has been the guiding principle of the medical profession. As an ethicist, I believe this is the foundation of healthcare ethics. Clinicians are trained to respond to ailments and offer a treatment in the best possible manner without being judgmental of lifestyle, age, sex, gender identity, ethnicity, health insurance, or legal status. This is clinical ethics, where the primary focus is relief of suffering while applying the principles of beneficence and non-maleficence. Clinical ethics respects patients’ autonomy in regard to treatment preference including end-of-life care for prolonging life by accepting or declining aggressive life support. However, during pandemic, epidemic, or emergency situations arising from mass calamity, public health ethics take precedence over individual care ethics. This may result into moral distress among healthcare providers, especially if their moral values conflict with promoting the public good. The goal of public health is to deliver and promote health of populations by reducing morbidity and mortality. Public health ethics guide us to do this with an eye toward the fair distribution of resources while balancing the needs of an individual in need of care with those of a population group. In a hospital setting, this tension is exemplified by how institutions distribute equipment to healthcare workers, and manage the time of their employees and contractors. In many regions of this country, hospitals face shortages of personal protective equipment, ventilators, ECMO, ventilator operating staff, respiratory therapists, ICU RNs, and critical care MDs. In New York, this lack of support and dearth of resources has led many healthcare workers and administrators to burn out

in the very early stages of this pandemic. In what follows, I review scientific and bioethics literature to recommend ways to harmonize the conflict between responsibilities of healthcare workers toward individuals, and responsibilities of institutions toward these workers and the community at large, in order to sustain care throughout the duration of this epidemic and encourage an ethical distribution of limited resources. During a pandemic, weighing potential risk versus benefits of a potential treatment for an individual is more crucial than ever. While a patientâ&#x20AC;&#x2122;s autonomy is a guiding principle of individual care ethics, in an emergency calamity situation, public health ethics suggests that the ethical principle of autonomy can be minimized. A situation where institutions face shortage of resources, and are responding to a public health crises such as COVID-19 is similar to a calamity situation. This reality is likely to give healthcare workers moral distress. However, the ethical principles at the core of clinical practice, beneficence and no-maleficence, should guide healthcare workers in reducing moral distress. Beneficence emphasizes reducing morbidity and mortality among population while doing no maleficence to individual patients during triaging disease burden. While in a normal situation, a patient may have more autonomy to dictate to term of her healthcare needs, in a pandemic situation, healthcare workers, with their years of experience, professional commitment, and refined training should be empowered to triage and utilize limited resources ethically.1 The 1997 Critical Care Medicine Ethics Committee Consensus Statement regarding futile and other inadvisable treatment outlines criteria for healthcare workers to consider when treating individuals in an emergency situation. 2 Since then, new guidance on CPR, chest

imaging, and ECMO have been released by the AHA, International Society of Thoracic and Radiology Medicine, and Society of Critical Care Medicine. 3 In addition, healthcare institutions play a critical role in supporting healthcare workers in providing the best care possible to the communities they are serving.4 The Hastings Center recommends a three-fold approach to guide health institutions and healthcare leaders in responding to the COVID-19 pandemic.5 First, leaders and institutions should plan for uncertainties arising from healthcare workersâ&#x20AC;&#x2122; exhaustion or their loss of work opportunity and income. Second, institutions should provide safeguards to minimize the risk of occupational harms for healthcare workers while also protecting vulnerable populations at higher risk of COVID-19 infection based on factors such as age, underlying health conditions, immigration status, and insurance status. Third, institutions should be prepared for contingency and crisis levels of care. In addition, the Hastings Center recommends that each institution, in collaboration with the local public health department, should decide broader base policies pertaining to surveillance, reporting, and quarantine. Individual hospital administrations, with the help of disaster planning committees and epidemiologists, should determine policies for resource allocation within the hospital system, and for advance notification to communities about limiting care or visitation. In order to better serve healthcare workers, I recommend that institutions consider the following in supporting their workers throughout the pandemic. To support workers in providing the best patient care, institutions should: 1. Support decision-making processes including appropriate use of advance

Seeking Chief Medical Officer Vista Community Clinic is a private, non-profit medical, dental and social services center providing a full range of health care services in a comprehensive, high quality setting focusing on those facing economic, social or cultural barriers. We are located in three counties: San Diego, Orange and Riverside.

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care planning documents, and including modifying CPR policies to minimize the health hazard to healthcare workers in hospital settings. 2. Facilitate ethics consultations service in collaboration with palliative care service to support clinicians in helping to manage ethical challenges that may arise due to conflicts between personal, moral, and institutional policies. 3. Establish adequate infection control and guidelines. 4. Secure, manage, and provide appropriate personal protective equipment, which will reduce health risks and improve the morale of the entire workforce. Second, institutions should support healthcare workersâ&#x20AC;&#x2122; wellbeing by: 1. Accommodating underlying health conditions and risk profile of healthcare workers in deciding staffing for clinical and nonclinical roles.

2. Providing social and spiritual support to help workers manage increased workplace and personal stress. 3. Arranging for child and elder care for quarantined employees, especially if there is a high-risk family member to be protected. 4. Considering additional life or disability insurance to those working in high-risk settings. 5. Developing policies to minimize furloughed time in order for workers to maintain their income. Finally, institutions should develop policies emphasizing their responsibilities to the communities they serve by: 1. Protecting the employee who acts as a whistle-blower if there is any breach in healthcare safety. 2. Serving immigrant populations without regard to legal status, and those without insurance. Ambroise Pare, a father of modern

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surgery, is often quoted as having said, “The art of medicine is to cure sometimes, relieve often, and to comfort always.”6 This cannot be more relevant than at this time. Healthcare professionals sometimes can cure infection with ventilators and antiviral medicine, and often provide symptom relief with supportive care. But because COVID-19 has no cure, we are learning the art of providing comfort always. I hope the above mentioned points will help all of us reflect upon our roles at the individual, institutional, and community levels. Dr. Trivedi is a hospitalist at Scripps Memorial Hospital La Jolla. Prior to joining Ximed Medical Group, Dr. Trivedi was in private practice for 20 years serving North County. She has been practicing medicine for the last 35 years, and is board certified in internal medicine and palliative care, and has taken advanced training in bioethics.

R eferences 1. McCullough, Laurence B. In Response to COVID-19 Pandemic Physicians Already Know What to Do. Bioethics.net. Published online April 3, 2020. Available at: http://www.bioethics.net/2020/04/in-response-to-covid-19pandemic-physicians-already-know-what-to-do/. 2. Consensus statement of the Society of Critical Care Medicine’s Ethics Committee regarding futile and other possibly inadvisable treatments, Critical Care Medicine: May 1997 - Volume 25 - Issue 5 - p 887-891. 3. New guidance on CPR, chest imaging, and ECMO, ACP Hospitalist weekly April 15, 2020. Available at: https://acphospitalist.org/weekly/ archives/2020/04/15/2.htm?utm_campaign=FY19-20_NEWS_HOSPITALIST_ DOMESTIC_041520_EML&utm_medium=email&utm_source=Eloqua. 4. Matheny Antommaria AH, Conflicting Duties and Reciprocal Obligations During a Pandemic. Published online first April 3, 2020. DOI: 10.12788/ jhm.3425 5. Berlinger, Nancy et. al., Ethical Framework for Health Care Institutions Responding to Novel Coronavirus SARS-CoV-2 (COVID-19) Guidelines for Institutional Ethics Services Responding to COVID-19. Published March 16, 2020, available at: https://www.thehastingscenter.org/wp-content/uploads/ HastingsCenterCovidFramework2020.pdf. 6. Jogerst, Kristen; Bowman, Jason. Toujours Reconforter: Comfort Always. Generalsurgerynews.com. Published online May 7, 2020. Available at: https:// www.generalsurgerynews.com/Jogerst-and-Bowman/Article/04-20/ Toujours-R-conforter-Comfort-Always/58239.

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SanDiegoPhysician.org 11

COVID-19

ANTI-VACCINE ACTIVISTS

Latch onto Coronavirus to Bolster Their Movement BY LIZ SZABO W

hile most of the world hungers for a vaccine to put an end to the death and economic destruction wrought by COVID-19, some anti-vaccine groups are joining with anti-lockdown protesters to challenge restrictions aimed at protecting public health. Vaccine critics suffered serious setbacks in the past year, as states strengthened immunization laws in response to measles outbreaks sparked by vaccine refusers. California tightened its vaccine requirements last fall despite protests during which anti-vaccine activists threw blood on state senators, assaulted the vaccine bill’s sponsor, and shut down the legislature. Now, many of these same vaccine critics are joining a fight against stay-at-

May/June 2020

home orders and business shutdowns intended to stem the spread of the coronavirus, which has killed tens of thousands of Americans. “This is just a fresh coat of paint for the anti-vaccine movement in America, and an exploitative means for them to try to remain relevant,” says Dr. Peter Hotez, a professor at Baylor College of Medicine in Houston. Hotez said anti-vaccine groups are seizing on the anti-government sentiment stoked by conservative-leaning protesters to advance their cause. “Unfortunately, their strategy may work,” he says. A group calling itself the Freedom Angels, whose members last year stood on chairs and chanted at public hearings on

the California vaccine bill, says governors are abusing their power by shutting down gun shops and other businesses. Many anti-vaccine activists — who have claimed that diseases such as measles aren’t that serious — now contend the coronavirus isn’t dangerous enough to justify staying home. They agree with President Donald Trump that the “cure” for the pandemic could be worse than the disease itself. That’s led some vaccine foes to join the protesters — whom Trump has encouraged on Twitter — in staging demonstrations in state capitals to “reopen America.” “This is the time for people to take notice and really evaluate the freedoms they’re giving up, all in the name of perceived safety,” said Freedom Angels co-founder Heidi Munoz Gleisner in a Facebook video. The group organized a rally in Sacramento on April 20 called “Operation Gridlock.” “People need to get back to work, get back to life, get back into contact with their loved ones who they’re isolated from, they need to be able to have a paycheck,” group co-founder Tara Thornton told The Sacramento Bee, which interviewed her during the demonstration. “This is the grounds they will enslave us upon.” Freedom Angels did not respond to requests for interviews. The group’s website mentions plans for additional rallies and includes photos from the April 20 demonstration, such as one in which a protester holds a sign proclaiming “No Mandatory Vaccines.” But after the Monday event, the California Highway Patrol announced it had revoked the group’s permit for future protests because the gathering — which included dozens of people — violated the governor’s social distancing order. The highway patrol has now banned all group events at the Capitol during the pandemic to avoid spreading the coronavirus.

A BIG TENT

The anti-vaccine movement has never been limited to one political party. Left-leaning vaccine critics — such as Children’s Health Defense, led by Robert F. Kennedy Jr. — include environmentalists who are suspicious of chemical pollutants, corporations and “Big Pharma.” The Kennedy group’s website attacks Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, for rushing “risky and uncertain coronavirus vaccines” into development as part of a “sweetheart deal” for drug companies. On the other side of the political spectrum, many anti-vaccine conservatives oppose state immunization requirements because they distrust “big government.” • A group called Texans for Vaccine Choice has called on the governor to promise that no one will be forced to get a coronavirus vaccine in order to go to work or school. • Posts on the Facebook page of Californians for Health Choice, which also opposed California’s vaccine laws, question stay-at-home orders and accuse government officials of refusing to admit the orders are a mistake. • In a video on the Freedom Angels’ Facebook page, its founders describe stay-at-home orders as an abuse of government authority, and the closure of California gun shops as an assault on the Second Amendment. The group notes that guns could be essential for protection from rioters and looters looking to steal food during the pandemic. In many ways, the conservative arm of the anti-vaccine movement is a natural ally for those leading “reopen America” rallies, says Dr. David Gorski, an oncologist and managing editor of the Science-Based Medicine site. Both harbor suspicions about government authority. Vaccine critics, for example, have long championed the false claim that vaccines

cause autism, and that the Centers for Disease Control and Prevention has tried to cover up that information, Gorski says. Trump has at times linked vaccines with autism, although he came out strongly in favor of vaccinations during the 2019 measles epidemic. Anti-vaccine groups are now rebranding themselves as advocates of “medical freedom.” Protests against social distancing began in Michigan but have spread to state capitols in Texas, Colorado, Nevada, Maryland, Wisconsin and elsewhere, with more planned. Most protests have been small, limited to a few hundred or fewer people. Yet the anti-vaccine movement doesn’t speak for everyone on the right. Stephen Moore, the senior economic contributor for FreedomWorks, a conservative advocacy group that has been helping publicize the protests, said he’s unfamiliar with the Freedom Angels or their rallies. “I’m personally pro-vaccine,” said Moore, a member of the White House council to reopen the economy. “Especially when it comes to coronavirus.” And some heroes of the anti-vaccine movement say they support coronavirus lockdowns. Dr. Jay Gordon, a Santa Monica pediatrician popular among vaccine foes for downplaying the risks of measles, said the risk of COVID-19 is real. Gordon says he approves of the lockdown, “and we have to keep it up.”

CONTAINING THE PANDEMIC

Dr. Richard Pan, a pediatrician and California state senator who has championed stronger vaccine mandates, described anti-vaccine and anti-lockdown protesters as “essentially selfish” because they put other people at risk. “One of the hallmarks of the antivaccine movement is this sense of selfishness and lack of concern for other

people’s health,” Pan says. “They like to talk about rights and freedom. But what they really want is freedom without consequences.” Both anti-vaccine parents and those who want to relax social distancing assume that the medical system will come to their rescue if they become sick, said Pan, who noted that thousands of healthcare workers have died while fighting the pandemic. Fauci has said that relaxing stay-athome orders is dangerous as long as the virus — for which there are no approved treatments or vaccines — is actively spreading. Reopening businesses too soon could spark a second wave of infections. More than 75 companies and research groups worldwide are trying to develop vaccines, which are seen as a key weapon against the novel coronavirus. In the meantime, the CDC says that social distancing measures — such as working from home and avoiding large gatherings — are critical to slowing the spread of the coronavirus and preventing patients from overwhelming hospitals. Health leaders say it won’t be safe to reopen the county until widespread testing shows the coronavirus has died down. Americans overwhelmingly support vaccination, according to surveys, and polling by the Kaiser Family Foundation found that 80% of Americans want lockdowns to continue. Only 19% said social distancing orders placed an unnecessary burden on the economy. (Kaiser Health News is an editorially independent program of the foundation.) Neither the anti-vaccine nor antilockdown demonstrators represent the opinions of most Americans, Pan says. “Let’s put this movement into proper context,” he says. “They’re loud, they’re noisy and they’re small.” Liz Szabo is a senior correspondent for Kaiser Health News, where this story first appeared.

SanDiegoPhysician.org 13

SAFETY CONCERNS AFFIRMED WITH HCQ IN COVID-19 COVID-19

Studies Highlight Importance of Close QTc Monitoring BY NICOLE LOU

T interval prolongation remained a safety concern with hydroxychloroquine (HCQ) for COVID-19 in reports from Boston and France, highlighting the need for careful monitoring. Risk was particularly elevated when HCQ was administered with azithromycin in both studies, published online in JAMA Cardiology. Both agents have been known to be mechanistically capable of extending the QT interval. “The risk for significant QT prolongation is significant and must be balanced with the potential benefit of therapy. Excessive QT prolongation is associated with a risk for sudden death. Blithely taking these drugs can potentially be more harmful than good,” commented Anil Gehi, MD, of the University of North Carolina School of Medicine in Chapel Hill, in an email.

FINDINGS FROM BOSTON

The first report, a 90-person cohort study from Boston, showed that 19% of hospitalized COVID-19 patients getting HCQ monotherapy developed QTc lasting 500 ms or more, and 3% had QTc prolonged by at least 60 ms after receiving the medication. For those receiving concomitant azithromycin, the rates were 21% and 13%, respectively, according to a group led by Nicholas Mercuro, PharmD, and Christina Yen, MD, both of Beth Israel Deaconess Medical Center, Boston. Magnitude change in QT interval was also greater with the combination compared with HCQ alone (median +23 ms vs +5.5 ms, P=0.03). One out of every nine HCQ users had administration of the drug stopped early because of adverse events. One patient

May/June 2020

developed torsades de pointes. “Although hydroxychloroquine and azithromycin administration was discontinued three days prior to the event, the patient also had severe acute respiratory distress syndrome, bradycardia, hypothermia, propofol co-administration, and a new cardiomyopathy, raising concerns that the risk of QTc prolongation likely persisted, given the prolonged terminal half-life of each agent,” Mercuro and Yen’s group noted. At the time that the manuscript was drafted, the COVID-19 patients had been followed for approximately nine days. Half the 90-person group remained hospitalized after 41 people were discharged and four died. The cohort study included patients hospitalized at Beth Israel Deaconess Medical Center with pneumonia related to COVID-19. All got at least one day of HCQ from March 1 to April 7. Of the 90, 53 received concomitant azithromycin. Mean age was 60.1 years, and the group was roughly split between men and women. Hypertension (53.3%) and diabetes (28.9%) were among the most common

comorbid conditions in this cohort. One-third of the group was critically ill at the time of COVID-19 testing, and 26% were on mechanical ventilation. The HCQ-only arm entered the study with a longer baseline QTc (473 vs 442 ms with azithromycin, P<0.001), the investigators noted. Two factors predicted prolonged QTc with HCQ use: • Concomitant loop diuretic administration (adjusted OR 3.38, 95% CI 1.03-11.08) • Baseline QTc of 450 ms or more (aOR 7.11, 95% CI 1.75-28.87) “While hydroxychloroquine and azithromycin administration likely contributed to the observed ADEs [adverse drug events], we cannot exclude COVID-19-associated stress cardiomyopathy or myocarditis,” study authors acknowledged. “Without a control arm, we cannot conclude that hydroxychloroquine and azithromycin conferred increased cardiotoxic risk,” although the difference between the combination and HCQ alone likely could be attributed to azithromycin, the group wrote.

THE EXPERIENCE AT A FRENCH ICU

The vast majority of COVID-19 patients in a French ICU who received HCQ with or without azithromycin developed an increase in QTc, according to a 40-person case series. Fully 93% of patients had QTc increase, and 36% developed QTc prolongation (with QTc reaching 500 ms or a change in QTc of at least 60 ms) after two to five days of antiviral treatment. A third of those on both HCQ and azithromycin developed a QTc interval of 500 ms or greater compared with 5% of those receiving only hydroxychloroquine (P=0.03). Unlike the Boston report, however, no HCQ user experienced any ventricular arrhythmias in the ICU, Martin Cour, MD, PhD, of Hôpital Edouard Herriot in Lyon, France, and colleagues reported. “In our cohort, close monitoring of patients (including continuous QTc interval monitoring, daily ECGs, and laboratory tests), which led to an interruption of these drugs for 17 patients (42.5%), may have averted further complications, including druginduced torsades de pointes,” Cour’s group reported. Included in this report were 40 consecutive patients with confirmed COVID-19 who were in the ICU at some point from March 15 to 29. HCQ was combined with azithromycin for 45%. Median age was 68 years. Four out of five were men. In this cohort, 75% required invasive mechanical ventilation, and 63% received vasoactive drugs. Half of the patients also received other treatments favoring QT prolongation in the ICU (e.g., propofol, amiodarone, ciprofloxacin, and ondansetron). The findings in the case series may have limited generalizability beyond the ICU, the French group acknowledged. “However, the finding that QTc intervals increased in more than 90% of patients raises concerns about the widespread use of hydroxychloroquine, with or without azithromycin, to treat COVID-19 in settings where patients cannot be adequately monitored,” they wrote.

CLINICAL IMPLICATIONS

“[R]igorous investigation is needed to guide treatment decisions. At a minimum, these reports should prompt clinicians to define guardrails before instituting novel therapeutics for new diseases,” commented Daniel Frisch, MD, of Jefferson University Hospitals in Philadelphia. HCQ had been given to treat various diseases over several decades without such safety fears, noted Dhanunjaya Lakkireddy, MD, of the Kansas City Heart Rhythm Institute at HCA Midwest Health. The difference now is that almost all these COVID-19 patients were “deathly sick,” explaining at least in part the “significantly increased incidence of QT prolongation than what you would typically expect in a community outpatient center,” he said in an interview. In careful consideration of HCQ use, clinicians should make sure that the patient is not on other QT-prolonging drugs and think about the patient’s comorbidity profile, according to Lakkireddy. And if the antiviral is used, close monitoring has to happen after each dose and be extended even long after the drug has been stopped or completed given that its effects can last for days, Lakkireddy suggested. Well-controlled clinical trials are now needed to determine whether the benefits of the antiviral medication in COVID-19 outweigh its risks, urged a trio led by Robert Bonow, MD, MS, Northwestern University Feinberg School of Medicine, Chicago, in an accompanying JAMA Cardiology editorial. They cited the ORCHID and RECOVERY trials as two such studies to watch out for. “Until then, treatment decisions for this disease will remain based on clinical judgment and, ideally, in the context of enrolling patients into clinical trials to provide definitive answers,” Bonow’s group said.

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SanDiegoPhysician.org 15

COVID-19

TOP 10 TIPS for Reopening Your Medical Office During COVID-19

By Kerin Torpey Bashaw, MPH, RN, and Debbie K. Hill, MBA, RN

We’ve heard from physicians that they are concerned about the risks involved in reopening their practices. In response to these concerns, we offer the following 10 recommendations:

Provide refresher training for all staff on triage, infection control, use of personal protective equipment (PPE), and patient communication.

Determine staff needs for PPE based on levels of infection in the community, types of patients seen, and types of patient care procedures performed. See guidance from the Occupational Safety and Health Administration (OSHA).

Contact your insurance agent or medical professional liability carrier to confirm that coverage has been reinstated at the desired level if you have requested adjustments in your professional liability coverage during the crisis.

Schedule in-person visits according to medical priority. Consider continued telehealth visits for patients at high risk for COVID-19 who don’t need to be seen in person.

Follow guidelines from the Centers for Disease Control and Prevention (CDC) for patient COVID-19 screening upon appointment scheduling and on day of appointment.

May/June 2020

Avoid patient-topatient contact by considering separate entrance and exit doors, limiting capacity, asking patients to wait in the car, and allowing only one-patient visits. If patient must be accompanied, screen chaperone for COVID-19. See the CDC’s Outpatient and Ambulatory Care Settings: Responding to Community Transmission of COVID-19 in the United States.

Assess whether public, work, and treatment areas are equipped to reduce the spread of COVID-19. For example, use Environmental Protection Agency (EPA)-approved cleaning chemicals with label claims against the coronavirus. For more information, see OSHA’s Ten Steps All Workplaces Can Take to Reduce Risk of Exposure to Coronavirus. For a list of disinfection products effective against coronavirus (COVID-19, also known as SARSCoV-2), see the Environmental Protection Agency list.

Screen healthcare personnel daily for symptoms/ travel/contacts relevant to COVID-19. Any unprotected occupational exposure by staff members should be assessed and monitored. See Interim U.S. Guidance for Risk Assessment and Public Health Management of Healthcare Personnel with Potential Exposure in a Healthcare Setting to Patients with Coronavirus Disease 2019 (COVID-19).

Follow return-towork guidelines for healthcare workers with confirmed or suspected COVID-19.

10.

Maintain an open line of communication with all vendors and supply chains for infection control purposes and access to available resources.

Concerns will persist regarding the possibility of COVID-19’s resurgence as state and local governments implement the phases of the Opening Up America Again Guidelines. We urge you to: • Reference the CDC, your state medical board, professional societies, and federal, state, and local authorities daily for public health guidance and new legislation. The CDC provides public health agency contact information at National Voluntary Accreditation for Public Health Departments. • Be mindful of expiration dates of executive orders related to licensing, telemedicine, prescribing rules, and regulatory compliance. See COVID-19: Executive Orders by State on Dental, Medical, and Surgical Procedures for a list of state executive orders from the American College of Surgeons. We’ve provided these tips because we are driven by our mission to advance the practice of good medicine. As always, use your best clinical judgment. Continue to be diligent and proceed with caution as you manage patients within your facility. Stay abreast of community incidence of disease and restructure your approach when needed.

CHAMPIONS FOR HEALTH

Zooming into COVID-19 By Adama Dyoniziak WHAT IS MULTILINGUAL IN EIGHT

languages, has been virtually attended by thousands, and is up-to-the-minute with fresh information? It’s Champions for Health Live Well San Diego Speaker’s Bureau COVID-19 presentations via Zoom. “We have been contracted by the County of San Diego HHSA to be the main point of contact for COVID-19 community presentations,” says Andrew Gonzalez, community wellness and partnership manager. “There is a lot of information on social media, the news, and in the general public. We want to make sure that San Diegans receive up-to-date information that is verified by the County,” During the past six weeks, Speaker’s Bureau volunteers have conducted presentations or taken part in panel discussions to 19 groups in five languages to 2,134 San Diegans. The Zoom presentation addresses real-time needs around the COVID-19 pandemic, such as prevention, spreading of the disease, symptoms, testing, telehealth, up-to-date public health orders, and concludes with a question and answer session. Our volunteers who Zoom for us include public health nurses, physicians, and nurse practitioners. We also support

our local physicians with COVID-19 updates, recruitment for COVID-19 relief, and connecting physicians with San Diego County Medical Society and County HHSA resources. The threshold languages for San Diego County — Arabic, English, Korean, Mandarin, Somali, Spanish, Tagalog, and Vietnamese — requires culturally competent and culturally sensitive information for each population. Our translations have been completed by local certified translators through our partners, ATISDA, and the American Translators Association. The community groups who received the information included American Heart Association, Catholic Charities of San Diego, Corporation for Supportive Housing Council, Ammar Campa-Najjar Community Meeting, Farm Worker Care Coalition, Greater San Diego Association of Realtors, Elderhelp, Teachers for Healthy Kids, Jewish Family Services, Rolando Community Council, and the San Diego Water Authority. Retired Lieutenant Commander and Navy Nurse Corps Officer Sheree Scott is volunteering with Champions for Health to give these virtual presentations in between teaching classes at San Diego

Continuing Education and earning a doctoral degree. “I felt a void after I left the military and often question myself with what else could I be doing. I’m really giving back in the smallest way,” Scott says. “After being in the Navy for 24 years, I think about the people I served with, worked with or worked for, and what they are going through right now and I think about where I would be deployed to if I was not retired.” In addition to volunteering and teaching, Scott is a doctoral student at the University of San Diego’s Hahn School of Nursing and Health Science. The goal, she said, is to contribute to the development and promotion of the profession of skilled healthcare workers through instruction and field research. For more information on how you can share your time and talent with our most vulnerable San Diegans, please contact Adama Dyoniziak at adama.dyoniziak@ championsfh.org or call (858) 300-2780. Join us in our Pledge Drive 2020 by clicking on the donate button at www. championsforhealth.org. Adama Dyoniziak is executive director of Champions for Health. SanDiegoPhysician.org 17

CLASSIFIEDS PHYSICIAN OPPORTUNITIES INTERVENTIONAL PHYSIATRY/PHYSICAL MEDICINE SPECIALIST POSITION AVAILABLE: Practice opportunity for part time interventional physiatry/physical medicine specialist with well-established orthopaedic practice. Position includes providing direct patient evaluation/care of spine and musculoskeletal cases, coordinating PMR services with all referring providers. Must have excellent interpersonal and communication skills. Office located near Alvarado Hospital. Onsite digital x-ray and emr. Interested parties, please email lisas@sdsm.net CARDIOLOGIST WANTED: San Marcos cardiology office looking for a part-time cardiologist. If interested, send CV to evelynochoa2013@yahoo.com or via fax to (760) 510-1811. PHYSICIAN CONSULTANT FULL-TIME: San Diego-Imperial Counties Developmental Services, Inc. (San Diego Regional Center). Great opportunity to work in a multidisciplinary setting in a private non-profit agency that serves persons with developmental disabilities. Must be licensed to practice medicine in California issued by the State Board of Medical Examiners. Experience in pediatrics, internal medicine, family practice and/or neurology. Training or experience in the field of developmental disabilities is desirable, but not required. Please visit our website at www.sdrc.org for more information and to submit an application. CHILD HEALTH OFFICER (MEDICAL DIRECTOR): The County of San Diego Health & Human Services Agency (HHSA), Medical Care Services (MCS), is seeking online applications and résumés from qualified individuals for Child Health Officer/Medical Director. This unclassified management position plays a key leadership role in our medical care system by supporting the planning, directing, and coordinating of all forensic and clinical functions specific to Medical Care Services. In accordance with Federal, state, and local policies and regulations, the Child Health Officer will have significant responsibility for monitoring and/or evaluating medical assessments of child abuse and/or neglect, pediatric care, and an array of services. Regular Full time $240,000.00 - $250,000.00 Annually. Please visit the County of San Diego website for more information and to apply online. PEDIATRIC POSITION AVAILABLE: Grossmont Pediatrics, a private pediatrics practice with Commercial HMO, PPO, Tricare, Medi-Cal patients, provides family-focused individualized care in East San Diego. Clinical cases include ADHD, asthma, adolescent behavioral health. Average 2.5 clinic patients per hour, 1-in-3 light call & newborns at one hospital. With Epic HER, access real-time care at Rady’s and area hospitals. Working 24 or 28 hours weekly, you will earn $130-150,000 annual compensation, up to 3 weeks PTO plus holidays, and future share in practice. Direct professional expenses are paid, Health, Dental, 401K, etc. Contact venk@gpeds.sdcoxmail.com or 619-5045830 with resume in .doc, .pdf or .txt. GENERAL FAMILY MEDICINE PHYSICIAN: to provide quality patient care to all ages of patient in a full-time traditional practice. The

May/June 2020

Physician will conduct medical diagnosis and treatment of patients using medical office procedures consistent with training including surgical assist, flexible sigmoidoscopy, and basic dermatology. The incumbent must hold a current California license and be board eligible. Bilingual Spanish/English preferred. Founded as a small family practice in Escondido 1932 by Dr. Martin B. Graybill, today we’re the region’s largest Independent Multi-specialty Medical Group. Our location is 277 Rancheros Dr., Suite 100, San Marcos, CA 92069. We are an equal opportunity employer and value diversity. Please contact Natalie Shields at 760-291-6637/nshields@ graybill.org. You may view our open positions at: https://jobs.graybill.org/ BOARD CERTIFIED OR BOARD-ELIGIBLE PHYSICIAN DERMATOLOGIST: Needed for busy, well-established East County San Diego (La Mesa) private Practice. We currently have an immediate part-time opening for a CA licensed Dermatologist to work 2-3 days per week with the potential for full-time covering for existing physicians, whenever needed. We are a full-service Dermatology office providing general, cosmetic and surgical services, including Mohs surgery and are seeking a candidate with a desire to provide general dermatology care to our patients, but willing to learn laser and cosmetics as well. If interested, please forward CV with salary expectation to patricia@ grossmontdermatology.com. PHYSICIAN CONSULTANT FULL-TIME: San Diego-Imperial Counties Developmental Services, Inc. (San Diego Regional Center). Great opportunity to work in a multidisciplinary setting in a private non-profit agency that serves persons with developmental disabilities. Must be licensed to practice medicine in California and certified by specialty board such as Neurology, Neurodevelopmental Disabilities, Developmental Behavioral Pediatrics, Pediatrics or Internal Medicine. Experience in the field of developmental disabilities and administrative or supervisory experience required. Please visit our website at www.sdrc.org for more information and to submit an application. (Posted 10/7/2019) DEPUTY PUBLIC HEALTH OFFICER: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a California licensed or license eligible physician to work for County of San Diego Public Health Services, nationally accredited by the Public Health Accreditation Board. Regular - Full Time: $220,000 - $230,000 Annually. For more information and to apply: https://www. governmentjobs.com/careers/sdcounty/ jobs/2359704/deputy-public-health-officer19092204u?keywords=Deputy%20Public%20 health%20&pagetype=jobOpportunitiesJobs TEMPORARY EXPERT PROFESSIONAL (TEP) MEDICAL DOCTORS (MD’s) NEEDED: The County of San Diego Health and Human Services Agency is seeking numerous MD positions to work in a variety of areas including Tuberculosis Control, Maternal and Child Health, Epidemiology and Immunizations, HIV, STD & Hepatitis, and California Children’s Services. Applicants (MD or DO) must hold a current California medical license. Applicants must be proficient in either Opioid Abuse Prevention and Treatment Strategies, Communicable Diseases and/or Healthcare Systems, and willing to minimally work three days

a week. Hourly rate is $103/hour. If interested, please e-mail CV to Anuj.Bhatia@sdcounty.ca.gov or call (619) 542-4008. PRACTICE OPPORTUNITY: Internal Medicine and Family Practice. SharpCare Medical Group, a Sharp HealthCare-affiliated practice, is looking for physicians for our San Diego County practice sites. SharpCare is a primary care, foundation model (employed physicians) practice focused on local community referrals, the Patient Centered Medical Home model, and ease of access for patients. Competitive compensation and benefits package with quality incentives. Bilingual preferred but not required. Board certified or eligible requirement. For more info visit www. sharp.com/sharpcare/ or email interest and CV to glenn.chong@sharp.com PRACTICE FOR SALE PRACTICE FOR SALE IN ENCINITAS: A GYNonly practice for sale in Encinitas with a majority of the patients in North County. Insurance accepted are PPO, cash and some Medicare patients. Could be turnkey or just charts. Practicing is closing December 31st, 2019. Please call Mollie for more information at 760-943-1011. CLINICAL RESEARCH SITE/MULTI-SITE SPECIALTY PHYSICIAN PRACTICE COMBO FOR SALE: Great opportunity for a Group Practice. Clinical Research offers a way for physicians to continue to practice medicine the way they like and provide an additional source of income that is compatible with their goal of providing great care and options for their patients. Patients will have the opportunity to participate in the research of new treatments. Current site has staff and facilities for research, physician suites, and X-Ray. Use as a primary location or as a satellite office with research site. Current physicians and staff willing to train and work alongside physicians new to research. Contact E-Mail: CL9636750@gmail.com PRACTICES WANTED PRIMARY OR URGENT CARE PRACTICE WANTED: Looking for independent primary or urgent care practices interested in joining or selling to a larger group. We could explore a purchase, partnership, and/or other business relationship with you. We have a track record in creating attractive lifestyle options for our medical providers and will do our best to tailor a situation that addresses your need. Please call (858) 832-2007. PRIMARY CARE PRACTICE WANTED: I am looking for a retiring physician in an established Family Medicine or Internal Medicine practice who wants to transfer the patient base. Please call (858) 257-7050. OFFICE SPACE / REAL ESTATE AVAILABLE PHYSICIAN OFFICE SUBLEASE SPACE AVAILABLE IN NEWLY REMODELED XiMED BUILDING SUITE IN LA JOLLA: . Conveniently located right off Highway 5 and Genesee Ave, highly sought after XiMed Building on the Scripps Memorial Hospital campus in La Jolla. Open floor plan with stylish, modern décor fully furnished 3 exam rooms, 2 offices, lunch room and a spacious lobby with HIPPA compliant reception. Area. Excellent space for any specialty to practice as part time or full time along with another practice as

LA JOLLA OFFICE FOR SUBLEASE OR TO SHARE Scripps Memorial Medical office building at 9834 Genesee Ave. Amazing location by the main entrance to the hospital between I-5 and I-805. Multidisciplinary group available to any specialty. Excellent referral base in the office and on the hospital campus. Great need for a psychiatrist. We have multiple research projects. If you have an interest or would like more information, please call 858-344-9024 or 858-320-0525.

shared space. For more information and to schedule a time to view the suite, please call 858-837-1540. ESCONDIDO MEDICAL OFFICE TO SHARE: Medical office space available at 1955 Citracado Parkway, Escondido. Close to Palomar Medical Center-West, Two to three furnished exam rooms, 2 bathrooms, comfortable waiting room, lab space, work area, conference room, kitchen. Radiology and Lab in the medical building. Ample free parking. Contact Jean (858) 673-9991. MEDICAL OFFICE SPACE FOR SUBLEASE: Brand new medical office space available for sublease in La Jolla near UCSD. 8950 Villa La Jolla at The Campus, easy access from I-5. Perfect for specialist, includes one exam room and one procedure room. Brand new flooring, paint, furniture etc. Please send your email to eferrermd@gmail.com if interested. MEDICAL OFFICE LEASE: We currently have a small medical office ready to lease. The office is located in Imperial county and is approximately 910 sqft. Please email us at info@ carlsbadimaging.com with any with further questions or needed details. NORTH COUNTY MEDICAL SPACE AVAILABLE: 2023 W. Vista Way, Suite C, Vista, CA 92083. Newly renovated, large office space located in an upscale medical office with ample free parking. Furnishings, décor, and atmosphere are upscale and inviting. It is a great place to build your practice, network and clientele. Just a few blocks from Tri-City Medical Center and across from the urgent care. Includes: Digital X-ray suite, multiple exam rooms, access to a kitchenette/break room, two bathrooms, and spacious reception area all located on the property. Wi-Fi is NOT included. Contact Harish Hosalkar at hhorthomd@gmail.com or call/text (858) 243-6883. MEDICAL OFFICE AVAILABLE FOR RENT: Furnished or unfurnished medical office for rent in central San Diego. Can rent partial or full, 5 exam rooms of various sizes, attached restroom. Easy freeway access and bus stop very close. Perfect for specialist looking for secondary locations. Call 858430-6656 or text 619-417-1500. MEDICAL OFFICE SPACE FOR SUBLEASE: Medical office space available for sublease in La Jolla-9834 Genesee Avenue, Suite 400 (Poole Building). Steps away from Scripps Memorial Hospital La Jolla. Please contact Seth D. Bulow, M.D. at 858-622-9076 if you are interested.

LA JOLLA OFFICE FOR SUBLEASE OR TO SHARE: Scripps Memorial Medical office building at 9834 Genesee Ave. Amazing location by the main entrance to the hosptial between 1-5 and 1-805. Multidisciplinary group available to any specialty. Excellent referral base in the office and on the hospital campus. Great need for a psychiatrist. We have multiple research projects. If you have an interest or would like more information, please call 858-344-9024 or 858-320-0525. SHARED OFFICE SPACE: Office Space, beautifully decorated, to share in Solana Beach with reception desk and 2 rooms. Ideal for a subspecialist. Please call 619-606-3046. OFFICE SPACE/REAL ESTATE AVAILABLE: Scripps Encinitas Campus Office, 320 Santa Fe Drive, Suite LL4 It is a beautifully decorated, 1600 sq. ft. space with 2 consultations, 2 bathrooms, 5 exam rooms, minor surgery. Obgyn practice with ultrasound, but fine for other surgical specialties, family practice, internal medicine, aesthetics. Across the hall from imaging center: mammography, etc and also Scripps ambulatory surgery center. Across parking lot from Scripps Hospital with ER, OR’s, Labor and Delivery. It is located just off Interstate 5 at Santa Fe Drive, and a half-mile from Swami’s Beach. Contact Kristi or Myra 760-753-8413. View Space on Website:www.eisenhauerobgyn. com. Looking for compatible practice types. OFFICE SPACE FOR RENT: Multiple exam rooms in newer, remodeled office near Alvarado Hospital and SDSU. Convenient freeway access and ample parking. Price based on usage. Contact Jo Turner (619) 733-4068 or jo@siosd.com. OFFICE SPACE / REAL ESTATE WANTED MEDICAL OFFICE SUBLET DESIRED: Solo endocrinologist looking for updated bright office space in Encinitas or Carlsbad to share with another solo practitioner. Primary care, ENT, ob/ gyn would be compatible fields. I would ideally have one consultation room and one small exam room but I am flexible. If the consultation room was large enough I could have an exam table in the same room and forgo the separate exam room. I have two staff members that will need a small space to answer phones and complete tasks. Please contact 858-633-6959. MEDICAL OFFICE SPACE SUBLET DESIRED NEAR SCRIPPS MEMORIAL LA JOLLA: Specialist physician leaving group practice, reestablishing solo practice seeks office space Ximed building, Poole building, or nearby. Less than full-time. Need procedure room. Possible interest in using your existing billing, staff, equipment, or could be completely separate. If interested, please contact me at ljmedoffice@ yahoo.com. MEDICAL EQUIPMENT / FURNITURE FOR SALE FOR SALE: Nuclear medicine equipment including Ge Millennium MG system, hot lab, and sources Cs-137. Rod Std 2. Cs-137. DCRS 3. Cs-137. Spot 4. Co-57. Flood sheet. Please contact us at 760-730-3536 if interested in purchasing, pricing or have any questions. Thank you.

NON-PHYSICIAN POSITIONS AVAILABLE INTERVENTIONAL PHYSIATRY/PHYSICAL MEDICINE SPECIALIST POSITION AVAILABLE: Practice opportunity for part time interventional physiatry/physical medicine specialist with well-established orthopaedic practice. Position includes providing direct patient evaluation/care of spine and musculoskeletal cases, coordinating PMR services with all referring providers. Must have excellent interpersonal and communication skills. Office located near Alvarado Hospital. Onsite digital x-ray and emr. Interested parties, please email lisas@sdsm.net EXECUTIVE DIRECTOR, STUDENT HEALTH AND COUNSELING SERVICES: California State University San Marcos (CSUSM) has announced a national search for a visionary and collaborative leader to serve as Executive Director of Student Health and Counseling Services. Selected candidate will be appointed into an Administrator III OR Administrator IV. Appointment will be determined by education and experience. Selected candidate with an M.D. will be appointed as Administrator IV, and selected candidate without an M.D. will be appointed as Administrator III. For position specifications, benefits summary and to apply, please visit our website at https://apptrkr.com/1852486 FINANCE DIRECTOR: San Diego Sports Medicine and Family Health Center is hiring a full-time Financial Director to manage financial operations. Primary responsibilities include monitoring of income, expenses and cash flow, reconciling bank statements, supervision of accounts payable, oversee billing department, oversee accounts receivables, payments and adjustments, prepare contracts, analyze data, prepare financial reports, prepare budgets, advise on economic risks and provide input on decision making. MBA/Master’s and 5+ years relevant work experience preferred. Excellent references and background check required. Salary commensurate with skills and experience. To apply, please send resume to Jo Baxter, Director of Operations jobaxter@sdsm.com NON-PHYSICIAN POSITIONS WANTED MEDICAL OFFICE MANAGER/CONTRACTS/ BILLING PERSON: MD specialist leaving group practice, looking to reestablish solo private practice. Need assistance reactivating payer contracts, including Medicare. If you have that skill, contact ljmedoffice@yahoo.com. I’m looking for a project bid. Be prepared to discuss prior experience, your hourly charge, estimated hours involved. May lead to additional work. PRODUCTS / SERVICES OFFERED DATA MANAGEMENT, ANALYTICS AND REPORTING: Rudolphia Consulting has many years of experience working with clinicians in the Healthcare industry to develop and implement processes required to meet the demanding quality standards in one of the most complex and regulated industries. Services include: Data management using advanced software tools, Use of advanced analytical tools to measure quality and process-related outcomes and establish benchmarks, and the production of automated reporting. (619) 913-7568 | info@rudolphia. consulting | www.rudolphia.consulting

SanDiegoPhysician.org 19

PERSONAL & PROFESSIONAL DEVELOPMENT

Nurturing Physician Wellness in the Age of Covid-19 By Helane Fronek, MD, FACP, FACPh

PHYSICIANS WERE STRUGGLING WITH EPIDEMIC levels of burnout — before a pandemic upended our lives and strained our coping mechanisms. Anxiety has soared as we fear for our and our loved ones’ health, the future of our careers, our financial foothold, and what challenges await. Our practices have been altered, creating an array of new concerns for physicians in the Covid-19 era. Telehealth brings worry we will miss something or unwisely delay treatment. If we’re not on the front lines, we feel guilty we aren’t contributing more. Those on the front lines fear bringing the virus home or falling ill themselves. The horror of seeing so many die, often without the comfort of family at their bedside, dehumanizes medical care. This threatens our ability to provide compassionate care and go forward in our lives with purpose, meaning, and the potential for joy. What can we hold onto in this time of tremendous uncertainty and fear? Affirming who we are as individuals and professionals helps anchor us in our core values and deeply held beliefs. Reminding ourselves of our strengths provides confidence that we already have significant abilities to meet the coming challenges. Remembering what internal and external resources helped us overcome previous challenges offers a roadmap for this time as well. Recognizing our successes with other difficult situations fortifies our sense of competence and wholeness. It is also crucial that we acknowledge the emotions arising within and washing over us. Unless we have experienced war or another catastrophic event, this level of medical need and 20

May/June 2020

uncertainty is new for us. Anger, fear, sadness, helplessness, despair, and anxiety are pervasive among physicians. Previously tolerable issues now feel overwhelming. Our profession must discard its antiquated and harmful belief that attending to our emotional needs is a sign of weakness. Refusing to feel cuts us off from our own humanity and hampers our ability to respond with compassion. Turning our backs on the parts of ourselves that are hurting, struggling to find footing amid chaos and uncertainty, and feeling the loss of humanity in this experience perpetuate our suffering. Accepting our true feelings reconnects us with ourselves, where we will find strengths and beliefs to fortify us and illuminate ways to take

meaningful action. Whether sheltering at home, on the front lines, or somewhere in between, we must choose to prioritize our own wellbeing. Exercise and mindfulness activities relieve anxiety and stress. Creating a schedule for each day provides structure and focus. Creative forms of interpersonal connection abound, easing our isolation. Spiritual connection with a source of higher power can comfort and strengthen us. The California Medical Association offers Care 4 Caregivers, free coaching or peer support services for physicians. And welcoming and feeling our emotions should be considered an essential daily activity. Our emotions arise from the precious parts of ourselves that hold our core values, principles, and ethical standards. Feeling our emotions asserts their importance and reaffirms our commitment to honoring the sacredness of life. It is these ideals that will sustain us and allow us to care for ourselves and others as we live through this unprecedented time. 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.com.

2020 pledge drive Champions for Health is dedicated to providing access to critically needed healthcare for uninsured, low-income residents of San Diego County who would otherwise face insurmountable barriers to care. We recruit, mobilize, and support hundreds of volunteer physicians and other professionals to provide free specialty healthcare. Since 2008, Project Access has facilitated care for 6,500+ uninsured patients by providing 14,000 free consultations and 1,563 free surgeries â&#x20AC;&#x201D; all thanks to the dedication, time and talent of our volunteer specialty healthcare physicians and healthcare professionals. For every $1 spent on program expenses, we provide $2.23 in contributed healthcare services â&#x20AC;&#x201D; a return on investment of 223%! During this time of crisis, your support of the patients of Project Access is more important than ever. Join our pledge drive with a one-time gift or a recurring monthly donation, both of which are tax deductible.

Please go to www.championsforhealth.org and click on the donate button! SanDiegoPhysician.org 21

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