May 2023

A NEW DAY Reform

of Organ

Procurement and Transplants

Editor: James Santiago Grisolia, MD

Editorial Board: James Santiago Grisolia, MD; David E.J. Bazzo, MD; Robert E. Peters, MD, PhD; William T-C Tseng, MD

Marketing & Production Manager: Jennifer Rohr

Art Director: Lisa Williams

Copy Editor: Adam Elder

OFFICERS

President: Nicholas (dr. Nick) J. Yphantides, MD, MPH

President–Elect: Steve H. Koh, MD

Secretary: Preeti S. Mehta, MD

Treasurer: Maria T. Carriedo-Ceniceros, MD

Immediate Past President: Toluwalase (Lase) A. Ajayi, MD

GEOGRAPHIC DIRECTORS

East County #1: Catherine A. Uchino, MD Hillcrest #1: Kyle P. Edmonds, MD

Hillcrest #2: Stephen R. Hayden, MD (Delegation Chair)

Kearny Mesa #1: Anthony E. Magit, MD, MPH

Kearny Mesa #2: Dustin H. Wailes, MD

La Jolla #1: Karrar H. Ali, DO, MPH (Board Representative to the Executive Committee)

La Jolla #2: David E.J. Bazzo, MD, FAAFP

La Jolla #3: Sonia L. Ramamoorthy, MD, FACS, FASCRS

North County #1: Arlene J. Morales, MD

North County #2: Christopher M. Bergeron, MD, FACS

North County #3: Nina Chaya, MD

South Bay #1: Paul J. Manos, DO

South Bay #2: Latisa S. Carson, MD

AT–LARGE DIRECTORS

#1: Rakesh R. Patel, MD, FAAFP, MBA

#2: Kelly C. Motadel, MD, MPH

#3: Irineo (Reno) D. Tiangco, MD #4: Miranda R. Sonneborn, MD

#5: Daniel Klaristenfeld, MD

#6: Alexander K. Quick, MD

#7: Karl E. Steinberg, MD, FAAFP

#8: Alejandra Postlethwaite, MD

ADDITIONAL VOTING DIRECTORS

Young Physician: Emily A. Nagler, MD

Resident: Alexandra O. Kursinskis, MD

Retired Physician: Mitsuo Tomita, MD

Medical Student: Jesse Garcia

CMA OFFICERS AND TRUSTEES

Immediate Past President: Robert E. Wailes, MD

Trustee: William T–C Tseng, MD, MPH

Trustee: Sergio R. Flores, MD

Trustee: Timothy A. Murphy, MD

AMA DELEGATES AND ALTERNATE DELEGATES

District I: Mihir Y. Parikh, MD

District I Alternate: William T–C Tseng, MD, MPH

At–Large: Albert Ray, MD

At–Large: Robert E. Hertzka, MD

At–Large: Theodore M. Mazer, MD

At–Large: Kyle P. Edmonds, MD

At–Large: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM

At–Large: David E.J. Bazzo, MD, FAAFP

At–Large: Sergio R. Flores, MD

At–Large Alternate: Bing Pao, MD

CMA DELEGATES

District I: Steven L.W. Chen, MD, FACS, MBA

District I: Franklin M. Martin, MD, FACS

District I: Eric L. Rafla-Yuan, MD

District I: Peter O. Raudaskoski, MD

District I: Ran Regev, MD

District I: Kosala Samarasinghe, MD

District I: Thomas J. Savides, MD

District I: James H. Schultz, MD, MBA, FAAFP, FAWM, DiMM

District I: Mark W. Sornson, MD

District I: Wynnshang (Wayne) C. Sun, MD

District I: Patrick A. Tellez, MD, MHSA, MPH

District I: Randy J. Young, MD

RFS Delegate: David J. Savage, MD

FEATURE

4

Monopoly Be Gone: An Announcement From HHS Has the Power to Transform Organ Procurement and Transplantation

By Greg Segal, Jennifer Erickson, MS, Donna Cryer, JD, and Bryan Sivak DEPARTMENTS

14

Gov. Newsom Wanted California to Cut Ties with Walgreens. Then Federal Law Got in the Way By Samantha Young

16

Fatigue Is Common Among Older Adults, and It Has Many Possible Causes By Judith Graham 18 Wag More

By Helane Fronek, MD, FACP, FASVLM, FAMWA

Medical Board of California Will Soon Stop Accepting, Processing Paper P&S Applications

BEGINNING JUNE 1, THE MEDICAL Board of California will no longer accept or process paper-based applications for a Physician’s and Surgeon’s (P&S) License. The Board will remove the paper application from the Board’s website on May 19.

The board began transitioning to a paperless application process on Feb. 1, 2023, when it stopped accepting and processing paper-based applications for Postgraduate Training Licenses (PTL) and the application to transition from a PTL to a P&S License.

The transition to a paperless application process helps both applicants and the board by increasing the efficiency of the review process, enhancing security, and reducing costs and impact to the environment.

Except under limited circumstances, paper applications submitted on or after June 1 will not be processed and the board

will notify the applicant they must apply through the BreEZe online system.

To apply online, you will need either a U.S. Social Security Number (U.S. SSN) or Individual Taxpayer Identification Number (ITIN). If you do not have a U.S. SSN or ITIN, please email the board at Licensing. Questions@mbc.ca.gov to request the Physician’s and Surgeon’s License Application be emailed or mailed to you. You will be required to submit the application and fees by mail only.

If your license has been cancelled and you are reapplying for a P&S License, please email the board at Licensing.Questions@mbc.ca.gov to request the Physician’s and Surgeon’s License Application be emailed or mailed to you. You will be required to submit the application and fees by mail only.

SDCMS’ Dr. Akilah Weber Announces Run for State Senate

CALIFORNIA STATE ASSEMBLYMEMBER

Dr. Akilah Weber has announced she is running for the soon-to-be vacant state Senate District 39 seat.

Weber has distinguished herself in the State Legislature as a vigorous advocate for the rights of patients and physicians. Her candidacy is a top priority for the San Diego County Medical Society and the California Medical Association. Dr. Weber is one of only three physicians currently in the State Assembly. There are no physicians in the State Senate.

Weber touted her work to improve healthcare access, the education system, and the environment during her time in the Assembly.

“As State Senator for District 39, I will continue this fight,” Weber said in a written statement. “My promise to voters is that I will always be their voice to create a stronger and healthier San Diego for all.”

Dr. Weber is running for the seat currently held by Senate President Pro Tem Toni Atkins, who will be termed out in 2024. Senate District 39 consists of nearly half of San Diego’s registered voters; the entirety of the cities of Lemon Grove, La Mesa, El Cajon, and Coronado; and unincorporated parts of San Diego County.

Previously, Weber was a La Mesa city council member and before entering politics, she was an ob-gyn with Rady Children’s Hospital and UC San Diego Health.

Meet Kendall Garvey, Your New SDCMS Membership Coordinator

“I WAS BORN AND RAISED IN MASSACHUSETTS, and while I will always be a New England girl at heart, I’ve spent the last three years making San Diego home. Not a hard thing to do here in paradise.

“You can usually find me exploring new coffee shops and grocery stores (in search for the perfect snack), taking a yoga class with friends, or adventuring in nature with a long hike or quick ocean dip.

“Prior to SDCMS, I worked in business development and marketing at a cybersecurity company. Before that, I worked in patient services at a community healthcare center in Burlington, Vermont. I am very excited to be a part of SDCMS and look forward to working with and meeting you all. If you ever see me at one of our member socials, please come up and chat! I’d love to learn more about you and how we can better support you. Or, if you’d like to talk local cafes and San Diego activities, I’m all ears!“

Kendall can be reached at kendall.garvey@sdcms.org or at (858) 565-8888.

Monopoly Be Gone

An Announcement From HHS Has the Power to Transform Organ Procurement and Transplantation

By Greg Segal, Jennifer Erickson, MS, Donna Cryer, JD, and Bryan Sivak

THE U.S. GOVERNMENT RECENTLY MADE A

transformative announcement: It is breaking up the flawed monopoly that manages the current organ procurement system, the Organ Procurement and Transplantation Network (OPTN).

This commonsense reform marks an unequivocal win for patients, and has been heralded by patient groups, equity leaders, and bipartisan Congressional offices alike.

Specifically, the announcement from HHS, unrolled as part of the OPTN Modernization Initiative, “will strengthen accountability, equity, and performance in the organ donation and transplantation system through a focus on five key areas: technology; data transparency; governance; opera-

tions; and quality improvement and innovation.”

The reforms will correct a 40-year wrong in which the government was, practically speaking, unable to promote innovation or engage best-in-class expert contractors to serve patients. As a result, the organ donation system has atrophied.

Currently more than 100,000 Americans are waiting for lifesaving organ transplants, and 33 of them — disproportionately people of color — die every day. And despite 95% of Americans supporting organ donation, federally funded research found in 2015 that the system recovers “only one-fifth of the true potential” for organ donors, adding that “these findings suggest that significant donation potential exists that is not currently being realized.”

It’s not only that snapshot that’s troubling, but also the related trends: after controlling for public health trends including tragic increases in opioid overdoses, gun deaths, suicides, and car accidents — which have increased the absolute number of organ donation-eligible deaths every year — donation rates have not even kept pace with simple population growth over the last 10 years. The organ procurement system has already plateaued and is now regressing; it is clearly in need of more structural incentives for innovation.

The historical context is elucidating: the only organization to ever hold, or even bid for, the OPTN contract since it was first awarded in 1986 is the United Network for Organ Sharing (UNOS). In the early 1980s, the predecessor orga-

nization to UNOS lobbied heavily to create a structure that gerrymandered the contract to UNOS and would continue to do so, which is precisely how things have since played out across seven subsequent contracting cycles.

In practice, this has stifled competition and innovation by preventing organizations with unique forms of expertise or approaches from participating in the OPTN, instead giving preference to an entrenched incumbent with a highly checkered history.

What has this meant for patients? Unnecessary death or prolonged morbidity.

The U.S. Digital Service (USDS) — the federal government’s top technologists — found that UNOS’s technology is insecure and often crashes, creating periods of downtime during which lifesaving organs literally cannot be matched with recipients in need. Investigative reporting found that UNOS maintains an archaic logistics infrastructure over which organs “are typically tracked with a primitive system of phone calls and paper manifests, with no GPS or other electronic tracking required,” contributing to “a startling number of lifesaving organs [being] lost or delayed after being shipped on commercial flights, the delays often rendering them unusable.”

In fact, USDS’s ultimate assessment was that the OPTN’s technology “needs to be vastly restructured,” and that UNOS “lacks sufficient technical capabilities to modernize [its] systems.”

The Senate Finance Committee, now three years into a bipartisan investigation of UNOS, separately arrived at a similar conclusion. “From the top down, the U.S. transplant network is not working, putting Americans’ lives at risk,” the committee stated, and recommended that HHS break up the OPTN monopoly.

Secure and stable technology and reliable logistics management have already been deployed in other areas of American life for decades, from Amazon’s rapid delivery to electronic prescriptions that improve accuracy, increase patient safety, and reduce costs. The proposed reforms from HHS now have the potential to allow transplant patients to benefit from system and technological modernization, too.

Breaking up the OPTN monopoly can also address problematic conflicts of interest. Under the historical structure, the OPTN has been responsible for oversight of its own members, which some allege has contributed to fatal consequences for patients.

An investigation from the Los Angeles Times found that UNOS “often fails to detect or decisively fix problems at derelict hospitals — even when patients are dying at excessive rates. … When it does act, UNOS routinely keeps findings of its investigations secret, leaving patients and their families

unaware of the potential risks.” The Times attributed this problem to the fact that “UNOS isn’t just a regulator; it is a membership organization.”

The Senate Finance Committee recognized a similar problem. In addition to thousands of unnecessary deaths resulting from unrecovered organs, the investigation identified preventable deaths resulting from errors as basic as kidneys accidentally thrown in the trash, and organ procurement organization (OPO) staff misreading bloodwork.

The problem appears to be structural: it seems the OPTN contractor has an incentive to protect industry from accountability, rather than ensure that patients are kept safe. For example, despite reassuring Congress that UNOS “provides appropriate and highly effective oversight,” UNOS’s own internal emails reveal its executives joking that their deeply flawed patient safety protection process is “like putting your kids’ artwork up at home. You value it because of how it was created rather than whether it’s well done,” and even deriding vulnerable patients as “dumb f***[s].”

HHS’s reforms will now allow for discrete, non-conflicted contracts for accountable and transparent organizations to protect patient safety.

Similarly, OPTN policy making has also given preference to industry over patients. Consider 2020 federal regulations aimed at holding organ procurement organizations (OPOs) accountable by using objective — rather than self-reported — data to evaluate OPO performance, and, by extension, to make OPO performance metrics legally enforceable. By introducing such transparency and accountability, HHS projected that

OPO performance would improve sufficiently to save more than 7,300 lives every year. Rather than serving as an unbiased data repository, however, UNOS appears to have lobbied against reforms championed by every major patient group on record, as well as celebrated by bipartisan Congressional offices and national health equity leaders.

HHS’s reforms will allow for expert data scientists and epidemiologists to inform ongoing, interactive research, and can be focused — free of conflicts — on promoting policies aimed at increasing the number of lifesaving organ transplants for patients every year.

Some have opposed the proposed reforms by asserting that even discussing UNOS or OPO failures will “Erod[e] public trust” in organ donation, and, by extension, depress organ donation rates.

But this is simply not supported by data, and we should not shy away from

any conversations that can improve patient outcomes. In fact, peer-reviewed research finds that criticisms of the system actually correspond with higher donation rates, which researchers attribute to the Hawthorne Effect standing in for oversight in a system that has been left unaccountable for decades.

Tonya Ingram, a kidney patient who testified before Congress in May 2021, called for increased system accountability, and then tragically died the following year. The suggestion that her self-advocacy was more of a threat to the system than the system’s failures were to her is obscene, and only serves to further ossify the problems patients are facing.

If we are ever to truly serve patients, every stakeholder needs to be honest in identifying and discussing problems, and urgent in solving them. HHS’s reforms will enable — and continually incentivize — exactly that.

Greg Segal is CEO of Organize, a patient advocacy group. Jennifer Erickson, MS, is a senior fellow at the Federation of American Scientists and served in the White House Office of Science and Technology Policy under President Obama, working on organ donation policy. Donna Cryer, JD, is president and CEO of the Global Liver Institute, the leading patient advocacy organization in liver health. Bryan Sivak is a healthcare investor and served as the chief technology officer of HHS under President Obama. He is on the board of directors for Organize. This article is commentary and first appeared in MedPage Today.

Addressing San Diego’s Behavioral Health Crisis With Expert, Compassionate Care

According to the National Alliance on Mental Illness, 1 in 5 U.S. adults experiences mental illness each year, with 1 in 20 experiencing serious mental illness. Each year, 1 in 6 people ages 6 to 17 experiences a mental health disorder, and for individuals ages 10 to 14, suicide is the secondleading cause of death in the United States.

“Our communities need help,” says Dr. Fadi Nicolas, chief medical officer of Sharp HealthCare Behavioral Health Services. “When individuals struggle with behavioral health issues, multiple interpersonal problems can arise, causing conflict in school, work, family life, and connecting with peers and friends.”

Sharp Mesa Vista Hospital’s legacy of caring for the San Diego community

As the region’s largest private behavioral health care provider, Sharp Mesa Vista Hospital is a critical partner in San Diego County’s efforts to address the ongoing mental health crisis. For 60 years, Sharp Mesa Vista has treated more than 200,000 people of all ages facing serious mental illness, including substance use disorders.

Sharp is a premier provider of crisis psychiatric evaluations, assessing more than 3,200 patients in county emergency rooms and facilitating over 72,000 outpatient visits each year. Sharp Mesa Vista’s intensive care unit annually cares for nearly 1,000 patients who experience significant mental health conditions. The $10 million specialty unit completed a remodel in March 2023 thanks to a $1 million gift from the Shiley Foundation and a $500,000 matching grant from the David C. Copley Foundation.

In addition, Sharp McDonald Center, an addiction treatment facility nearby, cares for patients with substance use disorders. Last year, more than 100,000 people in the U.S. died from a drug overdose. The synthetic opioid fentanyl is the number one killer among people ages 18 to 45, nationally and locally. Both behavioral health facilities are dedicated to empowering patients to reach their fullest potential. Experts include board-certified psychiatrists and psychiatric nurse practitioners, registered nurses, addictionologists, child and adult psychologists, social workers, recreational therapists, and additional behavioral health professionals.

“Mental Health Awareness Month is the perfect time to emphasize the importance of caring for our mental health and the mental health of those we love,” says Dr. Nicolas. “Tending to emotional, psychological and behavioral health needs is essential to our overall well-being.”

Programs and services include:

• Adult behavioral health services

Behavioral health support for military veterans

• Chemical dependency and substance use disorder programs

• Child and adolescent behavioral health services

• Clinical trials for Alzheimer’s disease and dementia

Cognitive treatment

• Dual recovery program

• Eating disorders treatment

Electroconvulsive therapy

• Medication-assisted treatment (MAT)

• Older adult behavioral health services

• Psychiatric outpatient treatment

• Trauma and PTSD recovery

• After-school cognitive therapy for teens

As the San Diego region’s largest private behavioral health care provider, Sharp Mesa Vista Hospital serves as a critical county partner for mental health services. Learn more at sharp.com/mesavista

Sharp McDonald Center offers the most comprehensive hospital-based program in San Diego for treating addiction, crossing the entire continuum of care. Learn more at sharp.com/mcdonald.

A Third of Docs Blame Prior Authorizations for Serious Harm to Patients

Four in Five Say They Waste Resources, Forcing Use of Ineffective Treatments, Extra Visits

By Shannon Firth

ONE IN THREE PHYSICIANS BLAMED PRIOR authorization for a patient’s serious adverse event, including hospitalization, permanent impairment, or death, according to a survey published by the American Medical Association (AMA) in March.

In addition, 86% of physicians surveyed said prior authorization rules led to greater use of healthcare resources overall.

“Health plans continue to inappropriately impose bureaucratic prior authorization policies that conflict with evidencebased clinical practices, waste vital resources, jeopardize quality care, and harm patients,” said AMA President Jack Resneck Jr., MD, in a press release. “The byzantine system of authorization controls is rife with opportunities for reform and the AMA continues to work with federal and state officials on legislative solutions to reduce waste, improve efficiency, and protect patients from obstacles to medically necessary care.”

Prior authorization requirements were enacted by insur-

ers to stop physicians from ordering expensive and unnecessary tests or procedures in the name of cost-effectiveness. However, physicians have argued that such policies prevent access to routine care or critically needed treatments, and increase overall use of healthcare resources.

Physician practices complete an average of 45 prior authorization requests per week, translating to about 14 hours, or roughly two business days. Approximately 35% of physicians said they have staff whose sole job is managing prior authorization requests.

The survey also highlighted the following impacts of prior authorization requirements:

• 64% of physicians said as a result of requirements, resources were steered toward “ineffective initial treatments.”

• 62% said requirements led to additional office visits.

• 46% said requirements led to urgent or emergency care.

Beyond waste and inefficiencies, 94% of physicians said prior authorizations delayed patient access to necessary care “always,” “often,” or “sometimes.” By that same measure, 80% of physicians said prior authorization requirements led patients to “at least sometimes” abandon recommended treatment, and 89% said the requirements had a “somewhat” or “significant” negative impact on patients’ clinical outcomes.

More than half of physicians with patients in the workforce said that prior authorization rules have impacted their patients’ job performances.

Curiously, a majority of physicians surveyed — 58% — said that prior authorization criteria were rooted in evidence-based medicine or guidelines from national medical specialty societies; 31% said that such criteria were “rarely” or “never” evidence-based, and another 11% weren’t sure.

In December, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would require some payers to automate their prior authorization processes, mandate deadlines for certain prior authorization decisions — 72 hours for expedited requests and seven calendar days for non-urgent requests — and require the provision of reasons for denials.

“The AMA continues to applaud the administrator for acknowledging patient and physician concerns in both sets of proposed rules,” Dr. Resneck noted. “The AMA also provided the administrator with several recommendations to strengthen CMS’ proposals, particularly around the rule’s scope, payer transparency, and processing time requirements.”

Shannon Firth has been reporting on health policy since 2014 for MedPage Today, where this article first appeared, as its Washington correspondent.

New DEA License Requirement Starts in June

The X Waiver Is Gone, but Clinicians May Need New Training to Renew Their DEA License

By Kristina Fiore

WHEN THE BIDEN ADMINISTRATION KILLED the X waiver late last year, all clinicians registered with the Drug Enforcement Administration (DEA) learned they would need eight hours of training on substance use disorder (SUD) management in order to renew their licenses.

The DEA has now issued a deadline for that requirement, and it’s less than three months away.

Starting June 27, all clinicians will have to check a box on their online DEA registration form — whether they’re renewing or initiating a license — affirming they’ve completed that training, according to the DEA’s recent announcement.

It’s a one-time requirement that won’t be part of future registration renewals, the DEA said.

Some clinicians will be exempt from completing the eighthour training, including those who are board-certified in addiction medicine or addiction psychiatry via the American Board of Medical Specialties, the American Board of Addiction Medicine, or the American Osteopathic Association.

Clinicians who have completed a “comprehensive curriculum” that included at least eight hours of training on treating and managing patients with opioid use disorders or other SUDs, including the appropriate clinical use of all drugs approved by the FDA to treat these conditions, will also be exempt.

Clinicians can satisfy the eight-hour training requirement on treating and managing SUDs by completing courses from a list of approved organizations, including the American Society of Addiction Medicine, the American Academy of

Addiction Psychiatry, the American Medical Association, and the American Osteopathic Association.

The training doesn’t have to occur in one session, and can be cumulative across multiple sessions, totaling eight hours, the DEA said. Past trainings can also count toward meeting requirements. For instance, relevant training from one of the qualified groups prior to the enactment of the policy would count toward the eighthour requirement.

And, of course, previous trainings completed as part of obtaining an X waiver count as well, the agency noted.

Several groups, including the American Society of Addiction Medicine and the Substance Abuse and Mental Health Services Administration, declined to comment on the new policy. The American Medical Association issued a press release announcing

the availability of its free courses that would satisfy the new DEA requirement.

The X waiver was a special DEA certification that allowed clinicians to prescribe buprenorphine (Suboxone) to treat SUDs, and it had long been considered a bureaucratic hurdle to improving access to treatment for these patients.

The Biden administration had been chipping away at barriers to care for patients with SUDs, and in April 2021 it scrapped the X waiver’s training requirements for doctors and other healthcare providers. Those wanting to prescribe buprenorphine only had to register for the waiver in order to do so.

Late last year, the administration’s omnibus spending bill carried language eliminating the X waiver requirement completely. Subsequently, the Medication Access and Training Expansion Act bolstered training requirements by requiring all clinicians with a DEA license to have completed a one-time, eight-hour training on managing patients with opioid use disorder and other SUDs.

Kristina Fiore is director of enterprise and investigative reporting for MedPage Today, where this article first appeared. She’s been a medical journalist for more than a decade.

Black Patients Dress Up and Modify Speech to Reduce Bias, California Survey Shows

By Annie Sciacca

A YOUNG MOTHER IN CALIFORNIA’S ANTELOPE Valley bathes her children and dresses them in neat clothes, making sure they look their very best — at medical appointments. “I brush their teeth before they see the dentist. Just little things like that to protect myself from being treated unfairly,” she told researchers.

A 72-year-old in Los Angeles, mindful that he is a Black man, tries to put providers at ease around him. “My actions will probably be looked at and applied to the whole race, especially if my actions are negative,” he said. “And especially if they are perceived as aggressive.”

Many Black Californians report adjusting their appearance or behavior — even minimizing questions — all to

reduce the chances of discrimination and bias in hospitals, clinics, and doctors’ offices. Of the strategies they describe taking, 32% pay special attention to how they dress; 35% modify their speech or behavior to put doctors at ease. And 41% of Black patients signal to providers that they are educated, knowledgeable, and prepared.

The ubiquity of these behaviors is captured in a survey of 3,325 people as part of an October study titled “Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health,” funded by the California Health Care Foundation. (KHN receives funding support from the California Health Care Foundation.) Part of its goal was to call attention to the effort Black patients must exert to get quality care from health providers.

“If you look at the frequency with which Black Californians are altering their speech and dress to go into a healthcare visit,” says Shakari Byerly, whose research firm, Evitarus, led the study, “that’s a signal that something needs to change.”

One-third of Black patients report bringing a companion into the exam room to observe and advocate for them. And, the study found, more than a quarter of Black Californians avoid medical care simply because they believe they will be treated unfairly.

“The system looks at us differently, not only in doctors’ offices,” says Dr. Michael LeNoir, who was not part of the survey.

Dr. LeNoir, an Oakland allergist and pediatrician who founded the African American Wellness Project nearly two decades ago to combat health disparities, found the responses unsurprising, given that many Black people have learned to make such adjustments routinely. “There is general discrimination,” he says, “so we all learn the role.”

There is ample evidence of racial inequality in healthcare. An analysis by the nonprofit Urban Institute published in 2021 found that Black patients are much more likely to suffer problems related to surgical procedures than white patients in the same hospital. A study published in November by the National Bureau of Economic Research found that Black mothers and babies had worse outcomes than other groups across many health measures. And a study published in January, led by Dana-Farber Cancer Institute investigators, found that older Black and Hispanic patients with advanced cancer are less likely to re-

ceive opioid medications for pain than white patients. (Hispanic people can be of any race or combination of races.)

Gigi Crowder, executive director of the Contra Costa County chapter of the National Alliance on Mental Illness, says she frequently sees delayed mental health diagnoses for Black patients.

“I hear so many stories about how long it takes for people to get their diagnoses,” Crowder says. “Many don’t get their diagnoses until six or seven years after the onset of their illness.”

Almost one-third of respondents in the California Health Care Foundation study — which looked only at Black Californians, not other ethnic or racial groups — reported having been treated poorly by a healthcare provider because of their race or ethnicity. One participant said her doctor advised her simply to exercise more and lose weight when she reported feeling short of breath. She eventually discovered she had anemia and needed two blood transfusions.

“I feel like Black voices aren’t as loud. They are not taken as seriously,” the woman told researchers. “In this case, I wasn’t listened to, and it ended up being a very serious, actually life-threatening problem.”

People KHN spoke with who weren’t part of the study

IS IT TIME TO EXAMINE

described similar bad experiences.

Southern California resident Shaleta Smith, 44, went to the emergency room, bleeding, a week after giving birth to her third daughter. An ER doctor wanted to discharge her, but a diligent nurse called Smith’s obstetrician for a second opinion. It turned out to be a serious problem for which she needed a hysterectomy.

“I almost died,” Smith says.

Years later and in an unrelated experience, Smith says, her primary care doctor insisted her persistent loss of voice and recurring fever were symptoms of laryngitis. After she pleaded for a referral, a specialist diagnosed her with an autoimmune disorder.

Smith says it’s not clear to her whether bias was a factor in those interactions with doctors, but she strives to have her health concerns taken seriously. When Smith meets providers, she will slip in that she works in the medical field in administration.

Black patients also take on the additional legwork of finding doctors they think will be more responsive to them.

Ovester Armstrong Jr. lives in Tracy, in the Central Valley, but he’s willing to drive an hour to the Bay Area to seek out

providers who may be more accustomed to treating Black and other minority patients.

“I have had experiences with doctors who are not experienced with care of different cultures — not aware of cultural differences or even the socialization of Black folks, the fact that our menus are different,” Armstrong says.

Once he gets there, he may still not find doctors who look like him. A 2021 UCLA study found that the proportion of U.S. physicians who are Black is 5.4%, an increase of only 4 percentage points over the past 120 years.

While health advocates and experts acknowledge that Black patients should not have to take on the burden of minimizing poor healthcare, helping them be proactive is part of their strategy for improving Black health.

Dr. LeNoir’s African American Wellness Project arms patients with information so they can ask their doctors informed questions. And the California Black Women’s Health Project is hiring health “ambassadors” to help Black patients navigate the system, says Raena Granberry, senior manager of maternal and reproductive health for the organization.

Southern California resident Joyce Clarke, who is in her 70s, takes along written questions when she sees a doctor to make sure her concerns are taken seriously. “Health professionals are people first, so they come with their own biases, whether intentional or unintentional, and it keeps a Black person’s guard up,” Clarke says.

While the study shed light on how Black patients interact with medical professionals, Katherine Haynes, a senior program officer with the California Health Care Foundation, says further research could track whether patient experiences improve.

“The people who are providing care — the clinicians — they need timely feedback on who’s experiencing what,” she says.

Annie Sciacca is a California-based journalist for Kaiser Health News, which produced this article.

Gov. Newsom Wanted California to Cut Ties With Walgreens. Then Federal Law Got in the Way

By Samantha Young

GOV. GAVIN NEWSOM DECLARED IN MARCH that California was “done” doing business with Walgreens after the pharmacy chain said it would not distribute an abortion pill in 21 states where Republicans threatened legal action. Since then, KHN has learned that the Democratic governor must compromise on his hard-line tweet.

California is legally bound to continue doing business with Walgreens through the state’s massive Medicaid program, health law experts say. And according to a public records request, the state paid Walgreens $1.5 billion last year. Newsom’s administration confirmed it will “continue to comply” with federal law by paying Walgreens through Medi-Cal, which provides health coverage to roughly 15 million residents with low incomes and disabilities. Were California to stop covering Medi-Cal prescriptions filled at Walgreens stores, legal scholars warned, the state would run afoul of federal law, which allows patients to get their medications at any approved pharmacy.

“California has no intention of taking any action that would violate federal Medicaid requirements, or that could undermine access for low-income individuals,” said Tony Cava, a spokesperson for the California Department of Health Care Services, in a statement.

Newsom spokesperson Anthony York explains, “Tweeting is not policy.” He adds that the governor will not “take any action that hurts people who need access to care.” Walgreens has even been reinvited to apply for a specialty drug contract that Newsom pulled back on renewing last month, York says. Walgreens has received about $54 million from the state under the contract.

The dust-up with the Illinois-based pharmacy chain illustrates Newsom’s panache for sweeping announcements on social media, where he garners national headlines but offers few specifics and little follow-through, political strategists say. Newsom has raised his national profile — and speculation of a presidential bid — by traveling to red states and launching a new political action committee.

“It’s much more about appearances and style and approach than it is about substance,” says David McCuan, political science department chair at Sonoma State University. Newsom and his administration “oversell their pronouncements and don’t actually deliver,” McCuan explains.

On March 6, the governor tweeted “California won’t be doing business with @walgreens — or any company that cowers to the extremists and puts women’s lives at risk,” after the second-largest U.S. pharmacy chain said it would not dispense mifepristone in states where it is illegal to dispense the pill or where the company faced potential lawsuits if it did so.

Democratic strategist Steve Maviglio says continuing to pay Walgreens through Medi-Cal doesn’t take away from Newsom’s support of abortion rights.

“He’s going to get the headline for protecting abortion rights, and this he can chalk up to a technical difficulty,” Maviglio says. “He will be rewarded for standing up to a corporation.”

Federal law is designed to ensure Medicaid patients have choices in where they get healthcare, including prescriptions. Approved providers like Walgreens are protected by Medicaid statute, which states that no health plan or entity can “restrict the choice of the qualified person from whom the individual may receive services.” Legal and Medicaid experts said that makes it extremely difficult for the Newsom administration to disqualify Walgreens.

“As long as Walgreens is performing for Medicaid beneficiaries as it should, dispensing all legal drugs in a manner that is consistent with permissible pharmacy practice, then I don’t see the basis for excluding them,” says Sara Rosenbaum, a professor of health law and policy at George Washington University.

The federal regulations that protect Walgreens are the same that have allowed Planned Parenthood to offer healthcare services to Medicaid enrollees in conservative states, where leaders have sought unsuccessfully to exclude the network of clinics from receiving taxpayer funding.

An approved pharmacy company can be excluded from state networks only if it has committed fraud or other contract violations, adds Edwin Park, a research professor at Georgetown University with expertise in Medicaid law.

“Certainly, that wouldn’t be the case for Walgreens,” Park says.

It’s unclear whether Newsom was aware of how difficult it would be for California to unwind its Medi-Cal provider agreement with Walgreens, says Daniel Schnur, a Republican-turned-independent strategist who also teaches political science at the University of Southern California.

“The original announcement sounded like a seminal step for the state of California to take on principle, even at great financial expense,” Schnur says. “They’ve quietly backed away.”

Through a records request, KHN learned the state paid Walgreens $1.5 billion last year to buy and dispense prescriptions to Medi-Cal enrollees. The bulk of the payment, $1.4 billion, reimbursed Walgreens for the prescriptions it distributed. And the remaining $123 million went to dispensing fees, a payment to pharmacists for each prescription they fill. The federal government covers at least half the state’s payments, which are also offset by rebates from drug manufacturers.

A Walgreens spokesperson declined to comment on its business with California, referring to the same statement it issued in March: “Providing legally approved medications to patients is what pharmacies do, and is rooted in our commitment to the communities in which we operate.”

Walgreens said it plans to dispense mifepristone “in any jurisdiction where it is legally permissible to do so.” The company was responding to an FDA rule finalized in January that allows certified pharmacies to dispense the abortion pill, which is the most common way people terminate pregnancies. Walgreens isn’t proposing to limit abortion pill sales in California or other states where abortion is legal and pharmacies are allowed to dispense it.

Democrats have urged pharmacy chains to sell the abortion pill even as GOP attorneys general threaten legal action. But many, including Walmart, Costco, Albertsons, and Health Mart, have not waded into the fight. Only Rite Aid and CVS have said they plan to begin certification to dispense the pills.

Had Newsom been able to sever Medi-Cal’s relationship with Walgreens, he would have contradicted one of his signature health initiatives. When he took office in 2019, Newsom proposed the state take over prescription drug coverage for Medi-Cal patients, many of whom had been covered through managed-care plans.

Part of Newsom’s pitch: Patients could go to nearly any pharmacy in California.

Fatigue Is Common Among Older Adults, and It Has Many Possible Causes

By Judith Graham

NOTHING PREPARED

Linda C. Johnson of Indianapolis for the fatigue that descended on her after a diagnosis of stage 4 lung cancer in early 2020.

Initially, Johnson, now 77, thought she was depressed. She could barely summon the energy to get dressed in the morning. Some days, she couldn’t get out of bed.

But as she began to get her affairs in order, Johnson realized something else was going on. However long she slept the night before, she woke up exhausted. She felt depleted, even if she didn’t do much during the day.

“People would tell me, ‘You know, you’re getting old.’ And that wasn’t helpful at all. Because then you feel there’s nothing you can do mentally or physically to deal with this,” she told me.

Fatigue is a common companion of many illnesses that beset older adults: heart disease, cancer, rheumatoid arthritis, lung disease, kidney disease, and neurological

conditions like multiple sclerosis, among others. It’s one of the most common symptoms associated with chronic illness, affecting 40% to 74% of older people living with these conditions, according to a 2021 review by researchers at the University of Massachusetts.

This is more than exhaustion after an extremely busy day or a night of poor sleep. It’s a persistent, whole-body feeling of having no energy, even with minimal or no exertion. “I feel like I have a drained battery pretty much all of the time,” wrote a user named Renee in a Facebook group for people with polycythemia vera, a rare blood cancer. “It’s sort of like being a wrung-out dish rag.”

Fatigue doesn’t represent “a day when you’re tired; it’s a couple of weeks or a couple of months when you’re tired,” says Dr. Kurt Kroenke, a research scientist at the Regenstrief Institute in Indianapolis, which specializes in medical research, and a professor at Indiana University’s School of Medicine.

When he and colleagues queried nearly 3,500 older patients at a large primary care clinic in Indianapolis about bothersome symptoms, 55% listed fatigue — second only to musculoskeletal pain (65%) and more than back pain (45%) and shortness of breath (41%).

Separately, a 2010 study in the Journal of the American Geriatrics Society estimated that 31% of people 51 and older reported being fatigued in the past week.

The impact can be profound. Fatigue is the leading reason for restricted activity in people 70 and older, according to a 2001 study by researchers at Yale. Other studies have linked fatigue with impaired mobility, limitations in people’s abilities to perform daily activities, the onset or worsening of

disability, and earlier death.

What often happens is older adults with fatigue stop being active and become deconditioned, which leads to muscle loss and weakness, which heightens fatigue. “It becomes a vicious cycle that contributes to things like depression, which can make you more fatigued,” said Dr. Jean Kutner, a professor of medicine and chief medical officer at the University of Colorado Hospital.

To stop that from happening, Johnson came up with a plan after learning her lung cancer had returned. Every morning, she set small goals for herself. One day, she’d get up and wash her face. The next, she’d take a shower. Another day, she’d go to the grocery store. After each activity, she’d rest.

In the three years since her cancer came back, Johnson’s fatigue has been constant. But “I’m functioning better,” she told me, because she’s learned how to pace herself and find things that motivate her, like teaching a virtual class to students training to be teachers and getting exercise under the supervision of a personal trainer.

When should older adults be concerned about fatigue? “If someone has been doing OK but is now feeling fatigued all the time, it’s important to get an evaluation,” says Dr. Holly Yang, a physician at Scripps Mercy Hospital in San Diego and incoming board president of the American Academy of Hospice and Palliative Medicine.

“Fatigue is an alarm signal that something is wrong with the body, but it’s rarely one thing. Usually, several things need to be addressed,” says Dr. Ardeshir Hashmi, section chief of the Center for Geriatric Medicine at the Cleveland Clinic.

Among the items physicians should check: Are your thyroid levels normal? Are you having trouble with sleep? If you have underlying medical conditions, are they well controlled? Do you have an underlying infection? Are you chronically dehydrated? Do you have anemia (a deficiency of red blood cells or hemoglobin), an electrolyte imbalance, or low levels of testosterone? Are you eating enough protein? Have you been feeling more anxious or depressed recently? And might medications you’re taking be contributing to fatigue?

“The medications and doses may be the same, but your body’s ability to metabolize those medications and clear them from your system may have changed,” Dr. Hashmi says, noting that such changes in the body’s metabolic activity are common as people become older.

Many potential contributors to fatigue can be addressed. But much of the time, reasons for fatigue can’t be explained by an underlying medical condition.

That happened to Teresa Goodell, 64, a retired nurse who lives just outside Portland, Ore. During a December visit to Arizona, she suddenly found herself exhausted and short of breath while on a hike, even though she was in good physical condition. At an urgent care facility, she was diagnosed

with an asthma exacerbation and given steroids, but they didn’t help.

Soon, Goodell was spending hours each day in bed, overcome by profound tiredness and weakness. Even small activities wore her out. But none of the medical tests she received in Arizona and subsequently in Portland — a chest Xray and CT scan, blood work, a cardiac stress test — showed abnormalities.

“There was no objective evidence of illness, and that makes it hard for anybody to believe you’re sick,” she told me.

Goodell started visiting long-COVID websites and chat rooms for people with chronic fatigue syndrome. Today, she’s convinced she has post-viral syndrome from an infection. One of the most common symptoms of long COVID is fatigue that interferes with daily life, according to the Centers for Disease Control and Prevention.

There are several strategies for dealing with persistent fatigue. In cancer patients, “the best evidence favors physical activity such as tai chi, yoga, walking, or low-impact exercises,” says Dr. Christian Sinclair, an associate professor of palliative medicine at the University of Kansas Health System. The goal is to “gradually stretch patients’ stamina,” he explains.

With long COVID, however, doing too much too soon can backfire by causing “post-exertional malaise.” Pacing one’s activities is often recommended: doing only what’s most important, when one’s energy level is highest, and resting afterward. “You learn how to set realistic goals,” says Dr. Andrew Esch, senior education advisor at the Center to Advance Palliative Care.

Cognitive behavioral therapy can help older adults with fatigue learn how to adjust expectations and address intrusive thoughts such as, “I should be able to do more.” At the University of Texas MD Anderson Cancer Center, management plans for older patients with fatigue typically include strategies to address physical activity, sleep health, nutrition, emotional health, and support from family and friends.

“So much of fatigue management is about forming new habits,” says Dr. Ishwaria Subbiah, a palliative care and integrative medicine physician at MD Anderson. “It’s important to recognize that this doesn’t happen right away: It takes time.”

Judith Graham, a contributing columnist, writes the “Navigating Aging” column for KHN, where this article first appeared. She has covered healthcare for more than 30 years.

Wag More

By Helane Fronek, MD, FACP, FASVLM, FAMWA

in negative thoughts. Even after being alerted to the possibility of a happier moment, I hold fast to my worry, irritation, or pain. Looking at Charlie, I wondered how I could learn to more easily allow both joy and sorrow to coexist.

“My Joy is Heavy,” a beautiful video by Abigail and Sean Bengson, provides clear evidence that this is possible. Their vulnerable and courageous approach to life, concomitantly feeling the grief of pregnancy losses, the suffering of mental health challenges, and the great joy of playing with their son, proves that wholehearted living awaits us all — if we are willing to allow the full range of emotions and experiences that life offers.

rify suffering, and medical training instills an alertness for negative outcomes and complications.

But there are many healthier and compelling reasons to allow happiness alongside the sadness.

WHEN OUR DAUGHTER IS AWAY, WE GLADLY care for her dog. Charlie is a happy rescue dog, delighted by any fun activity or expression of care. Her tail is a happiness meter, wagging anytime you speak to her, give her a treat, or play with her. The day after our daughter left on vacation, Charlie began to limp, with a newly sore and swollen paw. At the urgent care, as Charlie limped painfully onto the scale, the receptionist exclaimed, “Look at her — still wagging!” It was true — Charlie’s tail was wagging as if waiting for a ball to be thrown.

It reminded me how I tend to ignore the happy moments of my life when I am worried, preoccupied, or in discomfort. Sadly, I’ve missed many opportunities to share someone’s joy, feel the awe of a beautiful sunset or landscape, or be charmed by the smile or antics of a baby because I was lost

There are plenty of reasons to push away happy feelings when we are experiencing sadness, anger, or grief. Some of mine include not feeling I deserve to be happy when bad things are happening, fear of trivializing someone’s difficulties if I don’t focus on them, and an unwillingness to shift my feeling state or internal narrative. Our culture — secular, religious and medical — tends to glo-

First, life is full of both sadness and happiness. If we want to be fully present in our lives, we must acknowledge both. Moments of happiness connect us to others and the world around us, offering strength, wisdom, and support to help us get through our difficulties. Feeling awe fills our spirits with resourcefulness and possibility, and makes us nicer, kinder people. It also helps put our problems into perspective — rather than allowing them to dominate our awareness, we recognize them as just part of our lives. And by appreciating happy moments, we balance our lives and help to protect against burnout and the many disease processes triggered by chronic stress.

Even, and perhaps especially amid our challenging times, can we pause (no pun intended) and wag our tails more in appreciation of the good fortune, love, beauty, and caring that also exist in our lives?

Dr. Fronek is an assistant professor of clinical medicine at UC San Diego School of Medicine and a Certified Physician Development Coach, CPCC, PCC.

The Ladies of Project Access

By Adama Dyoniziak

PROJECT ACCESS SAN DIEGO (PASD), A program of Champions for Health (CFH), provides a referral pathway for uninsured adults ages 26–49, at 250% of federal poverty level, who are not eligible for Medi-Cal, Medicare, and cannot afford insurance. We arrange elective, medically necessary outpatient procedures by leveraging donated care. The Care Managers make the process smooth for the specialist and their office staff accepting PASD patients in the waiting room during normal office hours.

PASD care managers are the linchpin in, and facilitator of, this referral process. Celene Salazar, a registered nurse and the program manager, started with CFH as an immunization volunteer. Evelyn Peñaloza and Desseray Reyes, both care managers, started as college interns, with immunization and PASD respectively. These ladies screen clients for eligibility and match patients with specialists; navigate patients through all appointments and surgeries; coordinate all activities between PCP and specialist offices; provide (free to patient) medical interpreting, transportation, medicines, diagnostic tests, and DMEs. Most importantly, they are the patient’s advocate throughout the entire process.

“CFH opens a door into a community that is very close to me, which I am proud to be a part of: the Hispanic Latino community,” Salazar says. “Being able to serve this community is just like serving my family. It’s close to home, it’s my past and it’s my present.” She continues: “Being able to serve specifically 26- to 49-year-olds means we are helping parents of young kids be successful. The medical care they receive ensures that they can get better and can continue to provide for their families. The kids can see their parents as strong. We bridge that gap for them.”

“One of the most rewarding parts of working at CFH is to see the full transformation that a patient goes through, and know that I was a part of it,” Peñaloza says. “Being able to see the patients get better physically, and also be happy and lively — their entire demeanor changes from getting this help. Without CFH, these patients would not have been able to get this kind of medical care.”

Reyes simply enjoys being there for moral support. “I know some patients are scared when going to the doctor’s office, so they reach out and ask if it’s OK to accompany them,” she explains. “When I get to see a patient face-to-

face, it makes more of a personal connection. Being that form of support for them makes me feel very fulfilled.”

Peñaloza agrees. “Patients tell me all the time, if it weren’t for you, I don’t know what I would do,” she says.

Ultimately, Project Access is about health equity. “Health equity means having the same opportunities so that we can be the best version of ourselves, healthwise,” says Peñaloza. CFH removes barriers to medical access so that nothing gets in the way of the opportunity for treatment.

Since 2008, Project Access has facilitated $27 million in care for more than 7,500 uninsured patients by providing free consultations and surgeries — all thanks to the dedication, time, and talent of our volunteer specialty physicians. Join the Ladies of Project Access by providing pro bono services: call (858) 300-2780 or adama.dyoniziak@championsfh.org.

Adama Dyoniziak is the executive director of Champions for Health.

Celene Salazar, RN Project Access Program Manager

Desseray Reyes Project Access Program Manager

Evelyn Peñaloza Project Access Care Manager

CLASSIFIEDS

PRACTICE ANNOUNCEMENTS

PSYCHIATRIST AVAILABLE! Accepting new patients for medication management, crisis visits, ADHD, cognitive testing, and psychotherapy. Out of network physician servicing La Jolla & San Diego. Visit hylermed.com or call 619-707-1554.

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 SAN DIEGO: Volunteer physicians are needed in the following specialties: endocrinology, rheumatology, vascular surgery, ENT or head and neck, general surgery, GI, and gynecology. These specialists are needed in all regions of San Diego County to provide short term pro bono specialty care to adults ages 26-49 who are uninsured and not eligible for Medi-Cal. Volunteering is customized to fit your regular schedule in your office. Champions for Health is the foundation of the San Diego County Medical Society. Join hundreds of colleagues in this endeavor: Contact Evelyn. penaloza@championsfh.org or at 858-300-2779.

PHYSICIAN OPPORTUNITIES

MEDICAL CONSULTANT (MD/DO): The County of San Diego is currently accepting applications from qualified candidates for Medical Consultant-Public Health Services. Vacancies are in the Public Health Services, Epidemiology and Immunization Services Branch (EISB) and Tuberculosis (TB) Control and Refugee Health Branch. Salary: $183,747.20$204,900.80 Annually. An additional 10% for Board Certified Specialty and 15% for relevant Sub-Specialty. For job posting information CLICK HERE or visit https://www.governmentjobs.com/careers/sdcounty?keywords=23416202PHS.

MEDICAL DIRECTOR, FULL-TIME: FATHER JOE’S VILLAGES: Join us in ending homelessness! We are a dynamic team that runs an FQHC. The Medical Director oversees clinical aspects of the primary care, psychiatry, dental and behavioral health. This position will be a mix of clinic and admin time and will have direct reports (Dental Director, Director of Behavioral Health, and frontline primary care/psychiatry providers). Reports to the Chief Medical Officer, who is responsible for all aspects of the clinic. The Medical Director is a counterpart to the Clinic Director (who oversees admin staff, MA/RN team, billing, PSRs, etc.). See FJV Jobs to apply.

SEEKING MEDICAL DIRECTOR: subcontracted position 4-8 hours per month. Responsibilities: 1. Support case conferences, refractory SUD, co-occurring conditions, specialty populations. 2. Conduct clinical trainings on issues relevant to staff (e.g., documentation, ASAM Criteria, DSM5, MAT, WM, co-occurring conditions). 3. Provide oversight and clinical supervision. 4. Refer co-occurring conditions. 5. Lead Quality Improvement functions (e.g., Quality Improvement Projects, clinical team meetings, etc.) 6. Attend annually 5 hours of continuing medical education on addiction medicine. Required by contract with San Diego County BHS, position is for a Physician licensed by CA Medical Board or CA Osteopathic Medical Board. Contact Name: Jennifer Ratoff: e-mail: jratoff@secondchanceprogram.org, phone: 619-839-0950

PSYCHIATRIST SPECIALIST: The County of San Diego is currently accepting applications from qualified candidates. Annual Salary: $258,294.40. Note: An additional 10% is paid for Board Certification, or 15% for Board Certification that includes a subspecialty. Why choose the County? 1. Fully paid malpractice insurance. 2. 13 paid holidays. 3. 13 sick days per year. 4. Vacation: 10 days (1-4 years of service); 15 days (5-14 years of service; 20 days (15+ years). 5. Defined benefit retirement program. 6. Cafeteria-style health plan with flexible spending. 7. Wellness incentives. Psychiatrist-Specialists perform professional psychiatric work involving the examination, diagnosis, and treatment of specialty forensics, children/ adolescents and or geriatric patients. This is the specialty journey level class in the series that requires a fellowship or

experience in child and adolescent psychiatry or forensic psychiatry. For more information, visit our website at sandiegocounty.gov/hr or select this link to link to go directly to the Psychiatrist Specialist application.

PRIMARY CARE PHYSICIAN: Imperial Valley Family Care Medical Group is looking for Board Certified/Board Eligible Primary Care Physician for their clinics in Brawley & El Centro CA. Salaried/full time position. Please fax CV/ salary requirements to Human Resources (760) 355-7731. For details about this and other jobs please go to www. ivfcmg.com.

ASSISTANT, ASSOCIATE OR FULL PROFESSOR (HS CLIN, CLIN X, ADJUNCT, IN-RESIDENCE) MED-GASTROENTEROLOGY: Faculty Position in Gastroenterology. The Department of Medicine at University of California, San Diego, Department of Medicine (http://med.ucsd.edu/) is committed to academic excellence and diversity within the faculty, staff, and student body and is actively recruiting faculty with an interest in academia in the Division of Gastroenterology. Clinical and teaching responsibilities will include general gastroenterology. The appropriate series and appointment at the Assistant, Associate or Full Professor level will be based on the candidate’s qualifications and experience. Salary is commensurate with qualifications and based on the University of California pay scales. In-Residence appointments may require candidates to be self-funded. For more information: https://apol-recruit.ucsd. edu/JPF03179 For help contact: klsantos@health.ucsd.edu

DERMATOLOGIST NEEDED: Premier dermatology practice in La Jolla seeking a part-time BC or BE dermatologist to join our team. Busy practice with significant opportunity for a motivated, entrepreneurial physician. Work with three energetic dermatologists and a highly trained staff in a positive work environment. We care about our patients and treat our staff like family. Opportunity to do medical/surgical and cosmetic dermatology in an updated medical office with state-of-the art tools and instruments. Incentive plan will be a percentage based on production. If you are interested in finding out more information, please forward your C.V. to jmaas12@hotmail.com

INTERNAL MEDICINE PHYSICIAN: Healthcare Medical Group of La Mesa located at 7339 El Cajon Blvd is looking for a caring, compassionate, and competent physician for providing primary care services. We require well-organized and detail-oriented with excellent written and oral communication skills, and excellent interpersonal skills to provide high-quality care to our patients. We provide a competitive salary, paid time off, Health insurance, 401K benefits, etc. We provide plenty of opportunities to refine your clinical competency.

Our CEO Dr. Venu Prabaker — who has 30 years of teaching experience as a faculty at multiple universities Including Stanford, UCSD, USC, Midwestern, Western, Samuel Merritt, Mayo, etc. — will be providing teaching rounds once a week. You will also get plenty of opportunities to attend other clinical lectures at many of the 4- to–5-star restaurants in San Diego. We also have once a wee, one-hour meeting for all the staff for team building and to create a “family atmosphere” to improve productivity and thereby create a win-win situation for all. Visit us at caremd.us.

RADY CHILDREN’S HOSPITAL PEDIATRICIAN POSITIONS: Rady Children’s Hospital of San Diego seeking board-certified/eligible pediatricians or family practice physicians to join the Division of Emergency Medicine in the Department of Urgent Care (UC). Candidate will work at any of our six UC sites in San Diego and Riverside Counties. The position can be any amount of FTE (full-time equivalent) equal to or above 0.51 FTE. Must have an MD/DO or equivalent and must be board certified/eligible, have a California medical license or equivalent, PALS certification, and have a current DEA license. Contact Dr. Langley glangley@ rchsd.org and Dr. Mishra smishra@rchsd.org.

PER DIEM OBGYN LABORIST POSITION AVAILABLE: IGO Medical Group is seeking a per diem laborist to cover Labor and Delivery and emergency calls at Scripps Memorial Hospital in La Jolla. 70 deliveries/month. 24-hour shifts preferred but negotiable. Please send inquiries by email to IGO@IGOMED.com.

MEDICAL CONSULTANT, SAN DIEGO COUNTY: The County of San Diego, Health and Human Services Agency’s Public Health Services is looking for a Board Certified Family Practice or Internal Medicine physician for the Epidemiology and Communicable Disease Division. Under

general direction, incumbents perform a variety of duties necessary for the identification, diagnosis, and control of communicable diseases within the population. This position works closely with the medical and laboratory community, institutional settings, or hospital control practitioners. Learn more here: https://www.governmentjobs.com/careers/ sdcounty?keywords=21416207

KAISER PERMANENTE SAN DIEGO PER DIEM

PHYSIATRIST: Southern California Permanente Medical Group is an organization with strong values, which provides our physicians with the resources and support systems to ensure they can focus on practicing medicine, connecting with one another, and providing the best possible care to their patients. For consideration or to apply, visit https://scpmgphysiciancareers.com/specialty/physical-medicine-rehabilitation. For questions or additional information, please contact Michelle Johnson at 866-503-1860 or Michelle. S1.Johnson@kp.org. We are an AAP/EEO employer.

PRIMARY CARE PHYSICIAN POSITION: San Diego

Family Care is seeking a Primary Care Physician (MD/DO) at its Linda Vista location to provide direct outpatient care for acute and chronic conditions to a diverse adult population. San Diego Family Care is a federally qualified, culturally competent and affordable health center in San Diego, CA. Job duties include providing complete, high quality primary care, and participation in supporting quality assurance programs. Benefits include flexible schedules, no call requirements, a robust benefits package, and competitive salary. If interested, please email CV to sdfcinfo@sdfamilycare.org or call us at (858) 810-8700.

FAMILY MEDICINE OR INTERNAL MEDICINE PHYSI -

CIAN: 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 CountyHigh Quality Family Practice for a private-nonprofit outpatient clinic serving the communities of Riverside County and San Diego County. Work Full time schedule and receive paid family medical benefits. Malpractice coverage provided. Be part of a dynamic team voted ‘San Diego Top Docs’ by their peers. Please click the link to be directed to our website to learn more about our organization and view our careers page at www.Nhcare.org.

PHYSICIAN WANTED: Samahan Health Centers is seeking a physician for their federally qualified community health centers that emerged over forty years ago. The agency serves low-income families and individuals in the County of San Diego in two (2) strategic areas with a high density population of Filipinos/Asian and other low-income, uninsured individuals — National City (Southern San Diego County) and Mira Mesa (North Central San Diego). The physician will report to the Medical Director and provide the full scope of primary care services, including but not limited to diagnosis, treatment, coordination of care, preventive care and health maintenance to patients. For more information and to apply, please contact Clara Rubio at (844) 200-2426 EXT 1046 or at crubio@samahanhealth.org.

PHYSICIAN POSITIONS WANTED

PSYCHIATRIST AVAILABLE! Accepting new patients for medication management, crisis visits, ADHD, cognitive testing, and psychotherapy. Out of network physician servicing La Jolla & San Diego. Visit hylermed.com or call 619-707-1554.

CLASSIFIEDS

PRACTICE FOR SALE

GASTROENTEROLOGY GI PRACTICE FOR SALE: Looking to expand? or Move? Established 25+ years Gastroenterology GI office practice for sale in beautiful San Diego County, California. 500 active strong patient relationships and referral streams. Consistent total gross income of $600,000 for the past couple years; even through pandemic. Located in a professional-medical building with professional contract staff. All records and billing managed by a professional service who can assist with insurance integration. Office, staff & equipment are move-in ready. Seller will assist Buyer to ensure a smooth transition. Being On-Call optional. Contact Ferdinand @ (858) 752-1492 or ferdinand@zybex.com.

OTOLARYNGOLOGY HEAD & NECK SURGERY SOLO

PRACTICE FOR SALE: Otolaryngology Head & Neck Surgery solo practice located in the Ximed building on the Scripps Memorial Hospital La Jolla campus is for sale. The office is approximately 3000 SF with 1 or 2 Physician Offices. It has 4 fully equipped exam rooms, an audio room, one procedure room, one conference room, one office manager room as well as in-house billing section, staff room and a bathroom. There is ample parking for staff and patients with close access to radiology and laboratory facilities. For further information please contact Christine Van Such at 858-354-1895 or email: mahdavim3@gmail.com

OFFICE SPACE / REAL ESTATE AVAILABLE

ENCINITAS MEDICAL SPACE AVAILABLE: Newly updated office space located in a medical office building. Two large exam rooms are available M-F and suitable for all types of practice, including subspecialties needing equipment space. Building consists of primary and specialist physicians, great for networking and referrals. Includes access to the break room, bathroom and reception. Large parking lot with free parking for patients. Possibility to share receptionist or bring your own. Please contact coastdocgroup@gmail.com for more information.

NORTH COUNTY MEDICAL SPACE AVAILABLE: 2023

W. Vista Way, Suite C, Vista CA 92082. Newly renovated, large office space located in an upscale medical office with ample free parking. Furnishings, decor, 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: 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. For inquiries contact hosalkarofficeassist@gmail.com or call/text (858)740-1928.

PHYSICIAN OFFICE SPACE FOR LEASE. 1500 Sq ft. 3 exam room. Large private office. Large reception area and patient prep room. New upgraded flooring. Private entrance. Located in Rancho Bernardo in prime central location. Easy access to interstate 15. Palomar /Pomerado within 10 min. Security card access during off hours. $2500/month. Contact: (619) 585-0476. Ask for Peg.

HILLCREST OFFICE TO SUBLEASE OR SHARE: Gorgeous office located across from Scripps Mercy hospital. Office is approximately 2000 sq. ft. with procedure/effusion room. Office is fully staffed and looking to add a new provider. We currently have Rheumatology/Pulmonary/Allergy specialists but can accommodate any specialty or Internal Medicine. Multiple days per week and full use of office is available. If interested please reach out to Melissa Coronado at Melissa@ sdpulmonary.com or call (619) 819-7224.

SUBLEASE AVAILABLE: Sublease available in Del Mar off 5 freeway. Share rent. 2100 sq ft office in professional building. Utilities included. Great opportunity in a very desirable area. 858-342-3104.

CHULA VISTA MEDICAL OFFICE: Ready with 8 patient rooms, 2000sf, excellent parking ratios, Lease $4000/ mo. No need to spend a penny. Call Dr. Vin, 619-405-6307 vsnnk@yahoo.com

OFFICE SPACE AVAILABLE IN BANKERS HILL: Approximately 500 sq foot suite available to lease, includes private bathroom. Located at beautiful Bankers Hill. For more details, please call Claudia at 619-501-4758.

OFFICE AVAILABLE IN MISSION HILLS, UPTOWN SAN DIEGO: Close to Scripps Mercy and UCSD Hillcrest. Comfortable Arts and Crafts style home in upscale Mission Hills neighborhood. Converted and in use as medical / surgical office. Good for 1-2 practitioners with large waiting and reception area. 3 examination rooms, 2 physician offices and a small kitchen area. 1700 sq. ft. Available for full occupancy in March 2022. Contact by Dr. Balourdas at greg@ thehanddoctor.com.

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

OFFICE SPACE / REAL ESTATE WANTED

MEDICAL OFFICE SPACE WANTED IN HILLCREST/ BANKERS HILL AREA. Mercy Physicians Medical Group (MPMG) specialist is looking for office space near Scripps Mercy Hospital. Open to lease or share office space, full time needed. Please respond to rjvallonedpm@sbcglobal.net or 858-945-0903.

NON-PHYSICIAN POSITIONS AVAILABLE

PROJECT SCIENTISTS: Project Scientists (non-tenured, Assistant, Associate or Full level): The University of California, San Diego, Office of Research Affairs https://research. ucsd.edu/, in support of the campus multidisciplinary Organized Research Units (ORUs) https://research.ucsd. edu/ORU/index.html is conducting an open search. Project Scientists are academic researchers who are expected to make significant and creative contributions to a research team, are not required to carry out independent research but will publish and carry out research or creative programs with supervision. Appointments and duration vary depending on the length of the research project and availability of funding. https://apol-recruit.ucsd.edu/JPF03262/apply

OFFICE MANAGER: 1. Hiring, Training, Managing staff on procedures/policies. Monitors continuing compliance and office statistics. Oversee stocking/maintenance of supplies, retail. Equipment/ facilities management. Daily bookkeeping, collections.2. Ensure smooth/efficient patient flow with increasing production/collections.3. Create a friendly environment where patients expectations are exceeded, where staff can work together as a team. 4. Ensure staff working at maximum productivity/efficiency. Salary: $60-70K depending on experience/qualifications. Benefits: health care reimbursement, PTO, retirement, employee discount, bonuses, commission. Contact: info@ manageyourage.com.

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