May 2021 by San Diego Physician

Official Publication of SDCMS MAY 2021

Dr. Akilah Weber San Diego’s Newest State Assemblymember

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Contents MAY

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

VOLUME 108, NUMBER 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 AT-LARGE DIRECTORS #1: Thomas J. Savides, MD #2: Paul J. Manos, DO #3: Irineo “Reno” D. Tiangco, MD #4: Miranda R. Sonneborn, MD #5: Stephen R. Hayden, MD (Delegation Chair) #6: Marcella (Marci) M. Wilson, MD #7: Karl E. Steinberg, MD #8: Alejandra Postlethwaite, MD ADDITIONAL VOTING DIRECTORS Young Physician Director: Brian Rebolledo, MD Retired Physician Director: Mitsuo Tomita, MD Resident Director: Nicole Herrick, MD Medical Student Director: Lauren Tronick CMA TRUSTEES Robert E. Wailes, MD William T-C Tseng, MD, MPH Sergio R. Flores, MD

Features

San Diego’s Dr. Akilah Weber Is the Newest Member of the California State Assembly By SDCMS Staff

Mysterious Ailment, Mysterious Relief: Vaccines Help Some COVID Long Haulers By Will Stone

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: Legal Issues • Federal Issues • Health Insurance

The Shock and Reality of Catching COVID After Being Vaccinated By Steven Findlay

‘Breakthrough’ COVID Infection Rates As Expected By Kristina Fiore

The Neurology of Handwashing By James Santiago Grisolia, MD

Early Reports of UK Variant’s Lethality Appear Greatly Exaggerated By Molly Walker

Busy Bees By Adama Dyoniziak

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May 2021

LEGAL ISSUES

CMA Files Legal Brief with California Supreme Court in Important Peer Review Case THE CALIFORNIA MEDICAL ASSOCIATION (CMA) is involved as amicus curiae in an important case before the California Supreme Court that will have lasting ramifications on a physician’s ability to challenge peer review hearing officers for impermissible bias. The plaintiff in this case — Natarajan v. Dignity Health — is a hospitalist who lost his privileges after a peer review hearing. In his appeal, he did not dispute the factual findings and conclusions of the peer review panel, but rather claims that the hearing officer in his peer review proceeding was biased and should have been disqualified. The appellate court ruled against the plaintiff, holding that the “fair procedure” standard forbids only a direct financial interest in the outcome of the proceeding and the appearance of bias is not sufficient to disqualify a peer review hearing officer. Significantly, the appellate court’s ruling rejects precedential case law on this issue established in the Yaqub case from 2004. There, the court adopted a fact-specific inquiry into the impartiality of a hearing officer based on the potential for bias, harmonizing the “fair procedure” standard with the language of the peer review statute, Business & Professions Code §809, et. al. CMA filed an amicus brief in this case, which sought to provide the court with the appropriate background, procedural understanding, and evidentiary foundation to fashion a robust and clear hearing-officer-impartiality standard. Our brief also suggested guiding principles for crafting such a standard. CMA’s brief argues that the Yaqub court’s approach to analyzing hearing officer bias is the proper interpretation and application of a legal standard for hearing officer impartiality. The brief discusses the ways in which the appellate court’s “actual bias” standard is too narrow, and unmoored from both the legislature’s intent in enacting the peer review statute and the current healthcare landscape, in which large hospital systems are a significant presence. Unlike other briefings that have been submitted, CMA, as the sponsor of the bill that created the peer review statute, presents to the court a deep historical and empirical understanding of the role of hearing officers in the peer review process. CMA’s brief concludes by underscoring the importance of a robust impartiality standard that will ensure competent practitioners are shielded from arbitrary and discriminatory review while also upholding the protection of the public. The case is currently pending before the court.

FEDERAL ISSUES

2% Medicare Sequester Cuts Delayed Through End of 2021 ON APRIL 13, AFTER RETURNING from a two-week recess, the U.S. House of Representatives’ first order of business was to overwhelmingly pass HR 1868 to pause the 2% Medicare sequestration payment cuts to physicians. The bill, passed by the House in a 384 to 38 vote, had already passed 90 to 2 in the U.S. Senate. The law was signed by President Joe Biden on April 15, and extended the pause on the Medicare reimbursement cut through the end of 2021 because of the ongoing COVID-19 pandemic. The cost of the pause will be offset by extending the sequester one more year, into 2031. The moratorium on the sequestration cuts expired on March 31, 2021, but the Centers for Medicare and Medicaid Services held physician claims until Congress finalized the legislation so that all physicians could be paid at the higher rate. The House had passed HR 1868 a few weeks ago. However, the Senate made changes that had to be reconciled with a second vote in the House. The Senate rejected the House provision that also stopped the additional Medicare 4% payment cuts projected for 2022. The California Medical Association and the American Medical Association will be advocating for Congress to stop those cuts later this year.

FEDERAL ISSUES

HHS Proposes Rule to Strengthen the Federal Title X Planning Program

THE BIDEN ADMINISTRATION LAST week began to undo a Trump-era “gag rule” that bans physicians in the Title X program from telling women how they can safely and legally access abortion. The U.S. Department of Health and Human Services (HHS) has proposed readopting regulations established by HHS in 2000, with modifications that would “strengthen the program and ensure access to equitable, affordable, client-centered, quality family planning services for all clients, especially for low-income clients.”

The California Medical Association (CMA) had strongly opposed Trump’s gag rule since it was first proposed in 2018, arguing that it would interfere with the physician-patient relationship, undermine established medical access, and prevent low-income people from accessing the full range of reproductive healthcare. The gag rule barred qualified family planning providers that provide abortions or abortion referrals from participating in the $286 million federal Title X family planning program. It also eliminated current

HEALTH INSURANCE

Covered CA Opens Special Enrollment Period So Enrollees Can Benefit from New Stimulus Subsidies

requirements that Title X sites offer a broad range of medically approved family planning methods and nondirective pregnancy options counseling; and directed new funds to faith-based and other organizations that promote fertility awareness and abstinence as methods of family planning, rather than the full range of evidencebased family planning methods. Groups receiving money under the Title X program, which in California serves 1 million low-income women, were already prohibited from performing abortions with those funds. Under Trump’s gag rule, federally funded family planning clinics were required to maintain a “clear physical and financial separation” between services funded by the government and any organization that provides abortions or abortion referrals. Established in 1970, Title X is the sole federal program dedicated to funding family planning services for low-income individuals. Title X supports the delivery of family planning and related services including contraception, STD prevention and treatment, pregnancy tests, and life-saving cancer screenings. It plays a vital role in the nation’s public health safety net by ensuring that timely, safe, and evidence-based care is available to women, men and adolescents, regardless of their financial circumstances.

THE $1.9 TRILLION STIMULUS BILL RECENTLY SIGNED BY PRESIDENT Joe Biden — known as the American Rescue Plan — increases and expands eligibility for Affordable Care Act (ACA) premium subsidies for people enrolled in marketplace health plans. It also expands access to federal premium subsidies, making them available to people earning more than four times the federal poverty level (FPL) for the first time. To help consumers benefit from these new subsidies, Covered California launched a special open enrollment period starting April 12, 2021, which will continue through the end of 2021. The U.S. Department of Health and Human Services has also created a special open enrollment window for those seeking coverage through Healthcare.gov, which will remain open through Aug. 15, 2021. Consumers can find out how much of a subsidy they might be eligible for using the Kaiser Family Foundation’s subsidy calculator.

SanDiegoPhysician.org 3

SAN DIEGO’S

Dr. Akilah Weber IS THE NEWEST MEMBER OF THE CALIFORNIA STATE ASSEMBLY

Weber’s Landslide Election Is a Huge Victory for California’s Physicians BY SDCMS STAFF

May 2021

DR. AKILAH WEBER IS THE NEWEST MEMBER OF THE California State Assembly. Dr. Weber, a San Diego County Medical Society member, is now only the third physician currently serving in the entire California Legislature. One of those three physician-legislators, State Senator Richard Pan, MD, is termed out of the legislature after next year. Dr. Weber’s election was a top priority for SDCMS and for the California Medical Association (CMA). SDCMS raised $20,000 from its members while CMA raised an additional $10,000 from other physician members across the state and poured over $200,000 into an independent expenditure effort to support Weber’s candidacy. “I am beyond ecstatic at the victory of Dr. Weber,” says Dr. Toluwalase (Lase) A. Ajayi, secretary and incoming president-elect of SDCMS. “She is a phenomenal physician and person, and exactly the leader we need right now. I sincerely hope her victory is a trend that continues. I cannot wait to see the change she has been working toward continue with this victory.” Weber’s landslide victory in the April 6 special election was unexpected, as she won outright with a majority of the votes in the primary. She avoided a runoff election tentatively scheduled for June, which would have been held if no candidate earned more than 50% of the votes cast. Weber captured almost 52% of the vote, with 33,197 votes of the 64,189 ballots cast. She was one of four Democratic candidates for this heavily Democratic state legislative seat, and Republican Marco Contreras ran as well. Contreras finished second in the primary with 33.4% of the vote. Surprisingly, the Democrat who was considered Weber’s most serious Democratic challenger, labor union official Leticia Munguia, who was the beneficiary of approximately $500,000 in independent expenditure campaign spending from labor and other interest groups, finished a very distant third with only 8.24% percent of the vote. Democrats Shane Parmely won 5.07% and Aeiramique Glass received 1.28% of ballots cast. During the campaign, Weber captured a number of notable endorsements, including California Senate President Pro Tempore Toni Atkins, San Diego Mayor Todd Gloria, the California Democratic Party, California State Treasurer Fiona Ma, and the California Democratic Women’s Legislative Caucus, among others. In 2018, Weber became the first African-American elected to La Mesa’s City Council, which made her the only candidate in the race holding elected office. Weber becomes only the second African-American woman to currently serve in the California State Assembly. There is currently only one African-American woman in the California State Senate.

“I am beyond ecstatic at the victory of Dr. Weber. She is a phenomenal physician and person, and exactly the leader we need right now.” — DR. TOLUWALASE (LASE) A. AJAYI, SDCMS INCOMING PRESIDENT-ELECT

Dr. Weber is also the founder and director of the Pediatric & Adolescent Gynecology Division at Rady Children’s Hospital and heads the adolescent gynecology program at UC San Diego Health. She also is an assistant clinical professor at UC San Diego. “Dr. Weber’s presence in the California Legislature will have a huge significance for California’s physician and healthcare community,” says Dr. Robert Hertzka, chair of SDCMS’s Legislative Committee. “Her real-world experience and extensive medical expertise will be invaluable in helping shape California’s healthcare policy. The legislature needs more people like Dr. Akilah Weber, who brings a badly needed perspective to major public policy decisions that affect so many Californians.” “Dr. Weber is a very talented rising star who we and many others expect to have a big impact in Sacramento for years to come,” adds Dr. Hertzka. The 79th Assembly District seat opened in January after Weber’s mother, former Assemblymember Shirley Weber, who had held the post for a decade, was appointed to serve as California’s Secretary of State. Dr. Weber grew up in the assembly district she was elected to serve and she and her husband, Dennis, live in La Mesa with their boys, Kadir and Jalil, and their rescue dog, Shaka. The 79th District includes parts of southeastern San Diego, Bonita, Chula Vista, La Mesa, Lemon Grove, and National City. SanDiegoPhysician.org 5

COVID-19

Mysterious Ailment, Mysterious Relief Vaccines Help Some COVID Long Haulers BY WILL STONE

N ESTIMATED 10% TO 30%

of people who get COVID-19 suffer from lingering symptoms of the disease, or what’s known as “long COVID.” Judy Dodd, who lives in New York City, is one of them. She spent nearly a year plagued by headaches, shortness of breath, extreme fatigue, and problems with her sense of smell, among other symptoms. She said she worried that this “slog through life” was going to be her new normal. 6

May 2021

Everything changed after she got her COVID vaccine. “I was like a new person. It was the craziest thing ever,” Dodd says, referring to how many of her health problems subsided significantly after her second shot. As the U.S. pushes to get people vaccinated, a curious benefit is emerging for those with this post-illness syndrome: Their symptoms are easing and, in some cases, fully resolving after vaccination. It’s the latest clue in the immunological puzzle of long COVID, a still poorly understood condition that leaves some

who get infected with wide-ranging symptoms months after the initial illness. The notion that a vaccine aimed at preventing the disease may also treat it has sparked optimism among patients, and scientists who study the post-illness syndrome are taking a close look at these stories. “I didn’t expect the vaccine to make people feel better,” says Akiko Iwasaki, an immunologist at the Yale School of Medicine who’s researching long COVID. “More and more, I started hearing from people with long COVID having

blood samples to study their immune response. There are several leading theories for why vaccines could alleviate the symptoms of long COVID: It’s possible the vaccines clear up leftover virus or fragments, interrupt a damaging autoimmune response, or in some other way “reset” the immune system. “It’s all biologically plausible and, importantly, should be easy to test,” says Dr. Steven Deeks of the University of California, San Francisco, who is also studying the long-term impacts of the coronavirus on patients.

their symptoms reduced or completely recovering, and that’s when I started to get excited because this might be a potential cure for some people.” While promising, it’s still too early to know just how many people with long COVID feel better as a result of being vaccinated, and whether that amounts to a statistically meaningful difference. In the meantime, Iwasaki and other researchers are beginning to incorporate this question into ongoing studies of long haulers by monitoring their symptoms pre- and post-vaccination, and collecting

Patient Stories Offer Hope Before getting the vaccine, Dodd, who’s in her early 50s, said she felt as if she had aged 20 years. She had trouble returning to work, and even simple tasks left her with a crushing headache and exhaustion. “I’d climb the subway stairs and I’d have to stop at the top, and take my mask off just to get air,” Dodd says. After she got her first dose of the Pfizer vaccine in January, many of Dodd’s symptoms flared up — so much so that she almost didn’t get her second dose. But she did — and a few days later, she noticed her energy was back, breathing was easier, and soon even her problems with smell were resolving. “It was like the sky had opened up. The sun was out,” she says. “It’s the closest I’ve felt to pre-COVID.” In the absence of large studies, researchers are culling what information they can from patient stories, informal surveys, and clinicians’ experiences. For instance, about 40% of the 577 longCOVID patients contacted by the group Survivor Corps said they felt better after getting vaccinated. Among the patients of Dr. Daniel Griffin at Columbia University Medical Center in New York, “brain fog” and gastrointestinal problems are two of the most common symptoms that seem to resolve post-vaccination. Griffin, who is running a long-term

study of post-COVID illness, initially estimated that about 30% to 40% of his patients felt better. Now, he believes the number may be higher, as more patients receive their second dose and see further improvements. “We’ve been sort of chipping away at [long COVID] by treating each symptom,” he says. “If it’s really true that at least 40% of people have significant recovery with a therapeutic vaccination, then, to date, this is the most effective intervention we have for long COVID.” A small UK study, not yet peer reviewed, found about 23% of long-COVID patients had an “increase in symptom resolution” post-vaccination, compared with about 15% of those who were unvaccinated. But not all clinicians are seeing the same level of improvement. Clinicians at post-COVID clinics at the University of Washington in Seattle, Oregon Health & Science University in Portland, National Jewish Health in Denver, and the University of Pittsburgh Medical Center told NPR and KHN that, so far, a small number of patients — or none at all — have reported feeling better after vaccination, but it wasn’t a widespread phenomenon. “I’ve heard anecdotes of people feeling worse, and you can scientifically come up with an explanation for it going in either direction,” says UCSF’s Deeks. Why Are Patients Feeling Better? There are several theories for why vaccines could help some patients — each relying on different physiological understandings of long COVID, which manifests in a variety of ways. “The clear story is that long COVID isn’t just one issue,” says Dr. Eric Topol, director of the Scripps Research Translational Institute, which is also studying long COVID and the possible therapeutic effects of vaccination. Some people have fast resting heart rates and can’t tolerate exercise. Others suffer primarily from cognitive problems, or some combination of symptoms like SanDiegoPhysician.org 7

COVID-19

The clear story is that long COVID isn’t just one issue.” — DR. ERIC TOPOL, DIRECTOR, SCRIPPS RESEARCH TRANSLATIONAL INSTITUTE

exhaustion, trouble sleeping, and issues with smell and taste, he says. As a result, it’s likely that different therapies will work better for some versions of long COVID than others, says Deeks. One theory is that people who are infected never fully clear the coronavirus, and a viral “reservoir,” or fragments of the virus, persist in parts of the body and cause inflammation and long-term symptoms, says Iwasaki, the Yale immunologist. According to that explanation, the vaccine might induce an immune response that gives the body extra firepower to beat back the residual infection. “That would actually be the most straightforward way of getting rid of the disease, because you’re getting rid of the source of inflammation,” Iwasaki says. Griffin at Columbia Medical Center said this “viral persistence” idea is supported by what he’s seeing in his patients and hearing from other researchers and clinicians. He says patients seem to be improving after receiving any of the COVID vaccines — generally about “two weeks later, when it looks like they’re having what would be an effective, protective response.” Another possible reason that some patients improve comes from the understanding of long COVID as an autoimmune condition in which the body’s immune cells end up damaging its own tissues. A vaccine could hypothetically kick 8

May 2021

into gear the “innate immune system” and “dampen the symptoms,” but only temporarily, says Iwasaki, who has studied the role of harmful proteins, called autoantibodies, in COVID. This self-destructive immune response happens in a subset of COVID patients while they are ill, and the autoantibodies produced can circulate for months later. But it’s not yet clear how that may contribute to long COVID, says John Wherry, director of the Institute for Immunology at the University of Pennsylvania. Another theory is that the infection has “miswired” the immune system in some other way and caused chronic

inflammation, perhaps like chronic fatigue syndrome, Wherry says. In that scenario, the vaccination might somehow “reset” the immune system. With more than 77 million people fully vaccinated in the U.S., teasing apart how many of those with long COVID would have improved even without any intervention is difficult. “Right now, we have anecdotes; we’d love it to be true. Let’s wait for some real data,” says Wherry. Will Stone is a health journalist for NPR and KHNews, where this article first appeared, and is also part of a partnership between those two organizations.

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COVID-19

The Shock and Reality of Catching Covid After Being Vaccinated BY STEVEN FINDLAY

OBIN HAUSER, a pediatri-

cian in Tampa, Florida, got COVID in February. What separates her from the vast majority of the tens of millions of other Americans who have come down with the virus is this: She got sick seven weeks after her second dose of the Pfizer-BioNTech vaccine. “I was shocked,” Hauser says. “I thought: ‘What the heck? How did that happen?’ I now tell everyone, including my colleagues, not to let their guard down after the vaccine.” As more Americans every day are inoculated, a tiny but growing number are contending with the disturbing experience of getting COVID despite having had one shot, or even two. The Centers for Disease Control and Prevention reported that at least 5,800 people had fallen ill or tested positive for the coronavirus two weeks or more after they completed both doses of the PfizerBioNTech or Moderna vaccine. A total of about 78 million and quickly rising number of Americans are now fully vaccinated. These so-called breakthrough infections occurred among people of all ages. Just over 40% were in people age 60 or older, and 65% occurred in women. Twenty-nine percent of infected people reported no symptoms, but 7% were hospitalized and just over 1%, 74 people, died, according to the CDC. Public health officials have said breakthrough infections were expected, since manufacturers have warned loudly and often that the vaccines are not 100% protective. The Pfizer and Moderna 10

May 2021

versions have consistently been shown to be above 90% effective, most recently for at least six months. Studies have also shown they are nearly 100% effective at ensuring that the small fraction of vaccinated patients who do contract the virus will not get severe cases or require hospitalization. Still, people are usually shocked and befuddled when they become the rare breakthrough victim. After months of fear and taking precautions to avoid contracting COVID, they felt safe once they got their shots. Hauser, 52, had stayed home from work to care for her kids, ages 21 and 16, both of whom had contracted the virus. She was confident she was protected. She was also taking care of her father, who has cancer. “It’s a minor miracle that I didn’t infect him before I realized I, too, was sick,” Hauser says. In keeping with the virus’s fickle behavior, Hauser’s husband, Brian, who had not yet been vaccinated, also never got infected. Masha Gessen, a staff writer for The New Yorker, completed the two-shot process in mid-February. A month later, Gessen fell ill and tested positive after both Gessen’s son and partner, Julia Loktev, had weathered bouts of COVID. The experience was “unsettling, even a bit traumatic,” Gessen said. Loktev’s illness occurred six days after her first dose. “The psychological effect of getting the virus after a year of being very, very careful and getting vaccinated got to me,” Gessen, 54, said in an interview with KHN. “It took me about three weeks to feel back to normal.” Gessen wrote about the experience in April in The New Yorker.

Dr. Kami Kim, director of the infectious disease and international medicine division at the University of South Florida in Tampa, said physicians are equally disturbed when these cases crop up. “All this, while anticipated, is definitely confusing and frustrating for people, both doctors and patients,” Dr. Kim says. “We are all learning on the go and making judgments about what’s best for our patients — and ourselves.” Vaccine manufacturers said the number of breakthrough cases reported by the CDC was not surprising. Moderna’s latest analysis of its vaccine clinical trial data shows 900 people got COVID after being vaccinated, consistent with 90% or more efficacy for the vaccine, company spokesperson Colleen Hussey says. Pfizer spokesperson Jerica Pitts says the company would monitor trial participants for two years after their second dose to learn more about the Pfizer vaccine’s protection against COVID. In their reporting, the CDC is defining a breakthrough case strictly as illness or a positive test two weeks or more after full vaccination. But tens of thousands of people who have had a first shot or are short of two weeks after their second shot are also getting infected. Pfizer and Moderna report data showing up to 80% protection from infection two weeks or so after the first shot. But most experts believe protection ranges widely, from 50% to 80%, depending on the length of time after the shot and the individual variation that exists with any vaccine. The second shot boosts immunity further but not for a few days, at minimum, and then builds over two weeks. And again, this could vary from person to person. Leslie Fratkin, 60, a freelance photographer in New York City, got her second Pfizer dose March 12. So she was surprised when clear symptoms of COVID showed up March 24 and she was quite sick at home for three days. “You can’t print the words I uttered at the time,” she says. The CDC advises people who get COVID after a first shot to get the second dose

soon after recovery, with no minimum wait time specified. That’s a change from prevalent advice back in December and January, when some state health departments advised people to wait 90 days after a bout of COVID to get a first or second shot, and especially a second shot. Driving this important change is mounting evidence from studies and experience indicating that immunity to infection conferred by the vaccines is stronger and possibly more “stable” over time than immunity derived from COVID infection. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota in Minneapolis, says further research and better public health guidance are urgently needed. For example, is a second dose even needed for people who get COVID after the first dose, or does the infection itself serve as enough of an immune system booster? And if a second shot is recommended, what’s the optimal waiting period before getting it? “These are important practical questions that need to be prioritized,”

Osterholm says. “We are sort of flying blind now.” Other countries have handled the second dose rollout differently. In Great Britain, health authorities delayed it up to 12 weeks, to stretch vaccine supply and prioritize getting at least one shot into more people’s arms more quickly. In Canada, a government vaccine advisory committee recommended April 7 that second doses be delayed up to four months. At two press briefings, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases and a COVID adviser to President Joe Biden, said that the number of breakthrough cases in the U.S. so far is not cause for alarm and that the administration will continue to monitor these instances closely. One important line of investigation is how big a role variants or mutated versions of the initial coronavirus play in these breakthrough cases. Research suggests the current vaccines may be somewhat less effective against some new variants. Martha Sharan, a CDC spokesperson,

said the agency is now urging states to use genetic sequencing to test virus specimens from patients with breakthrough cases to identify variants. In Washington State, for instance, eight variants were detected in the genetic sequencing of nine breakout cases reported through April 3. The Biden administration announced $1.7 billion in spending would be directed from the COVID relief bill to help the CDC, states, and other jurisdictions more effectively detect and track variants by scaling genomic sequencing efforts. The CDC also has launched a national COVID vaccine breakthrough database in which state health departments can store and manage data. “We are behind on sequencing samples,” says Osterholm. “That will give us valuable information.” Steven Findlay, a contributing writer at Kaiser Health News, where this story first appeared, came down with COVID 30 days after his first dose and 24 hours after his second dose. KHN senior correspondent JoNel Aleccia contributed to this story. SanDiegoPhysician.org 11

COVID-19

‘Breakthrough’ COVID Infection Rates As Expected Low Numbers of Breakthrough Infections Are Reported Among the Fully Vaccinated BY KRISTINA FIORE

HILE FEDERAL DATA

on breakthrough COVID-19 infections following vaccination only recently became available, a handful of states and independent health systems have put forward their own analyses, and the findings are reassuring: The rate of breakthrough infections are as expected. Michigan was among the first states to report numbers last week: 246 people who were fully vaccinated (more than 2 weeks out from their second dose) came down with COVID from January to March. Three of those people died. That was out of a total of 1.8 million people in the state who were fully vaccinated at that time, according to the Detroit Free Press. State health department spokesperson Lynn Sutfin told the Free Press that some of those cases may still be excluded after they’re fully adjudicated against other CDC criteria, such as not having a positive COVID test less than 45 days prior to their post-vaccination positive. Data from other states suggest similar 12

May 2021

low rates of breakthrough infection. Oregon, for instance, reported 168 cases of breakthrough infection among more than 700,000 fully vaccinated people as of April 2, with 19 hospitalizations and three deaths. Minnesota reported 89 cases among 800,000 fully vaccinated people as of March 22, with no deaths. Other states that have reported breakthrough cases include Washington (102 cases, eight hospitalizations, two deaths among one million fully vaccinated); South Carolina (155 cases among more than 560,000 fully vaccinated); and Nevada (58 cases among more than 500,000 fully vaccinated). The CDC recently reported national data, finding 5,800 breakthrough infections, with 396 requiring hospitalization and 74 deaths. The agency has a team that has been monitoring these infections since February, according to the Washington Post. During a White House press briefing, National Institute of Allergy and Infectious Diseases Director Dr. Anthony Fauci said he didn’t have any concerns about breakthrough infections after vaccination. More than 74 million people in the U.S. have been fully vaccinated as of April 13, according to the CDC’s vaccination tracker. “That number of individuals who were breakthrough infections is not at all incompatible with a 90-plus percent vaccine efficacy,” Fauci says. “I don’t think that there needs to be concern about any shift or change in the efficacy of the vaccine.” “There’s nothing there yet that’s a red flag,” Fauci says. “We’re obviously going to keep an eye on that very, very carefully.” Evidence from health systems also supports low rates of vaccine breakthrough. According to a letter published March 23 in The New England Journal of Medicine, the majority of

post-vaccination infections among healthcare workers at UC San Diego and UCLA occurred before workers were fully vaccinated. Only seven infections among 36,659 fully vaccinated healthcare workers occurred more than two weeks after the second dose, researchers reported. David Perlin, PhD, chief science officer for Hackensack Meridian Health in New Jersey, told MedPage Today that among about 25,000 healthcare workers, only about 100 have tested positive for COVID-19 after vaccination, and most infections were mild. Few were hospitalized and none had severe illness, he says. “It’s about the level we expected,” Perlin says, adding that there hasn’t been any clear pattern as to whether breakthrough infection is being driven by a particular variant — notably, the B.1.351 or “South African” variant, which has been shown to evade vaccine immunity to some extent. “Among the vaccinated individuals who were virus-positive, we see the occasional E484K mutation, but there’s no correlation” with breakthrough infection, Perlin says. “We were concerned about that at first, but with the analysis we’ve done so far, that does not seem to be the case.” Perlin noted that as with the rest of the country, the B.1.1.7 variant is now dominant in New Jersey and appears to be outcompeting other variants. “N501Y [the key mutation in B.1.1.7] seems very robust and may well outcompete E484K, which has immune escape but is facing selection pressure,” Perlin says. But that doesn’t mean we should rest easy, he warned. “Once N501Y gets a foothold, it seems to move quickly, but as long as we have infection, and people mount an immune response that’s somewhat weak, there will be selection pressure” that can drive further mutation, he says. “That’s another reason that, more than ever, we need to vaccinate as quickly as possible.” Kristina Fiore leads the Enterprise & Investigative team for MedPage Today, where this article first appeared, and has been a medical journalist for the past decade.

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NEUROLOGY

The Neurology of Handwashing A Time for Pause, and for Us to Ponder a Prayer BY JAMES SANTIAGO GRISOLIA, MD

HE PANDEMIC BROKE OPEN

normal time. At first, fear echoed in our empty streets. A trip to the grocery store suddenly loomed potentially fatal, let alone working with COVID-19 patients in the hospital. Nurses, doctors, and layfolk all washed their hands too much, obsessively. While Lady Macbeth hunted that last, suspicious spot, we scoured for viral particles, deadly but unseeable. Airborne transmission clearly spread disease, but we all worried over logical offshoots: hand to eye or hand to mouth from touching surfaces, despite ambiguous data support. Handwashing became our ritual of control. Yes, masks; yes, distancing; but always handwashing: going out, coming 14

May 2021

home, touching anything, anywhere. Gloves quickly became soiled and suspicious, but handwashing remained our purification rite. Control in frightening times. The ritual came with a song: Sing “Happy Birthday” all through, twice, to get to a full 20 seconds for the full ablution. But in the midst of the COVID-19 baby bust, to whom are we singing? I tried singing “Happy Birthday, dear COVID,” but that was too dark, celebrating our scourge. So I started singing the chorus to “It’s a Small World (After All)” to myself, figuring that our very small world let the coronavirus leap like lightning from Wuhan to Milan to Tehran, then back to New York, the rest of Europe, then the

world. How small our world — the very problem! My own personal resonance echoed from childhood memories of the UNICEF pavilion from the 1964 New York World’s Fair. As children, how thrilled we were to find this old friend, again, when we finally got to Disneyland. In its first 50 years, the various Disney theme parks have played this song more than 50 million times — truly the pandemic of earworms. Since 1847, handwashing took an honorable place in Western medicine, when Ignaz Semmelweis found that it reduced childbed fever. However, the frenetic pace of 20th century hospitals rendered handwashing sporadic rather than routine. When The Joint Commission began to focus on hospital-acquired infections, it mandated handwashing between each patient contact as part of the National Patient Safety Goals in 2003. In our hospital, sanitizer dispensers bloomed almost overnight in the halls and rapidly spread to every patient room. Our handwashing culture changed abruptly. But it took COVID-19 to bring personal risk to handwashing, beyond

risk to the patient. And hospital culture changed again. Human ritual requires a fixed, stereotyped behavior, with a symbolic meaning that reduces anxiety or binds the community together. Carl Jung commented on the deep symbolism of handwashing, citing Egyptian and Old Testament sources, as well as the priest washing his hands before Catholic Mass. World Health Organization Guidelines on Hand Hygiene in Health Care cite specific times and activities when handwashing becomes mandatory in Islam, Judaism, and Sikhism, as well as in Ghana and other countries of West Africa. In religion and in literature, handwashing purifies, cleanses guilt, and removes sin or other contamination. Our busy hands grasp, pull and lift the world around us, shovel food into our mouths, caress a loved one. Consequently, the important hand claims large acreage in the sensory and motor cortices of the brain. From medi-

Carl Jung commented on the deep symbolism of handwashing, citing Egyptian and Old Testament sources, as well as the priest washing his hands before Catholic Mass. cal school we recall the ugly sensory and motor homunculi draped over the central sulcus, with hands, mouth, and tongue dwarfing the rest of the body. The somatosensory cortex boasts alternating stripes registering touch and position sense with functional connections to the corresponding motor cortex, and to visceral and emotional zones in the insula and anterior cingulate cortex. Bimanual tasks such as handwashing or opening a tight jar lid activate complex sensory and motor systems, distinct from the sum of left- and right-handed tasks. Abstract concepts like cleanliness, pu-

rity, or guilt are deeply grounded in the body reality of the somatosensory cortex. Speaking a lie lights up the mouth cortex in a different way than speaking truth, while writing a lie similarly affects the hand cortex. Ironically, washing hands removes guilt but also reduces our motivation to improve our task performance. Washing the hands resonates deeply within our brain, sounding deep notes of acting with care and integrity in a dirty, sometimes dangerous world. It’s a pause, a redirection, and withdrawal from the immediate world to engage in something higher and holier. In the hospital, 20 seconds of unbreathed song transforms handwashing into a secular prayer for the patient we’re about to see, for the patient we just saw, and for us all. Dr. Grisolía is chief of staff-elect at Scripps Mercy Hospital in San Diego and a clinical neurologist. He is also an SDCMS member and editor of San Diego Physician. This column first appeared in MedPage Today.

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INFECTIOUS DISEASE: COVID-19

Early Reports of UK Variant’s Lethality Appear Greatly Exaggerated British Observational Study Clashes with Prior Findings BY MOLLY WALKER

HE COVID-19 VARIANT

B.1.1.7, also known as the UK variant, was not associated with more severe disease in hospitalized patients versus nonvariant strains, but it does appear to be more transmissible, British researchers found. There was no association between severe disease and death and the SARSCoV-2 strain (adjusted prevalence ratio 1.02, 95% CI 0.76-1.38), though viral load was higher among patients with B.1.1.7 versus non-B.1.1.7 strains, reported Eleni Nastouli, MD, of University College London in England, and colleagues, writing in Lancet Infectious Diseases. Most research supports the idea that B.1.1.7 is more transmissible, but a report released by the British government in February examining several studies concluded, “It is likely that infection 16

May 2021

with ... B.1.1.7 is associated with an increased risk of hospitalization and death compared to infection with non[variant] viruses.” However, the government report noted that these analyses used a proxy for B.1.1.7, the S-gene target failure on PCR assay, to determine if a case was caused by a variant or not, where research by Nastouli and colleagues used genomic sequencing to find a more definitive answer. An accompanying editorial by David Lye, MBBS, of the National Centre for Infectious Diseases in Singapore, and colleagues noted this, as well as other reasons for differences. The populations differed, for example, with the earlier studies relying on a “community-based testing dataset,” whereas the current research examined hospitalized patients who included “substantially more older

adults” than the earlier studies. “Although these large community studies found a significant difference in mortality at a population level, the absolute risk increase affecting individual patients is probably minimal,” the editorialists wrote, adding that the advantages of the current research include “use of whole-genome sequencing, recruitment of hospitalized patients, and a population reflective of the spectrum of severity in whom increased virulence will have the greatest effect on outcomes.” Lye and colleagues characterized these findings as “reassuring,” but emphasized that further confirmation from larger studies was needed. Nastouli’s group examined SARSCoV-2 samples from patients at two British hospitals on or before Dec. 20, 2020. Of the 496 patients meeting inclusion

Limitations to the data include potential confounding and the possibility of missed or misclassified data.

criteria, 341 had samples that could be sequenced, and 58% of those were B.1.1.7. They defined severe disease as point 6 or higher on the WHO ordinal scale within 14 days of either a positive test or symptoms, and death was defined as within 28 days. The authors used PCR cycle threshold values and sequencing read depths as a proxy for viral load, which defined transmissibility. Compared with patients with nonB.1.1.7 strains, those with B.1.1.7 were more likely to be younger, have fewer comorbidities, and belong to an ethnic minority. Mortality was nearly identical in the two groups: 16% of patients with B.1.1.7 died within 28 days vs. 17% of those without B.1.1.7. Cycle threshold values associated with B.1.1.7 were significantly lower than with other strains, and median genomic read depths were higher.

Reported COVID-19 Symptoms No Worse With UK Variant A second study, published simultaneously in Lancet Public Health by Mark Graham, PhD, of King’s College London in England, and colleagues found no significant differences in reported symptoms or disease duration in patients with B.1.1.7 among users reporting their COVID-19 test results through an app. Test results and symptom reports were collected from Sept. 28 to Dec. 20 from about 37,000 users of the COVID Symptom Study app. Graham and colleagues put that together with data on regional proportion of infections, symptoms, disease duration, reinfection rates, and transmissibility from the COVID-19 Genomics U.K. Consortium and Public Health England. No significant association was found between the proportion of B.1.1.7 in a region and the symptoms that patients experienced. There was also no evidence of any change in total number of symptoms from people in the region with the earliest rise of B.1.1.7, and no difference in the proportion of people experiencing long COVID symptoms. Similar to other studies, Graham and colleagues found that B.1.1.7 appeared to increase the overall reproduction number by 1.35 versus the original strain. An accompanying editorial by Britta Jewell, MD, of Imperial College London, emphasized that while B.1.1.7 may have “similar symptomatology” as other strains, “improving genomic surveillance of variants will be essential to the goal of ending the pandemic.” She suggested that apps like the COVID Symptom Study app, which allows patients to monitor their symptoms and disease characteristics in real time, “could help to identify potentially important changes in symptomatology, transmissibility, mortality, or vaccine avoidance as early as possible.”

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CHAMPIONS FOR HEALTH

Busy Bees BY ADAMA DYONIZIAK

pring has sprung, and Champions for Health has been busy bees with our mobile vaccination sites. People getting vaccinated as well as the volunteer vaccinators are feeling a mix of emotions: relief, satisfaction, pride, and joy. “So many partners are coming together to support their communities, like a call to action,” says Andrew Gonzalez, director of community health. “At times, it feels like a celebration.” Champions for Health addresses the health needs of low-income, uninsured, and under-immunized populations within San Diego County by providing free flu vaccinations. We were ready for our call to action when San Diego County’s Health and Human Services Agency contracted with us to administer COVID vaccinations in health-equitypriority zip codes. COVID-19 vaccine distribution is vital in mitigating the disproportionate impacts of the virus for people of color and preventing widening racial health disparities in the future. Barriers to vaccination that disproportionately affect people of color include language, finding and making appointments, and lack of technology and transportation. With our vaccination team of consultants and our volunteer partners comprising nursing schools, nursing

May 2021

associations, physicians, and medical and pharmacy students, we have provided more than 8,500 COVID vaccinations at 118 community locations in 11 weeks, 97% of which were in health-equity zip codes. (The statewide recommendation is 40% of vaccinations.) Since CFH has always concentrated our preventive and specialty care efforts in these zip codes, we knew we had the right mix of eager medical, healthcare, and community partners to fill the COVID vaccination need. “The magic sauce that makes our vaccination efforts a success combines community partners serving their community with a client base who trusts them. Add to this our smooth process and friendly compassionate volunteers, and we have a recipe for success,” Gonzalez adds when explaining how CFH simplifies a potentially stressful process. Volunteers have commented on how professional and stress-free the process is, and how they are proud to be part of this massive effort. “I cannot express how grateful I am to have had the opportunity to partner with Champions for Health while serving the community in the most impactful way possible,” says Qiana Neff, Southwestern College School of Nursing student. “It felt very empowering to have the experience

Dr. Stony Anderson is trained by nurse Han Asoy on Pfizer vaccinations

of vaccinating others. We are making history. As a person that comes from a lower socioeconomic background, I really appreciate the vision and heart of Champions for Health. It brought me great joy to meet people in need, right where they are at. It is because of organizations such as Champions for Health that I can hang on to my hope that equity gaps will be addressed and change will come.” “It felt wonderful to be part of such a historic moment,” says Zarifulla Naseh, a Grossmont College School of Nursing student. “It is rewarding to know that I contributed to fighting and preventing the spread of this terrifying virus.” Part of this pandemic that has been the hardest to endure is the social isolation and social distancing between family members. Alona Hernandez, our COVID vaccination team medical assistant, had an unexpected surprise when she went to vaccinate senior residents at a skilled nursing facility — where her mom, Pranee Minster, lives. Hernandez had not seen her mom in a year. She cried with joy and called her children to say hi to their grandma. They hugged and walked around, the joy mixed with sadness since her 77-year-old mom did not recognize her due to her Alzheimer’s. “I think she knew it was me when she hugged me,” says Hernandez. It was all possible due to COVID vaccinations. We will continue to bring our mobile vaccination team to senior-care facilities and low-income senior housing, local

Skilled Nursing and Long-Term Care Facilities

Low-Income Senior Housing

Nonprofit Senior Care Providers

Schools of Nursing

Concord Career College Grossmont Health Occupations Center

Food Workers

Migrant Workers

Healthcare Workers

Point Loma Nazarene University Mira Costa College School of Nursing SDSU School of Nursing

Faith-Based Organizations

Seniors

Homeless Providers

Southwestern College School of Nursing USD School of Nursing

Nursing Associations San Diego National Association of Hispanic Nurses Phillipine Nurses Association of San Diego San Diego Black Nurses Association Andrew Gonzalez holds Moderna vaccines in front of a new refrigerator

farms, faith based organizations, homeless providers, and health equity zones as we prepare for eligibility to expand in April. As new vaccines arise and eligibility expands, we will continue our trend in serving the most vulnerable in the community. The dedicated physician volunteers of the San Diego County Medical Society envisioned being of service to the community, so they created the foundation, which is now Champions for Health. Please contact Adama Dyoniziak at adama.dyoniziak@championsfh.org or call (858) 3002780 to join our busy bees in transforming lives! Ms. Dyoniziak is executive director of Champions for Health.

Mira Mesa Senior Center

Physicians & Medical and Pharmacy Students San Diego County Medical Society Physicians Operation Jab (retired physicians)

Vallecitos Elementary School

Dramm Echer Farms

UCSD School of Medicine, Preventive Medicine Residency UCSD School of Pharmacy

Dr. Holly Yang vaccinates a farmworker at Catholic Charities La Posada de Guadalupe

Volunteers at Dram Echer Farms

SanDiegoPhysician.org 19

CLASSIFIEDS VOLUNTEER OPPORTUNITIES

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

CHULA VISTA VETERANS HOME SEEKS A STAFF PSYCHIATRIST: The Veterans Home of California – Chula Vista seeks a 30 hour/week Staff Psychiatrist. This facility contains three levels of care for our 300 resident veterans: independent living, assisted living and skilled nursing. A Geropsychiatry background is recommended but not mandatory. More information may be reviewed at the following URL https://www. jobs.ca.gov/CalHrPublic/Jobs/JobPosting. aspx?JobControlId=221636 or you may email Paul. D. Wagner, MD, FACP, Chief Medical Officer at paul.wagner@calvet.ca.gov. PRIMARY CARE PHYSICIAN POSITION: San Diego Family Care is seeking a Primary Care Physician (MD/DO) at its Linda Vista location to provide direct outpatient care for acute and chronic conditions to a diverse adult population. San Diego Family Care is a federally qualified, culturally competent and affordable health center in San Diego, CA. Job duties include providing complete, high quality primary care, and participation in supporting quality assurance programs. Benefits include flexible schedules, no call requirements, a robust benefits package,

May 2021

and competitive salary. If interested, please email CV to sdfcinfo@sdfamilycare.org or call us at (858) 810- 8700. FAMILY MEDICINE OR INTERNAL MEDICINE PHYSICIAN: TrueCare is more than just a place to work; it feels like home. Sound like a fit? We’d love to hear from you! Visit our website at www.truecare.org. Under the direction of the Chief Medical Officer and the Lead Physician, ensure the provision of effective quality medical service to the patients of the Health center. The physician is responsible for assuring clinical procedures are continually and systematically followed, patient flow is enhanced, and customer service is extended to all patients at all times. PUBLIC HEALTH LABORATORY DIRECTOR: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a qualified individual to work for a Level 3 Public Health Laboratory. The Public Health Services department, part of the County’s Health and Human Services Agency, is a local health department nationally accredited by the Public Health Accreditation Board and first of the urban health departments to be accredited. Public Health Laboratory Director-21226701UPH NEIGHBORHOOD HEALTHCARE MD, FAMILY PRACTICE AND INTERNISTS/ HOSPITALISTS: Physicians wanted, beautiful Riverside County and San Diego County- High Quality Family Practice for a private-nonprofit outpatient clinic serving the communities of Riverside County and San Diego County. Work Full time schedule and receive paid family medical benefits. Malpractice coverage provided. Be part of a dynamic team voted ‘San Diego Top Docs’ by their peers. Please click the link to be directed to our website to learn more about our organization and view our careers page at www.Nhcare.org. PHYSICIAN WANTED: Samahan Health Centers is seeking a physician for their federally qualified community health centers that emerged over forty years ago. The agency serves low-income families and individuals in the County of San Diego in two (2) strategic areas with a high density population of Filipinos/Asian and other lowincome, uninsured individuals — National City (Southern San Diego County) and Mira Mesa (North Central San Diego). The physician will report to the Medical Director and provide the full scope of primary care services, including but not limited to diagnosis, treatment, coordination of care, preventive care and health maintenance to patients. For more information and to apply, please contact Clara Rubio at (844) 200-2426 EXT 1046 or at crubio@samahanhealth.org.

FULL-TIME CARDIOLOGIST POSITION AVAILABLE: Seeking full time cardiologist in North County San Diego in busy established general cardiology practice. EP or Interventional also welcome if willing to hold general cardiology outpatient clinic also at least 50% of time while building practice. Please email resume to jhelmuth1220@ gmail.com. Immediate opening. 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. GENERAL FAMILY MEDICINE PHYSICIAN: to provide quality patient care to all ages of patient in a full-time traditional practice. The Physician will conduct medical diagnosis and treatment of patients using medical office procedures consistent with training including surgical assist, flexible sigmoidoscopy, and basic dermatology. The incumbent must hold a current California license and be board eligible. Bilingual Spanish/English preferred. Founded as a small family practice in Escondido 1932 by Dr. Martin B. Graybill, today we’re the region’s largest Independent Multi-specialty Medical Group. Our location is 277 Rancheros Dr., Suite 100, San Marcos, CA 92069. We are an equal opportunity employer and value diversity. Please contact Natalie Shields at (760) 291-6637/nshields@graybill.org. You may view our open positions at: https://jobs. graybill.org/. BOARD CERTIFIED OR BOARD-ELIGIBLE PHYSICIAN DERMATOLOGIST: Needed for busy, well-established East County San Diego (La Mesa) private Practice. We currently have an immediate part-time opening for a CA licensed Dermatologist to work 2-3 days per week with the potential for full-time covering for existing physicians, whenever needed. We are a full-service Dermatology office providing general, cosmetic and surgical services, including Mohs surgery and are seeking a candidate with a desire to provide general dermatology care to our patients, but willing to learn laser and cosmetics as well. If interested, please forward CV with

salary expectation to patricia@grossmontdermatology.com. OFFICE SPACE / REAL ESTATE AVAILABLE

OFFICE SPACE FOR MENTAL HEALTH PRACTIONER: Available June 1st, 2021, Mercy Medical Building, one large consultation room facing eastern mountains, large windows, recently remodeled. Includes waiting room, plenty of storage, BR, parking for patients. Walking distance to UCSD medical center and Mercy Hospital and lots of restaurants. Freeway close. Contact Randall Hicks MD, at 619-298-7135. TURNKEY MEDICAL OFFICE FOR LEASE IN BRAWLEY, CA: 6,504 SF medical office space available at 283 Main Street Brawley, CA. Office includes a large reception area, 10 exams rooms, 5 offices, 5 restrooms, X-ray room, lounge, lab space and nurses station. Located on the main road with easy access and abundant parking. Available for a short or long term lease. Please call Melissa at 310-471-2700 for more information. TURNKEY OFFICE SPACE FOR RENT NEAR ALVARADO HOSPITAL: Turnkey office space for rent. Modern, remodeled and clean. We have a little space available or a lot, depending on your needs. We are located near Alvarado hospital. Conference room, nurses station and many exam rooms, along with Doctors and Admin spaces.To inquire or to schedule a showing, please contact Jo Turner (619) 733-4068. OFFICE SPACE IN POWAY: Office in Poway. Centrally located. Close to Pomerado Hospital. Radiology, pharmacy next door. Fully furnished, WiFi included. Three exam rooms, reception area, waiting room. Half days to full time available. Ideal for specialist who wants to expand. Call Dr. Luna if interested: (619) 472-1914. KEARNY MESA OFFICE FOR SUBLEASE: Kearny Mesa area sublease in our orthopedic office which includes: onsite x-ray available, storage space, space for 1-2 employees and free parking. Can discuss internet, phones, fax line, access to printer/ copier, and more. Please contact Kaye Spotz at kspotz@synergysmg.com for more information. SAN DIEGO OFFICE NEAR SHARP FOR SUBLEASE OR TO SHARE: Rady Children’s Hospital medical office building at 7910 Frost Street. Central location near to both Rady Children’s Hospital and Sharp Memorial Hospital, between HWY 163 and I-805. Available to any specialty. The space available includes access to one office, two exam rooms and a nurse’s station / common area desk. Be close to excellent referral sources in the building and from

the hospital campus. If you have an interest or would like more information, please call (858) 278-8300 x. 2210 or email nhughes@ synergysmg.com 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) 6336959. MEDICAL EQUIPMENT / FURNITURE FOR SALE

MEDICAL EXAM TABLES FOR SALE: Unfortunately for us, we are unable to utilize our medical exam tables which are in great condition. Our practice is going in a different direction, thus the need for us to provide these tables, which were barely used. The tables are approximately 70 x 30 inches and have black padding on top of a natural pine wood frame. Each table adjusts up and has a headrest with a pillow included. We are interested in moving these out of our office as soon as possible, since we are remodeling and need the space to complete the project. We can provide a picture and schedule time to see the tables between 9am - 5pm M-Th, or 9am - 2:00pm Friday. Price is negotiable and we are just looking for a reasonable donation for the tables. We can sell individually as well, but will provide a greater incentive for taking both. Please contact Rick at 619-795-6700 or email rick@ manageyourage.com.

OBGYN RETIRING WITH OFFICE EQUIPMENT FOR DONATION: Retiring from practice and have the following office equipment for donation: speculums, biopsy equipment, lights, exam tables with electric outlets, etc. Please contact kristi.eisenhauermd@yahoo. com or (760) 753-8413. MEDICAL EQUIPMENT FOR SALE: 2 Electric tables one midmark, 3 Ultrasounds including high resolution Samsung UGHE60 with endovag and linear probes, STORTZ hysteroscopy equipment, 2 NOVASURE GENERATORS ,ENDOSEE OFFICE HYSTEROSCOPY EQUIPMENT : NEW MODEL, OLDER MODEL, Cynosure laser equipment:MONALISATOUCH (menopausal atrophy), TEMPSURE Vitalia RF (300 watts!) for incontinence, ENVI for face, Cynosure SculpSure with neck attachment for body contouring by warm sculpting. Please contact kristi.eisenhauermd@yahoo.com or 760-753-8413. FOR SALE: Nuclear medicine equipment including Ge Millennium MG system, hot lab, and sources 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 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.

PLACE YOUR AD HERE Contact Jennifer Rohr at (858) 437-3476 or Jennifer.Rohr@sdcms.org

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