June 2019 by San Diego Physician

JUNE 2019

Official Publication of SDCMS

HIV testing

JUNE 2019

SAN DIEGO PHYSICIAN.ORG

JUNE

CONTENTS

VOLUME 106, NUMBER 6

Editor: James Santiago Grisolia, MD Editorial Board: James Santiago Grisolia, MD; David E.J. Bazzo, MD; Robert E. Peters, MD, PhD; William T-C Tseng, MD MARKETING & PRODUCTION MANAGER: Jennifer Rohr SALES DIRECTOR: Dari Pebdani ART DIRECTOR: Lisa Williams COPY EDITOR: Adam Elder OFFICERS President: James H. Schultz, MD President-elect: Holly B. Yang, MD Secretary: Sergio R. Flores, MD Treasurer: Toluwalase (Lase) A. Ajayi, MD Immediate Past President: David E. J. Bazzo, MD GEOGRAPHIC DIRECTORS East County #1: Heidi M. Meyer, MD East County #2: Rakesh R. Patel, MD Hillcrest #1: Kyle P. Edmonds, MD Hillcrest #2: Steve Koh, MD Kearny Mesa #1: Anthony E. Magit, MD Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Laura H. Goetz, MD La Jolla #2: Marc M. Sedwitz, MD, FACS North County #1: Patrick A. Tellez, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Veena A. Prabhakar, DO South Bay #2: Maria T. Carriedo, MD GEOGRAPHIC ALTERNATE DIRECTORS Kearny Mesa #2: Eileen R. Quintela, MD La Jolla: Wayne C. Sun, MD North County #1: Franklin M. Martin, MD South Bay: Karrar H. Ali, DO AT-LARGE DIRECTORS #1: Thomas J. Savides, MD; #2: Paul J. Manos, DO; #3: Irineo “Reno” D. Tiangco, MD; #4: Nicholas J. Yphantides, MD (Board Representative to Executive Committee); #5: Stephen R. Hayden, MD (Delegation Chair); #6: Marcella (Marci) M. Wilson, MD; #7: Karl E. Steinberg, MD

ADDITIONAL VOTING DIRECTORS Communications Chair: William T-C Tseng, MD Finance Committee Chair: J. Steven Poceta, MD Young Physician Director: Obiora “Obi” Chidi, MD Retired Physician Director: David Priver, MD Medical Student Director: Grace Chen

feature

ADDITIONAL NON-VOTING MEMBERS Alternate Retired Physician Director: Mitsuo Tomita, MD San Diego Physician Editor: James Santiago Grisolia, MD CMA Past President: James T. Hay, MD CMA Past President: Robert E. Hertzka, MD (Legislative Committee Chair) CMA Past President: Ralph R. Ocampo, MD, FACS CMA President: Theodore M. Mazer, MD CMA Trustee: William T-C Tseng, MD CMA Trustee: Robert E. Wailes, MD CMA Trustee: Sergio R. Flores, MD

6 National HIV Testing Day: The Key to Ending the Epidemic BY WINSTON TILGHMAN, MD

departments 4

Briefly Noted: Calendar • In Memoriam • Advocacy

30-Year Member Profile : Steven A. Green, MD, ABFD, FAAFP

10 Physicians Fight to Curb Health Harms Caused by Sugary Drink Intake, While Beverage Industry Plays Cynical Politics

BY STEVE KOH, MD, MPH, MBA

17 Inviting Communication

CMA TRUSTEES Robert E. Wailes, MD William T-C Tseng, MD, MPH Sergio R. Flores, MD AMA DELEGATES AND ALTERNATE DELEGATES: District 1 AMA Delegate: James T. Hay, MD District 1 AMA Alternate Delegate: Mihir Y. Parikh, MD At-large AMA Delegate: Albert Ray, MD At-large AMA Delegate: Theodore M. Mazer, MD At-large AMA Alternate Delegate: Robert E. Hertzka, MD At-large AMA Alternate Delegate: Holly B. Yang, MD

BY HELANE FRONEK, MD, FACP, FACPh

BY NATALIE D. MUTH, MD, MPH, RDN,

FAAP, AND CASSANDRA PADGETT, MS

Physician Classifieds

Initiating a Conversation with Patients Regarding Dementia

Creation and Dust: The Best of Times, The Worst of Times

BY BARBARA MANDEL, MBA

BY DANIEL J. BRESSLER, MD, FACP

JUNE 2019

AT-LARGE ALTERNATE DIRECTORS #1: Mark W. Sornson, MD; #2: Steven L-W Chen, MD, FACS, MBA; #3: Susan Kaweski, MD; #4: Al Ray, MD; #5: Preeti Mehta, MD; #6: Vimal I. Nanavati, MD, FACC, FSCAI; #7: Peter O. Raudaskoski, MD; #8: Kosala Samarasinghe, 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.]

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/////////BRIEFLY /////////////////NOTED //////////////////////////////////////////////////////////////////////// CALENDAR

JUNE 30: Champions Soirée 2019: “Awakening Wellness,” 5 p.m. Japanese Friendship Garden, Balboa Park NOW–JUNE 30: OnDemand CME Webinar on Pain Management for Older Adults available at no charge. Covers appropriate prescribing of opioid medication. Produced in partnership with The Doctors Company and Champions for Health. Visit https://championsforhealth. org/pain-managementand-opioid-prescribingfor-older-adults/ for more information and to access the webinar. JUNE 28–30: 62nd San Diego Academy of Family Physicians’ Annual Symposium, Paradise Point Resort, 1404 Vacation Road, San Diego. Visit http://sandiegoafp.org/ to register. JULY 25: SDCMS Physician Mixer, Location TBD OCT 12–16: Academy of Integrative Health & Medicine Annual Conference, Sheraton Hotel & Marina, San Diego, Learn evidence-based integrative medicine, AMA PRA Category 1 CME accredited program. Visit https://conference.aihm. org/annual/2019/index.cfm for more information and to attend.

JUNE 2019

I N M EM O RIAM :

Lori Gilbert-Kaye DR. HOWARD KAYE LOST HIS WIFE, Lori Gilbert-Kaye, on April 27. Lori was killed on Shabbat morning, the last of the eight days of Passover, during the anti-Semitic shooting attack at Chabad-Lubavitch of Poway, which shocked and outraged the nation. Lori was there to pray for and honor her mother, who recently passed away. Dr. Kaye is a member of Scripps Coastal Medical Group specializing in rheumatology and a member of SDCMS for 25 years. Howard and Lori have a 22-year-old daughter, Hannah. Lori was a beloved pillar of the Southern California Jewish community and widely praised as a loving, generous, and inspirational member of the Chabad and a large number of other community organizations. She placed herself between the gunman and the Rabbi he was targeting when she was shot. Dr. David E.J. Bazzo, president of the San Diego County Medical Society, stated, ”Gun violence is a public health issue that threatens the safety of our communities. The physicians and staff at the San Diego County Medical Society want to express our grief and distress about the shooting at the Chabad of Poway synagogue. We condemn all acts of hate and want to convey our support and love for the Jewish community and all affected by this violence. On behalf of the entire San Diego medical community, we wish to extend our deepest condolences to Howard and Hannah Kaye during this sad and difficult time.”

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LEGISLATIVE ADVOCACY

SDCMS Visits Sacramento for CMA’s Legislative Day A DELEGATION FROM the San Diego County Medical Society visited the state capital for CMA’s Legislative Day at the end of April. Attendees met with state legislators and their staffs to discuss health policy issues, heard from Governor Gavin Newsom and Lieutenant Governor Eleni Kounalakis, and received updates on legislation from top California Medical Association staff. The San Diego County delegation included SDCMS CEO Paul Hegyi and Drs. Robert Hertzka, Steven Hayden, Vimal Nanavati, Mihir Parikh, Bing Pao, William Tseng, Sergio Flores, Susan Kaweski, Alex Quick, Mark Sornson, and Bob Wailes. Medical students James Lui, Rachel Hartsell, Abhishek Kumar, Connor O’Hare, Grace Chen, and Cecelia Leggett and Champions For Health staffmembers Rebecca Valenzuela and Andrew Gonzalez attended as well. The San Diegans also lobbied in support of SB 276 (Pan) to limit exemptions for immunizations and for AB 764 (Bonta) to prohibit incentives for sugar-sweetened beverages. 5

1. Meeting with Assemblyman Todd Gloria. 2. CMA Chief Executive Officer Dustin Corcoran updates members. 3. Meeting with Assemblywoman Lorena Gonzalez. 4. Gov. Gavin Newsom addresses physicians during their Legislative Conference in Sacramento. 5. SDCMS members meeting with Senator Pat Bates. 6. Meeting with Victoria Harris of Assemblywoman Shirley Weber’s Office.

SAN DIEGO PHYSICIAN.ORG

A woman in her seventies, who had previously complained of frequent back and body aches, sore throat, and diarrhea, presented to her primary care clinic. She was last sexually active with her ex-husband 20 years ago. She was tested for HIV, as routine opt-out testing for HIV had been implemented in the clinic. Her test was positive. A man in his thirties presented to another clinic where routine HIV testing was implemented. He had been seen at a medical clinic several times over the course of a year for gastrointestinal complaints. He had male sexual partners, but he had not disclosed this to any of his medical providers and had not been tested for HIV prior to this visit. His test was positive.

JUNE 2019

national testing HIVday The Key to Ending the Epidemic

BY WINSTON TILGHMAN, MD

These two cases represent missed opportunities for early diagnosis of HIV infection and highlight the limitations of traditional focused or riskbased testing strategies. The first case demonstrates the problem of risk misperception, which occurs when a patient is inaccurately perceived by a provider to be at low risk or a patient is unaware of personal or partner behaviors that may make him or her vulnerable to HIV infection. The second case is an example of the continued stigma surrounding HIV and the fear that prevents many people from seeking an HIV test and discussing HIV risk. Both patients had multiple contacts with the healthcare system but never requested and never were offered an HIV test until they presented to facilities where HIV testing was a routine and normal part of clinical practice. June 27, 2019, is National HIV Testing Day (NHTD). First observed in 1995, NHTD is a day to encourage people to get tested for HIV and to know their status. It is an opportu-

nity for people who are living with HIV to take charge of their health and access care and treatment, and for people who are HIV-negative but vulnerable to infection to access preventive services. It is an opportunity to prevent future transmission of HIV by people who are living with HIV but not aware of it. It also is an opportunity to normalize HIV testing and decrease the stigma around HIV that prevents many people from testing. On March 25, 2019, the County of San Diego issued a recommendation for routine HIV testing of all adults and adolescents in healthcare settings, regardless of risk factors. This recommendation is part of the County’s Getting to Zero initiative to end the HIV epidemic in the region and aims to identify all people living with HIV (PLWH) and link them to life-saving antiretroviral therapy (ART). The vision is for all adults and adolescents in San Diego County to receive at least one lifetime test for HIV and to know their HIV status. This recommendation is

aligned with a recommendation issued by the Centers for Disease Control and Prevention (CDC) in 2006 for all persons aged 13 to 64 years to get tested for HIV at least once in life as a part of routine healthcare, regardless of risk factors. The CDC also recommended opt-out testing, which means that providers advise patients that HIV testing will be done as a part of their routine healthcare, unless they opt out of the test. CDC removed the requirement for a separate written consent and intensive pre-test counseling.1 Routine HIV testing also is supported by the United States Preventive Services Task Force (USPSTF), which issued a Grade A recommendation for routine testing of all persons aged 15 to 65 years and endorsed the opt-out approach recommended by CDC.2 Those with negative baseline HIV testing who are at ongoing vulnerability to HIV infection should receive at least annual HIV testing. Groups who are vulnerable to HIV include: SAN DIEGO PHYSICIAN.ORG

• Men who have sex with men (MSM) • Persons who inject drugs (PWID) • Persons who have acquired or required testing for other sexually transmitted infections • Persons who have unprotected vaginal or anal intercourse with someone who is HIVpositive or of unknown HIV serostatus • Persons with sexual partners who are MSM or PWID • Persons who exchange sex for drugs or money Providers should regularly obtain information about sexual partners and practices and substance use in order to determine who would benefit from follow-up testing.1 Advances in antiretroviral medications for HIV treatment and prevention have provided the necessary tools to end the HIV epidemic, but HIV testing is the critical first step to ensure that these tools reach those who need them.

JUNE 2019

Currently available HIV treatment regimens are highly effective at reducing viral replication and decreasing the virus circulating in the blood to levels that are too low to be detected by commercially available tests (i.e., undetectable viral load or viral suppression). Viral suppression prevents HIV from infecting target immune cells and weakening the host immune system, which prevents progression to the acquired immune deficiency syndrome (AIDS) and improves health outcomes for PLWH. In contrast to earlier treatment regimens, currently recommended agents are safer, have more favorable side effect profiles, and are associated with lower pill burden. In fact, several first-line ART regimens are available in the form of a single daily pill. Although a cure for HIV infection remains elusive, with medication PLWH enjoy long life expectancy and high quality of life similar to that experienced by people living with other manageable chronic diseases.

In addition to the individual benefits conferred by ART, HIV treatment benefits the general population by decreasing onward transmission. Several recent clinical trials have demonstrated that PLWH with sustained viral suppression (i.e., undetectable viral load for ≥6 months) have effectively no risk of sexually transmitting the virus to an HIV-negative partner.3-5 This concept of HIV treatment as prevention has been described as “U=U,” or “Undetectable = Untransmittable.” Therefore, HIV testing, early diagnosis of all PLWH, and ART for all PLWH have the potential to interrupt transmission and stop new HIV infections from occurring. ART also has shown benefit in preventing HIV infection when used by people who are HIV-negative but at elevated risk of acquiring HIV. The use of antiretroviral medications by people who are HIV-negative is known as pre-exposure prophylaxis, or PrEP. Currently one antiretroviral medication, which is a fixed-dose combination of emtricitabine and tenofovir disoproxil fumarate (Truvada®, Gilead Sciences), has been approved for use as PrEP by the U.S. Food and Drug Administration. Clinical trials have demonstrated that, if taken as directed, Truvada can decrease the risk of HIV acquisition by up to 99%.6 In addition to identifying PLWH who would benefit from treatment, HIV testing also is an opportunity to identify vulnerable HIV-negative individuals who may benefit from PrEP and other prevention strategies (e.g., condoms). Despite the promise of HIV medications as treatment and prevention, delayed diagnosis of HIV infection is still a reality that limits the ability of these strategies to end the HIV epidemic. According to a recent CDC report, among people diagnosed with HIV infection in 2015, the median interval from the time of infection to the time of diagnosis was three years (interquartile range 0.7-7.8 years) overall and even longer (4.9 years) for heterosexual males. Among MSM, PWID, and vulnerable heterosexuals who reported not having been tested for HIV in the previous 12 months, about twothirds reported having seen a healthcare provider in the past year. Of those who were not tested for HIV in the past 12 months but had seen a provider during the same time frame, three-fourths reported not being offered the test at any of their visits.7 Local surveillance data also indicate delays in HIV diagnosis. In 2015, 22% of new cases of HIV infection in San Diego County also received an AIDS diagnosis within the first year of HIV diagnosis. Furthermore, a total of 20% of individuals diagnosed with HIV infection between 2012 and 2016 received “simultaneous diagnoses” (i.e., were diagnosed with AIDS within 30 days of HIV diagnosis). People aged 50 years and older, who often are not tested due to perceived low risk, were more likely to have simultaneous diagnoses than other age cohorts (30.2% versus 8.0%, 14.6%, and 20.4% of newly diagnosed persons aged 20–29 years, 30–39 years, and 40–49 years respectively). Delayed and simultaneous diagnoses indicate a time interval of several years between HIV infection and diagnosis. Thanks to effective medications and a well-developed

infrastructure for the delivery of HIV care, treatment, and preventive services, San Diego County can end the HIV epidemic. In 2017, a total of 392 new cases of HIV infection were reported in the region, representing a 21% decrease from 499 cases reported in 2016 and the lowest number of new diagnoses since 1984. However, it is estimated that there are about 1,446 PLWH in San Diego County who are unaware of their status. Identifying these individuals through testing is important, as about 38% of HIV transmissions are attributed to PLWH who are unaware of their status.8 Even in the absence of treatment, being aware of an HIV diagnosis is associated with decreased engagement in behaviors that could result in transmission of HIV to others.9

NHTD is a reminder of the importance of HIV testing and the central role that testing plays in efforts to get to zero new HIV infections. To commemorate NHTD, the County of San Diego will partner with Walgreen’s and the Greater Than AIDS campaign to provide free HIV testing at the Walgreen’s Hillcrest location. Free walk-in HIV testing also is available at County of San Diego STD clinics and other locations throughout San Diego County. More information about HIV testing locations is available at http://getting2zerosd.com/get-tested/. Dr. Tilghman is the medical director/STD controller, HIV, STD & Hepatitis Branch of Public Health Services for the County of San Diego Health & Human Services Agency.

References: 1 Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in healthcare settings. MMWR Recomm Rep. 2006;55(RR14):1–17. 2 Moyer VA. U.S. Preventive Services Task Force. Screening for HIV: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159(1):51–60. 3 Cohen MS, Chen YQ, McCauley M, et al. Antiretroviral therapy for the prevention of HIV-1 transmission. N Engl J Med. 2016;375(9):830–9. 4 Rodger AJ, Cambiano V, Bruun T, et al. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. JAMA. 2016;316(2):171–81. 5 Bavinton BR, Pinto AN, Phanuphak N, et al. Viral suppression and HIV transmission in serodiscordant male couples: an international, prospective, observational, cohort study. Lancet HIV. 2018;5(8):e438e447. 6 Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med. 2010;363(27):2587–99. 7 Dailey AF, Hoots BE, Hall HI, et cal. Vital Signs: Human Immunodeficiency Virus Testing and Diagnosis Delays—United States. MMWR Morb Mortal Wkly Rep. 2017;66(47):1300–1306. 8 Li Z, Purcell DW, Sansom SL, Hayes D, Hall HI. Vital Signs: HIV Transmission Along the Continuum of Care—United States, 2016. MMWR Morb Mortal Wkly Rep. 2019;68:267-272. 9 Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. 2006;20(10):1447-50.

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P U B L I C H E A LT H

Physicians Fight to Curb Health Harms Caused by Sugary Drink Intake, While Beverage Industry Plays Cynical Politics By Natalie D. Muth, MD, MPH, RDN, FAAP, and Cassandra Padgett, MS

JUNE 2019

AS THE DIRECTOR and health coach of a pediatric nutrition and healthy weight clinic, every day we see children harmed by sugary drinks — from the teen diagnosed with type 2 diabetes to the toddler already showing signs of fatty liver disease. Sugary drinks are a mainstay in many kids’ diets. The ubiquity, low cost, slick marketing, and sweet taste of soda, sports drinks, and fruit-flavored beverages appeal to kids and teens. As adults, all of us need to do more to protect our kids from the very real and lasting harm these drinks pose to our children’s health. For years, physicians and other healthcare professionals have tried various strategies to get our patients to cut back on sugar in general and sugary drinks in particular. We talk about healthy eating with our patients and their families at every well visit. We encourage kids to eat more fruits and vegetables and avoid sugary drinks. We share the strong evidence linking too much sugar to diabetes, heart disease, tooth decay, and myriad other health harms. Yet, a typical child consumes more than 30 gallons of sugary drinks every year. That is enough to fill a small bathtub, and it doesn’t even include added sugars from food. The 2015–2020 Dietary Guidelines for Americans recommend that children and teens consume fewer than 10 percent of calories from added sugars. But data show that children and teens now consume nearly double that, more than half of which comes from drinks. While individual choices and creating a healthy home environment are critically important, they are not enough. Just as public health and policy approaches were necessary to curb tobacco and alcohol use, we need similar initiatives to reduce sugary drink consumption in children and adolescents. In a recent joint policy statement, the American Academy of Pediatrics and the American Heart Association endorsed several public health measures designed to reduce kids’ consumption of sugary drinks, including a tax, decreased marketing to children and adolescents, milk and water as default options on children’s menus, nutrition and warning labels, and hospital policies that limit or discourage their purchase (Muth et al, 2019). These policies work when implemented, but the pushback from food and beverage companies is persistent. A January 2019 report from the University of Connecticut

Rudd Center for Food Policy and Obesity found that food and beverage corporations are spending millions of dollars each year on ads targeted at kids and teens, and many specifically target Hispanic and black youth, who already face increased risk for chronic disease due to health disparities (Harris et al, 2019). Last year, the American Beverage Association promised to drop its ballot measure to require a two-thirds majority of voters to approve any local tax increase only if legislators passed a law prohibiting California cities from introducing new sugary drink taxes until 2031. The beverage industry got its way. Big Soda spends millions each year advertising to children and teens, and lobbying to influence policymakers, making it challenging to gain traction under their market power. The American Beverage Association spent $11.8 million in the last two years lobbying California elected representatives, and more than $30 million lobbying nationwide (Lobbying Spending Database Food & Beverage, 2018). Unfortunately, many California state senators, assembly, and/or staff accepted a campaign contribution or donation in 2017/2018 from the American Beverage Association, the CocaCola Co. or PepsiCo. In an effort to reduce sugary drink consumption and improve health in a state where 1 in 12 have diabetes, California legislators introduced a package of bills earlier this year aligned with recommendations from the AAP/AHA joint statement. The California Medical Association, the California American Academy of Pediatrics, and the California Dental Association cosponsored these bills. A Sugary Drink Tax Assemblymember Bloom’s (D-Santa Monica) AB 138 proposed a statewide sugary drink tax with revenues directed to a Community Health Fund to promote health and reduce the impacts of diabetes, obesity, and heart and dental disease in California. The bill is currently on hold for the remainder of the current legislative session, and will be reviewed again next year by the Assembly Committee on Revenue and Taxation. We know that price increases are associated with a decrease in consumption. As tobacco taxes increased, cigarette use dropped precipitously, especially in kids and people of lower socioeconomic status.

“As the director and health coach of a pediatric nutrition and healthy weight clinic, every day we see children harmed by sugary drinks — from the teen diagnosed with type 2 diabetes to the toddler already showing signs of fatty liver disease.” Alcohol excise taxes reduced excess alcohol consumption and alcohol-associated motor vehicle collisions. Excise taxes on sugary drinks have successfully reduced consumption in cities like Berkeley and San Francisco. Studies have found that a sugary drink tax would be the most effective strategy to lower rates of childhood obesity, leading to prevention of obesity in 575,000 children and a savings of $31 per dollar spent over 10 years nationwide (Gortmaker et al, 2015). Opponents argue that the taxes can be regressive, as lower-income individuals bear a greater burden from the tax. However, when the monies raised pay for programs that will reduce health inequities, the communities most impacted by the tax are the same communities who benefit most from both an economic and health perspective. Promotional Discount Assemblymember Bonta’s (D-Alameda) AB 764 proposes to ban the soda industry practice of targeting communities with promotional discounts that make soda cheaper than water. As of early May 2019, the bill is still active and in committee process. Keeping water cheaper than soda supports recent research that shows a relationship between water and soda intake. The National Health and Nutrition Examination Survey data revealed that one in five kids did not drink any water in the previous 24 hours (CDC, 2016). Kids who don’t drink water are SAN DIEGO PHYSICIAN.ORG

P U B L I C H E A LT H

likely to get their fluids elsewhere, which can mean extra sugar and calories. Not drinking water is associated with drinking an average of 92 extra calories per day, while it only takes an extra 70 calories per day to gain excess weight and be at risk for overweight or obesity (Rosinger et al, 2019). Checkout Counter AB 765 “California Healthy Checkout Aisles for Healthy Families Act” by Assemblymember Wicks (D-Oakland) proposes removing soda from checkout counters in retail, grocery, or convenience stores in order to decrease impulse purchases. Instead, the bill suggests that stores would be required to only offer water, milk, or fruit juice in place of sodas. This bill follows tobacco legislature that supports “out of sight, out of mind”. Removing tobacco from point of sale displays was particularly impactful in denormalizing smoking for youth, decreased brand awareness or preference, as well as an added barrier for teen smokers (Hurk et al, 2018 &Bogdanovica et al, 2014). Portion Sizes Assemblymember Chiu’s (D-San Francisco) AB 766 proposed to cap fountain drink portions at 16 ounces. New York passed a similar law in 2013; however, it was appealed in 2014, when the New York State Court of Appeals wrote that the New York Board of Health “exceeded the scope of its regulatory authority.” The beverage industry fought hard and spent millions lobbying against this bill. Opponents argue that restricting beverage size is an overstep of the government, and borders on “nanny state” territory. With fountain drinks and “Big Gulp” options exceeding 50 ounces or 600 calories, where should the line be drawn? Warning Label Senator Monning’s (D-Monterey) SB 347, or the “Sugar-Sweetened Beverages Safety Warning Act,” would require labels on sweetened drinks to warn that “drinking beverages with added sugar(s) may contribute to obesity, type 2 diabetes, and tooth decay.” The bill would also require that vending machines that sell sweetened drinks would have such warning labels as well. As of mid-May 2019, the bill is still active and headed to the full Senate for a vote. Research on the impact of sugar-sweetened beverage warning labels found that having warning labels increased perceived

JUNE 2019

risk of drinking sweetened drinks among adolescents (Popova et al, 2019). Similarly, warning labels on tobacco became a requirement in 1965, however, recent research indicates that “graphic” warning labels are more impactful in reducing use. Regardless, warning labels are an important step in educating the public about the health consequences of consuming sugary drinks. Unfortunately, given the influence of the beverage industry in Sacramento, only two of these bills are still active. Still, California legislators have promised to continue to pursue public health measures to curb sugary drinks consumption. Every child deserves to grow up to be healthy. We need to do more to promote healthy beverage options like water and milk and discourage sugary drinks. For the sake and wellbeing of California’s kids, strong support and advocacy from California’s physicians is needed to help hold our elected officials accountable and counteract the powerful influence of the beverage industry in Sacramento.

Editor’s Note: The California Medical Association is spearheading efforts to qualify a 2020 ballot measure that would create a new 2-cent-per-ounce excise tax on sugary drinks that could generate $2 to 3 billion a year. The majority of the revenue would go to fund prevention and treatment programs for medical and dental diseases linked to sugary drinks. A portion of it would pay for improving access to fresh fruits and vegetables as well as research on diseases linked to sugar-sweetened drinks. Dr. Muth, a pediatrician, registered dietitian, and lead author of the AAP/ AHA joint statement on public policies to reduce sugary drink consumption in children and adolescents, and health coach Cassandra Padgett lead the W.E.L.L. Clinic at Children’s Primary Care Medical Group-La Costa as well as San Diego County’s first chapter of Walk with a Doc, held Tuesdays at 4 p.m. at Stagecoach Park in Carlsbad.

Bogdanovica, I., Mcneill, A., Szatkowski, L., & Britton, J. (2013). Exposure to point-of-sale tobacco displays and changes in susceptibility to smoking in secondary school students. Addiction,110, 693–702. doi:10.1016/s01406736(13)62451-4

Harris, J. L., Frazier, W., Kumanyika, S., & Ramirez, A. G. (2019, January). Rudd Report: Increasing disparities in unhealthy food advertising targeted to Hispanic and Black youth. Retrieved May 2, 2019, from http:// uconnruddcenter.org/targetedmarketing

Gortmaker, S. L., Wang, Y. C., Long, M. W., Giles, C. M., Ward, Z. J., Barrett, J. L., . . . Cradock, A. L. (2015). Three Interventions That Reduce Childhood Obesity Are Projected To Save More Than They Cost To Implement. Health Affairs,34(11), 1932–1939. doi:10.1377/hlthaff.2015.0631

Hurck, M. M., Nuyts, P. A., Monshouwer, K., Kunst, A. E., & Kuipers, M. A. (2018). Impact of removing point-of-sale tobacco displays on smoking behaviour among adolescents in Europe: A quasi-experimental study. Tobacco Control. doi:10.1136/tobaccocontrol-2018-054271

Grynbaum, M. (2014, June 26). New York’s Ban on Big Sodas Is Rejected by Final Court. Retrieved from https://www.nytimes. com/2014/06/27/nyregion/cityloses-final-appeal-on-limitingsales-of-large-sodas.html

Lobbying Spending Database Food & Beverage, 2018. (n.d.). Retrieved from https://www. opensecrets.org/lobby/indusclient.php?id=N01&year=2018

References

Muth, N. D., Dietz, W. H., Magge, S. N., & Johnson, R. K. (2019). Public Policies to Reduce Sugary Drink Consumption in Children and Adolescents. Pediatrics,143(4). doi:10.1542/ peds.2019-0282 CDC National Center for Health Statistics. National Health and Nutrition Examination Survey (NHANES): MEC In-Person Dietary Interviewers Procedures Manual. https://wwwn.cdc.gov/ nchs/data/nhanes/2015-2016/ manuals/2016_MEC_In-Person_Dietary_Interviewers_Procedures_Manual.pdf. Published January 2016. Popova, L., Nonnemaker, J., Taylor, N., Bradfield, B., & Kim, A. (2019). Warning Labels on Sugar-sweetened Beverages: An Eye Tracking Approach. American Journal of Health Behavior,43(2), 406-419. doi:10.5993/ ajhb.43.2.16

Rosinger, A. Y., Bethancourt, H., & Francis, L. A. (2019). Association of Caloric Intake From SugarSweetened Beverages With Water Intake Among US Children and Young Adults in the 2011–2016 National Health and Nutrition Examination Survey. JAMA Pediatrics. doi:10.1001/jamapediatrics.2019.0693 Vedantam, S., Shah, P., & Boyle, T. (2019, April 25). This Is Your Brain On Ads: How Mass Marketing Affects Our Minds. Retrieved from https://www. npr.org/2019/04/25/717105311/ this-is-your-brain-on-ads-howmass-marketing-affects-ourminds Young, S., Young, S., & Young, S. (2019, April 09). Big Soda Pours Big Bucks Into California’s Capitol. Retrieved from https:// californiahealthline.org/news/ big-soda-pours-big-bucks-intocalifornias-capitol/

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SAN DIEGO PHYSICIAN.ORG

M E N TA L H E A LT H

10 Warning Signs of Dementia to Assess

Memory loss that disrupts daily life

Challenges in planning or problem solving

Initiating a Conversation with Patients Regarding Dementia By Barbara Mandel, MBA

Difficulty completing familiar tasks

Confusion with time or place

Trouble with visual images or spatial relationships

Problems finding appropriate words

FAMILY PHYSICIANS, internists, and other primary care providers have a lot on their plates, particularly when caring for older adult patients. With a higher proportion of cardiovascular disease, diabetes, pulmonary disease, and other health issues, older adults typically require more frequent and more complicated medical visits. These are key reasons that primary care providers are the most appropriate healthcare professionals to assess cognitive function. Further, the close relationship and trust built over time provides the primary care physician the optimal opportunity for identifying and communicating cognitive changes. The Alzheimer’s Project, launched by the County of San Diego in 2014 to address the growing incidence of Alzheimer’s disease and related dementias in our community, is a multipronged initiative to drive for a cure, provide support for caregivers and family members, increase public awareness of dementia and its ramifications throughout the community, and support physicians whose responsibility is to care for the thousands of older adults struggling with

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Misplacing items and inability to retrace steps

Decreased or poor judgement

Withdrawal from work or social activities

Changes in mood and personality

cognitive decline. The Clinical Roundtable, led by a dedicated group of neurologists, psychiatrists, geriatric psychiatrists, and geriatricians, and facilitated by Champions for Health, has developed a set of best-practices guidelines and tools to support our community’s physicians. When should a physician begin to assess cognitive capacity? Medicare encourages a check for cognitive impairment during the annual wellness visit while conducting the prescribed review of the beneficiary’s potential risk factor for depression. Some health systems utilize nurse care managers to conduct an initial screen (often an AD8) over the telephone, and then communicate the results with the primary care physician for follow-up. At times, a patient may initiate the conversation with their physician. But most commonly, a caregiver or family member accompanying the patient for an office visit for another health issue raises a concern, or the physician notices changes in demeanor or behaviors during a scheduled visit. But how can a physician address this complex subject during a typical 12-minute visit when facing other pressing issues? According to Michael Lobatz, MD, neurologist at Neurology Center of Southern California, co-chair of the Clinical Roundtable and medical director of the Rehabilitation Center at Scripps Memorial Hospital Encinitas, the key is to begin the conversation about the importance of cognitive/memory function assessment, and suggest a separate appointment to solely address these concerns. The physician can then request that the family member complete an informant survey, such as an AD8 or IQCODE, at home and bring it to the next

appointment. “By completing the survey outside of the medical office, the family member has more time to recall specific concerns, and can provide this valuable information to the provider without disclosing too much in front of their loved one,” says Dr. Lobatz. “The caregiver or spouse generally provides the most pertinent information, either by reiterating specific instances for concern, or frequently through nonverbal cues like rolling their eyes when you ask about memory issues, difficulties with functional activities, or driving.” Daniel Sewell, MD, associate vice chair and co-director, Division of Geriatric Psychiatry at UC San Diego, and Clinical Roundtable member adds, “It

is critical when initiating the conversation to explain that, like all parts of the body, the brain ages, and changes in memory and cognition that may occur with aging are important aspects of overall health. Encourage older patients to be aware of changes, and make sure they understand that cognitive aging is not a disease and is not the same as dementia.” Individuals concerned about their memory may be among the ‘Worried Well’ and need reassurance that their experience is part of normal aging. Tracking concerns over time will give the practitioner information regarding changes in cognitive function. “A way to initiate the conversation is to ask a few simple questions, like, ‘Are you worried about

A way to initiate the conversation is to ask a few simple questions, like, ‘Are you worried about your memory? Have you noticed a change in your memory that concerns you?’

your memory? Have you noticed a change in your memory that concerns you?’” adds Dr. Lobatz. Drs. Lobatz and Sewell recently produced an ondemand webinar providing CME credits on initiating the conversation, which will soon be available on the ChampionsforHealth.org/alzheimers website. The website also includes a robust toolkit including the Guidelines, listing of resources for caregivers, information on the mobile application AlzDxRx, and a complement of on-demand webinars. Ms. Mandel is the facilitator for the Alzheimer’s Project Clinical Roundtable and former CEO of Champions for Health.

SAN DIEGO PHYSICIAN.ORG

MEMBER PROFILES

Steven A. Green, MD, ABFD, FAAFP 30-YEAR SDCMS MEMBER By Steve Koh, MD, MPH, MBA

IF THERE IS ONE THEME that can describe the career of Steven Green, MD, it is the value in mentorship. As the chief medical officer of Sharp Rees-Stealy Medical Group, he cites past mentors, touts importance of physician leadership, and mentoring of younger colleagues as important factors in his success. In many ways, his leadership and clinical care philosophy at Sharp revolves around the concept of mentoring the team to provide the best care to their patients. While Dr. Green was born and raised in LA, after graduating from UC San Diego School of Medicine, he realized he wanted to make a life in San Diego. After Family Medicine residency training at Northridge Hospital, he started practice in San Diego in

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1988 with SRSMG and has been there ever since. While no one in his family is in medicine, “I always had interest in sciences in school and was fascinated by biochemistry, and looked for a career where I can use that interest and skills to help people,” Dr. Green says. “So a career in medicine was ideal for me.” As he looks back on his medical career, he cites three individuals who had lasting impact: Mike Greengold, MD (his residency director and “a role model from whom I learned a great deal”), Don Balfour, MD (predecessor CMO of Sharp Rees-Stealy Medical Group “who shared his wealth of knowledge and leadership experience at how to lead our group”), and Don Cauthen, MD (organizer of Scott and White Clinic in Dallas where “I first learned about what

physician leadership was all about”). Since starting his career in FM in 1988, he has steadily taken on physician leadership roles, both inside and outside SRSMG, including being president of the California Academy of Family Physicians, that led up to him becoming CMO of Sharp Rees-Stealy Medical Group in 2015. This appointment is cited as one of the highlights of his career. “I get to be a leader of a group of amazing physicians who I work with to come up with great, innovative ideas and help them maximize their potential in improving patients’ lives,” Dr. Green says. As he looks back on his career, he values the increase in accountability in healthcare but at times feels the overabundance of data, reporting requirements and administrative duties can be overwhelming. He hopes physicians are able to deal with pertinent information in more efficient ways; one of his pet peeves is the misuse of information that leads people to jump to conclusions. To this end, one of his proudest projects recently has been the primary care transformation effort “to redesign care to deliver better care and at the same time support physicians so their work can be done at work, not at home,” Dr. Green says. As he looks forward, he hopes he can continue to contribute to the improvement of Sharp Rees-Stealy so it can be the “best place to practice medicine, receive care and work,” he says. As a long-standing member of the San Diego County Medical Society, he has found value in its role in bringing physicians and physician leaders together. In this collaboratively enriching environment, he is hopeful that the Society will continue to advocate and lead our peers to work on important issues such as physician burnout. Outside of a dedicated career in medicine and being a physician leader, he enjoys the company of his wife, who trains and rides horses, and their three children, two of whom are college students, and one who is pursuing a career in film. In his spare time, he loves open-water swimming, having swum across the English Channel, Catalina Channel, and around Manhattan Island, and rowing with the San Diego Rowing Club.

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

Inviting Communication By Helane Fronek, MD, FACP, FACPh

WHENEVER I PICK UP a new activity, I’m struck by the breadth of things I never knew I didn’t know. I laugh as I recall my naivete on beginning to play the bass guitar. “It’s just four strings … how hard can it be?” One of many new challenges is learning my role in a band, creating a bass line that supports the melody and adapts to what my fellow musicians are playing. During a recent practice, while attempting to correct yet another blunder, I heard the voice of an observer behind me, insistently telling me what I was doing wrong and how to correct it. While I appreciate suggestions that help me find a solution or see another perspective, there was too much for me to integrate in that moment and my attention was focused on

my band members. What this person didn’t recognize is that there are times when communication can effectively occur, and others when it’s best to hold our ideas until the person is better able to hear them. As George Bernard Shaw remarked, “The single biggest problem in communication is the illusion that it has taken place.” In the SPIKES protocol for delivering bad news, we’re encouraged to ask our patient for an invitation to share information. We have all had the experience of telling a patient they had a serious condition and watching their eyes become distant as they were consumed by emotion. If we forge ahead and tell them everything we think they should know, they become overwhelmed, leading to inaccurate or

missed communication. At these times, we’re wise to pause and check in with our patient. We can ask if they are ready to hear more, what they want to hear and how they want to hear it. Not only does this improve the chance that we will be heard, it also demonstrates respect for our patient and lets them know they are in a safe and caring environment. Asking for an invitation before any difficult or high-stakes conversation can significantly improve our chance of success. Explain what you wish to talk about and ask if this is a good time or if there might be a better time to have the discussion. This gives the person a measure of control, setting up a level playing field for free and respectful communication. Allowing the person to ready themselves to confront the challenging issue affords them an opportunity to reflect on what they believe and want to share. While we each grew up talking, most people aren’t skillful communicators. Communicating is more than delivering information. We must consider who we are speaking with and enhance their ability to hear us. The words we use and their congruence with our tone of voice and body language make us understandable, believable, or not. Exploring the other person’s reaction to what we’ve said completes the communication. By first asking for an invitation, we demonstrate respect and open the channel so true communication can occur. Dr. Fronek, SDCMS-CMA member since 2010, is assistant clinical professor of medicine at UC San Diego School of Medicine and a certified physician development coach who works with physicians to gain more power in their lives and create lives of greater joy. Read her blog at helanefronekmd.com. SAN DIEGO PHYSICIAN.ORG

CLASSIFIEDS PHYSICIAN OPPORTUNITIES PEDIATRICIANS WANTED: Grossmont Pediatrics mission of providing family-focused individualized care of the child - a private pediatrics practice with over 4500 Commercial HMO, PPO, Tricare and MediCal patients. Clinical cases include ADHD, asthma, adolescent mental, behavioral health and minor procedures. See an average of 2.8 patients/hour, very light call & newborn rounding at one hospital 1 in 3. Using Epic EHR access real-time to Rady Children’s, UCSD, Scripps, Sharp for outside care to your patients. Working 28 or 32 hours per week [M-F only] you will earn between $150,000 and $180,000 annually in compensation; accrue 2-3 weeks PTO plus holidays, and a future share in practice growth. Grossmont Pediatrics pays for professional expenses related to your employment; and after 90 days, Health and Dental, 401K, etc. Contact venk@ gpeds.sdcoxmail.com or 619-504-5830 with resume in .doc, .pdf or .txt (Posted 4/9/19) UCSD, DEPARTMENT OF PEDIATRICS AND RADY CHILDREN’S HOSPITAL, CLINICAL POSITIONS AVAILABLE: The University of California, San Diego (UCSD) Department of Pediatrics (http://wwwpediatrics.ucsd.edu), and Rady’s Children’s Hospital of San Diego (http://www.rchsd.org ) is seeking clinicians to provide patient care at the Urgent Care Clinics of the Division of Emergency Medicine and Urgent Care. Clinicians should be board certified or board eligible in general pediatrics and have some experience in urgent care. The Urgent care has 5 centers located throughout San Diego County. We have full time and part time clinical positions available and see about 60,000 pts/year. We have a great team of nurses, patient access reps and physicians and are looking for those who can work independently with excellent personal and clinical skills. UC beneﬁts are acknowledged to be among the ﬁnest in higher education. As UC Staff, you’ll enjoy comprehensive health and welfare plans protecting you and your family, an attractive pension, and optional retirement savings opportunities. Interested persons should contact Katherine M. Konzen, MD, MPH at 858-9668036. (Posted 2/28/2019) IMPERIAL RADIOLOGY - RADIOLOGIST NEEDED: Our Facility is an outpatient Diagnostic facility located in Imperial, CA and we are in search of a Part-Time/Full-Time Radiologist. All candidates must have an active California Medical License. Pay to be determined. Please contact us at info@ carlsbadimaging.com if this job is of interest to you. FAMILY MEDICINE PHYSICIANS NEEDED: Graybill Medical Group is one of North San Diego County’s largest independent multi-specialty groups with over 80+ physicians and advanced practitioners. We currently have FM openings in our Ramona and Valley Center locations (solo practices) 3-4 days/week and a full-time FM or IM opening in Vista. Current CA and DEA licenses required. Must be BC/BE. Conduct medical diagnosis and treatment of patients in an outpatient setting. Bilingual in English/Spanish helpful. We offer a competitive compensation and benefit package including malpractice coverage and shareholder opportunity. Check out a full list of our benefits under Careers at www.graybill.org. Send CVs to ssnodgrass@graybill. org, apply online, or fax (760)738-7101. CARDIOLOGIST POSITION AVAILABLE: Seeking a cardiologist to work part-time in an outpatient cardiology practice in North San Diego County. Practice opportunities from Mon.-Friday. Hours are from 8 to 5 p.m. There is no night calls, or holidays work days. The contracted cardiologist would decide from the days available which days to work. Please fax resume to 760.510.1811 or via e-mail at evelynochoa2013@yahoo.com. FAMILY PRACTICE MD/DO: Family Practice MD/ DO wanted for urgent care and family practice office in Carlsbad, CA. Flexible weekday and weekend

JUNE 2019

shifts available for family practice physician at busy, well-established office. FAX or email CV to (760) 603-7719 or gcwakeman@sbcglobal.net. PRACTICE OPPORTUNITY: Internal Medicine and Family Practice. SharpCare Medical Group, a Sharp HealthCare-affiliated practice, is looking for physicians for our San Diego County practice sites. SharpCare is a primary care, foundation model (employed physicians) practice focused on local community referrals, the Patient Centered Medical Home model, and ease of access for patients. Competitive compensation and benefits package with quality incentives. Bilingual preferred but not required. Board certified or eligible requirement. For more info visit www.sharp.com/sharpcare/ or email interest and CV to glenn.chong@sharp.com. PHYSICIAN NEEDED: Family Practice MD. San Ysidro Health is looking for an MD for our Family Practice center. The Family Practice MD manages and provides acute, chronic, preventive, curative and rehabilitative medical care to patients and determines appropriate regimen in specialized areas such as family practice, prenatal OB/GYN, pediatrics and internal medicine. Bilingual preferred but not required. Medical school graduate, CPR, CA MD and DEA License, board certified or eligible in primary care specialty. For more info on San Ysidro Health, visit: http://www.syhealth.org/ If interested, please email CV to Meagan.underwood@syhealth.org. DERMATOLOGIST NEEDED: Premier dermatology practice in beautiful San Diego seeking a full-time/ part-time BC or BE eligible Dermatologist to join our team. Existing practice taking over another busy practice and looking for a lead physician. This is a significant opportunity for a motivated physician to take over a thriving patient base. Work with two 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, cosmetic and surgical dermatology (including MOHs) in a medical office with state of the art tools and instruments. Please call Practice Administrator at (858) 761-7362 or email jmaas12@ hotmail.com for more information. OUTPATIENT PRIMARY CARE OPPORTUNITY: San Diego Internal Medicine Associates (SDIMA) is looking for a strong MD candidate to join our 6 physicians and 6 physician assistants in providing excellent care in a private practice setting. SDIMA is a well-established office with board certified internists and med/peds physicians. No hospital call. Please send your CV, or any questions you may have to Jared.Kowerski@SDIMA.com.” PRACTICE FOR SALE MEDICAL SPA AVAILABLE TO LICENSED PHYSICIAN: Southern California | Owner Benefit: $410,000 | This practice performs cosmetic procedures such as dermal fillers, Botox, and cosmetic laser treatments. The business has strong cashflow and is poised for continued growth. Minimal physician in-clinic time required and patients pay at time of service. Owner is retiring. A strong operations team will remain post acquisition. To see more (video interview with seller, assessment report, financials, etc.) visit: https://goexio.com/ med-spa and select “Private Access” to sign an electronic NDA. Diligence materials available to qualified buyers only. Prefer a personal touch? Contact Bill Littlefield: (541) 429-2950. bill. littlefield@goexio.com. FOR SALE, BUSY FAMILY PRACTICE POTENTIAL URGENT CARE: Established family practice for 27 years located in Chula Vista near H Street at 805 in upscale mall setting. Ideal location with free and easily accessible parking. Spacious 2600ft office space with CLIA Certified Lab and X-Ray. Practice accepts and experienced in billing: Medicare, Tricare, Immigration Exams, DOT Certification, Workers Comp. Contact: S.J. Anderson 858-736-5818 or email marva.winchi.garcia@gmail.com

INTERNAL MEDICINE PRACTICE OPPORTUNITY: Internal Medicine practice in North San Diego County, Tri-City community, established for over forty years, available for full or part-time physician. This practice has an established EMR system, exceptional office staff and shares overhead with five other Internists. Inpatient activity available at your option. Please email:jalafata@aol.com, or call North County Internal Medicine at 760-726-2180. (Posted 1/14/2019). HIGHLY PROFITABLE MEDSPA NOW AVAILABLE TO LICENSED PHYSICIAN: Southern California | Asking Price: $1,050,000 | Cash Flow: $410,419 | This profitable and expandable company performs non-invasive cosmetic procedures, including dermal fillers, Botox, and laser treatments. Experienced staff plans to stay, and protects current physician/ owner at 30 hours/week max. If you’re ready to see online financials, a studio-quality video of their story, an industry-leading assessment, and more – visit: https://goexio.com/med-spa-landing-sd for a summary. Interested? Click on “Private Access” to sign an instant nondisclosure and unlock the entire story. Full financials available on request. Prefer a personal touch? Contact Doug Miller: (208) 7623451. doug.miller@goexio.com. PRACTICE AVAILABLE IN EL CAJON: Mature board certified Family physicians grossing $ 1 million per year are selling this practice in El Cajon, California. This is a busy practice, on the Allscripts EHR in a busy neighborhood and contracted with local IPAs. I will lease the 1500 sqft office condo to you as well. Send an inquiry to Dennis O Dominguez dd489583@gmail.com or send text to 619 2464548 and I will call you. PRACTICES WANTED PRIMARY OR URGENT CARE PRACTICE WANTED: Looking for independent primary or urgent care practices interested in joining or selling to a larger group. We could explore a purchase, partnership, and/or other business relationship with you. We have a track record in creating attractive lifestyle options for our medical providers and will do our best to tailor a situation that addresses your need. Please call (858) 832-2007. PRIMARY CARE PRACTICE WANTED: I am looking for a retiring physician in an established Family Medicine or Internal Medicine practice who wants to transfer the patient base. Please call (858) 257-7050. OFFICE SPACE / REAL ESTATE AVAILABLE

NEW OFFICE SPACE IN VISTA

500-4000 sq. ft. office units available for lease in brand new high-quality building, in second story with elevator above a thriving primary care clinic and urgent care attracting 100 patients per day of foot traffic. Street-facing and located in Vista along the growing redevelopment zone. Please contact Richard Alvarez at Prime Investors Corp. ralvarez2@verizon.net or 760-224-9283. EL CAJON MEDICAL OR DENTAL BUILDING FOR SALE OR LEASE: 3,700 square foot medical or dental building with 11 exam rooms available for sale or lease! Sink in all exam rooms, nurses station, break room, abundance of storage, etc. Building has been very well cared for and $200,000+ has gone into it since 2006. Prime location only three blocks from I-8 freeway exit right off of Broadway. Property also features oversized lot with 20+ parking spaces. Asking Sale: $1,199,000. Asking Lease: $7,500/month + NNN. Terms are negotiable.

Please contact: Dillon.Myers@TonyFrancoRealty. com | (619) 738-2318 (Posted 4/30/2019) MEDICAL OFFICE LEASE: We currently have a small medical office ready to lease. The office is located in Imperial county and is approximately 910 sqft. Please email us at info@carlsbadimaging.com with any with further questions or needed details. (posted 4/29/2019)

KEARNY MESA MEDICAL OFFICE - FOR LEASE 7910 Frost Street. Class A medical office building adjacent to Sharp Memorial and Rady Children’s hospitals. Suites ranging from 1,300-5,000 SF. For details, floor plans and photos contact David DeRoche (858) 966-8061 | dderoche@rchsd.org

MEDICAL OFFICE SPACE FOR LEASE: Medical office space available for lease, located at 15721 Pomerado Road, Poway, 92064 in the Gateway Medical Center. This large facility has a large shared waiting room, front desk reception area, two exam rooms, nursing station, private office, 3 shared in office restrooms & staff lounge. The suite is shared with an internal medicine group, neurology group, podiatry group, laboratory, endocrinology, & acupuncture. Walking distance to Pomerado Hospital. Ample parking & private tenant gym with showers. Imaging, Lab Corp & Quest are located in an adjacent building. Great opportunity in this affluent community. Call Angie (858) 485-6644. (Posted 4/29/19) OFFICE SPACE AVAILABLE FOR LEASE: 5004000 sq. ft. office units available in brand new high-quality building, in second story with elevator above a thriving primary care clinic and urgent care attracting 100 patients per day of foot traffic. Street-facing and located in Vista along the growing redevelopment zone. Please contact Richard Alvarez at Prime Investors Corp. ralvarez2@verizon.net or 760-224-9283. (Posted 4/18/19) SUBLEASE OFFICE SPACE: 9834 Genesee (Poole Bldg) La Jolla Scripps Memorial campus. Sublease full or part of the office with 5 plus rooms, bathroom/shower. Excellent referral situation. Between I-5 and I-805. Call 858-344-9024 or 858320-0525. (Posted 4/18/19) LA JOLLA (NEAR UTC) OFFICE FOR SUBLEASE FOR 2-3 DAYS PER WEEK in the 4520 Executive Drive Bldg. Excellent location between I-5 and I-805. Beautiful renovated office space with 2 exam rooms and large physicians office for consultations. Ideal for Vein and vascular, primary care, pain management, physical therapy, rheumatology, infectious disease, dermatology, orthopedics. Interested parties, please email missyphilip@gmail.com ENCINITAS OFFICE SPACE TO SHARE/ SUBLEASE: Longstanding (38 years) allergist in Encinitas has a 3000 square foot office space available to share/sublease. Six exam rooms and a permanent private office/consultation room. Office is available Tuesday morning and all day Wednesdays and Fridays. Office located on El Camino Real in Encinitas. Please contact wwpleskow@sbcglobal.net or call 760-436-3988. MEDICAL OR DENTAL SPACE AVAILABLE: For lease a medical or dental related practice or business in a small boutique office space located close to Moonlight Beach in Encinitas. First floor with 570 square feet and peek ocean views. Available February 1st. Physician/Dentist parking spot comes with lease and lease would be

until December 31, 2020. Sinks in 2 exam rooms, office space for physician/dentist and laboratory storage area in addition to lobby/reception area. Asking: $2,000/month. Terms are negotiable. This will rent fast so hurry! Please contact: dana@ sdrheumatology.com | (858) 603-2068. (Posted 11/18/2018) SHARED OFFICE SPACE: Office Space, beautifully decorated, to share in Solana Beach with reception desk and 2 rooms. Ideal for a subspecialist. Please call 619-606-3046. OFFICE SPACE/REAL ESTATE AVAILABLE: Scripps Encinitas Campus Office, 320 Santa Fe Drive, Suite LL4 It is a beautifully decorated, 1600 sq. ft. space with 2 consultations, 2 bathrooms, 5 exam rooms, minor surgery. Obgyn practice with ultrasound, but fine for other surgical specialties, family practice, internal medicine, aesthetics. Across the hall from imaging center: mammography, etc and also Scripps ambulatory surgery center. Across parking lot from Scripps Hospital with ER, OR’s, Labor and Delivery. It is located just off Interstate 5 at Santa Fe Drive, and a half-mile from Swami’s Beach. Contact Kristi or Myra 760-753-8413. View Space on Website:www.eisenhauerobgyn.com. Looking for compatible practice types. OFFICE SPACE AVAILABLE: La Jolla (Near UTC) office for sublease or to share: Scripps Memorial medical office building, 9834 Genesee Ave-great location by the front of the main entrance of the hospital between 1-5 and 1-805. Multidisciplinary group and available to any specialty. Note we are in great need of a psychiatrist. Excellent referral base in the office and on the hospital campus. Please call (858) 455-7535 or (858) 320-0525 and ask for Sofia or call Dr. Shurman, (858) 344-9024. (Posted 8/10/2018) OFFICE SPACE FOR RENT: Multiple exam rooms in newer, remodeled office near Alvarado Hospital and SDSU. Convenient freeway access and ample parking. Price based on usage. Contact Jo Turner (619) 733-4068 or jo@siosd.com. MEDICAL OR DENTAL SPACE AVAILABLE: For lease a medical or dental related practice or business in an office space with other medical offices located in downtown Chula Vista close to Scripps Chula Vista hospital. First floor with ~1000 square feet. Available January 1st. 2 physician/ dentist parking spots comes with lease and lease would be until June 4, 2020 or longer should you negotiate with the building manager. Sinks in 3 exam rooms, office space for physician/dentist, bathroom, and laboratory area or additional exam room in addition to lobby/reception area. There is a long term subleasor on Fridays, so rent could be lower if you are willing to keep the subleasor, but asking: $2,000/month. Terms are negotiable. Please contact: dana@sdrheumatology.com | (858) 603-2068.

the patients and ability to adequately document are expected. Supervising physician is a faculty in multiple universities and has great experience with teaching. The office is run in a pleasant and friendly atmosphere. Candidate must have current California license and DEA certificate. Compensation is competitive and commensurate on experience. Interested candidates can E-mail CV to vprabaker@gmail.com (Posted 4/30/2019) CLINICAL RESEARCH ASSISTANT WANTED: Experience in supporting or managing clinical research studies is a plus (we are not targeting laboratory-based research professionals). The position is part-time (24 hrs a week) and flexible. Tuesday and Wednesday mornings preferable. Applicants must speak Spanish to help with our Spanish-speaking population. Individuals need also be organized and detailed. A high degree of computer literacy is required. A Bachelor’s degree in life sciences (or equivalent, e.g. RN) is preferred but candidates with ‘qualification through experience’ will be considered. Please email your resume and desired pay to careers@rheumSD.com (posted 4/9/2019) SEEKING PHYSICIAN ASSISTANT/NURSE PRACTIONERS: Graybill Medical Group is one of North San Diego County’s largest independent multi-specialty groups with over 80+ physicians and advanced practitioners. The PA or NP will provide direct, in office patient care; this will include examination and treatment of patients and completion of all necessary paperwork. We currently have a FM part-time opening in our Ramona & Valley Center offices and a full-time Urology opening in Escondido. Prior Urology experience highly preferred. Must have a current CA (PA or NP) license, and be ACLS and CPR certified. Comfortable working independently. Bilingual in English/Spanish helpful. Send CVs to ssnodgrass@ graybill.org or apply online at www.graybill.org, or fax (760)738-7101. SEEKING PART-TIME FM AND UROLOGY PHYSICIAN ASSISTANT/NURSE PRACTIONER: Graybill Medical Group is one of North San Diego County’s largest independent multi-specialty groups with over 80+ physicians and advanced practitioners. The PA or NP will provide direct, in office patient care; this will include examination and treatment of patients and completion of all necessary paperwork. We currently have a FM part-time opening in our Ramona office and a parttime Urology opening in Escondido. The Urology position is 2 days per week; preferably Mondays & Thursdays 8 am - 5 pm. Prior Urology experience highly preferred. Must have a current CA (PA or NP) license, and be ACLS and CPR certified. Comfortable working independently. Bilingual in English/Spanish helpful. Send CVs to ssnodgrass@ graybill.org or apply online at www.graybill.org, or fax (760)738-7101. RESIDENTIAL REAL ESTATE FOR SALE

OFFICE SPACE / REAL ESTATE WANTED MEDICAL OFFICE SPACE SUBLET DESIRED NEAR SCRIPPS MEMORIAL LA JOLLA: Specialist physician leaving group practice, reestablishing solo practice seeks office space Ximed building, Poole building, or nearby. Less than full-time. Need procedure room. Possible interest in using your existing billing, staff, equipment, or could be completely separate. If interested, please contact me at ljmedoffice@yahoo.com. NON-PHYSICIAN OPPORTUNITIES PHYSICIAN ASSISTANT POSITION AVAILABLE: Full time Physician Assistant position for a busy Internal Medicine outpatient practice in La Mesa. Efficient, hardworking, team player with compassion towards patient care is expected. Clinical competency, knowledge about Quality measures as well as HCC codes are preferred. Communication skills, Caring, connecting with

FOR SALE • DOCTOR OWNED SPECTACULAR 40 ACRE JULIAN MOUNTAIN CABIN $699,000 SURROUNDED BY TOWERING INCENSE CEDARS This wonderful retreat features excellent artesian spring fed pond, large fruit orchard, 900 sf garage, solar panels, well water, fireplace, wood burning stove and much more. Please call Dennis Frieden, Broker/Owner Julian Realty 760-310-2191 email def12358@aol.com

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Creation And Dust The screen streams continuous outrage While tragedies beg to be solved Dopamined pleasure and rampage Keep us thrilled yet scarcely involved Superficial is hotly debated Essential is barely discussed For you the world was created You are nothing but ashes and dust The voices of kindness and reason Too often drowned out by the crowd To point out the truth can be treason For saying what’s so and out loud

Creation and Dust: The Best of Times, The Worst of Times By Daniel J. Bressler, MD, FACP

THE FIELD OF MEDICINE blends optimism and pessimism, scientific progress and philosophical fatalism. We are cheerleaders for our patients’ recoveries and symbolic pallbearers at their inevitable funerals. We are the purveyors of hopefulness and the truth tellers of mortality. As with clinical practice, so with broad aspects of our society’s health. Ageadjusted cardiovascular disease has been reduced by potent drugs and interventions but more patients are now living with severe congestive heart failure. Rates of COPD are down but rates of asthma are up. Psychiatric medications are better but rates of depression and suicide are increasing. Treatment options for diabetes have expanded while rates of obesity and its comorbidities continue to rise. Perhaps this notion of the world as triumph and terror is encoded in human nature itself. There is a teaching story attributed to the Hasidic Rabbi Bunim, who lived in what is now Poland in the late 18th and early 19th century, that has always struck me as an apt summary of this dual nature of our lives:

JUNE 2019

Everyone must have two pockets, with a note in each pocket, so that he or she can reach into the one or the other, depending on the need. When feeling lowly and depressed, discouraged or disconsolate, one should reach into the right pocket, and, there, find the words: “For my sake was the world created.” But when feeling high and mighty one should reach into the left pocket, and find the words: “I am but dust and ashes.” In this poem, “Creation and Dust,” I have taken this notion by Rabbi Bunim and used it in a rhyming meditation on the modern world with both its incredible range of progress and its discouraging trends. Dr. Bressler, SDCMS-CMA member since 1988, is on the Biomedical Ethics Committee at Scripps Mercy Hospital and is a longtime contributing writer to San Diego Physician.

Virtue becomes dissipated While ambition’s ascent is robust For you the world was created You are nothing but ashes and dust The staunchest agreements can fumble Unless they are freshly renewed The strongest of structures can crumble Breaking down to bacterial food Chemical laws demonstrate it Oxidation turns steel to rust For you the world was created You are nothing but ashes and dust We question the notion of progress Of rising tides raising all boats Our ship seems hijacked by pirates Who are holding their shivs to our throats With hope for the future deflated Our vision’s been forced to adjust For you the world was created You are nothing but ashes and dust Then what kind of map guides our travel? Which are the standards to choose? With conventional wisdom unravelled And all the old knots shaken loose Success may be much overrated But failure’s an ongoing bust For you the world was created You are nothing but ashes and dust Take into account all these features Our species blends scoundrel and saint The most contradictory creatures A mosaic of crime and restraint Render your plans calibrated Do what you can and you must For you the world was created You are nothing but ashes and dust

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