June 2023

Moving Toward Viral Hepatitis Elimination

Medicine & the Environment

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 (Board Representative to the Executive Committee)

#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

A Call for Viral Hepatitis Elimination for the U.S. and the World

By Dr. Robert G. Gish, Dr. Christian Ramers, MD, MPH, Dr. Binh Tran, PharmD, MS, MBA, and Scott Suckow

DEPARTMENTS

2

Briefly Noted: SDCMS

Membership • COVID -19

8 The House of Medicine Raises Its Voice for the Planet

By David Neison, MD, Vi Thuy Nguyen, MD, and Rachel Abbott, MD

11 Mind the Gap

By Helane Fronek, MD, FACP, FASVLM, FAMWA

12

State Lawmakers Eye Forced Treatment to Address Overlap in Homelessness and Mental Illness

By April Dembosky, Amelia Templeton, and Carrie Feibel

16

CMA Legislative Advocacy Day 2023

8

16

By California Medical Association

18

Curbside Consultations: Patient Safety and Legal Risks

By Richard Cahill, JD

20

Classifieds

Dr. Ralph Allen (‘Al’) Heising Passes Away

(December 20, 1929 - May 3, 2023)

ship at the U.S. Naval Hospital in Bethesda, Maryland, where he met lifelong friends: the Fosbergs, the Mazurs, the Woods, the Stevens, the Kaufmans, and the Yuricks, thereafter forever known as “The Intern Group.” Dr. Heising completed his residency in dermatology at the U.S. Naval Hospital in Philadelphia from 1956 to 1959, and at the Graduate School of Medicine at the University of Pennsylvania in 1959. After completing his residency, he was transferred to the San Diego Naval Hospital and, for a boy from North Dakota, thought he had found “heaven on earth.” In 1963, Dr. Heising left the Navy and opened his private practice, La Mesa Dermatology, where he cared for thousands of patients until his retirement in 1994.

RALPH ALLEN (“AL”) HEISING, MD, beloved father, grandfather, great-grandfather, uncle, and friend, died on May 3 at the age of 93 at home with his family at his bedside. Dr. Heising was born on Dec. 20, 1929, in Bismarck, North Dakota, to Earl and Ethel Heising. He attended Bismarck High School, where he was quarterback and co-captain of the football team, as well as point guard for the undefeated 1947 all-state basketball team, graduating with honors that same year. He went on to attend the University of North Dakota, where he was a member of the Phi Delta Theta social fraternity and the Blue Key Honorary Service fraternity.

Dr. Heising also played running back on the UND football team, achieving all-conference honorary mention, and was very proud to be one of the Fighting Sioux! He did not escape his college football career unscathed, as later in life his gridiron injuries necessitated two total knee replacements and caused lifelong shoulder pain.

In 1953, Dr. Heising graduated from UND with honors with a BS in medicine, and went on to attend Harvard Medical School, graduating in 1955. He completed his intern-

Dr. Heising married Nancy Ann Peterson, of Bismarck, in 1954, and they had four children, Karen Lazar (Tom), Scott (Lorrie), Stuart, and Douglas. Dr. Heising was very active in various dermatology organizations and served as president of the San Diego Dermatology Society, president of the Sonoran Dermatology Society, and president of the Pacific Dermatologic Association. He also served as a professor of clinical medicine at UCSD and as a consultant in dermatology at Naval Medical Center San Diego. Throughout his career, he remained a member in good standing with the CMA, AMA, FAAD, FABD, and FACP.

Dr. Heising was preceded in death by his wife, Nancy, his parents, brother John, and is survived by his four children and six grandchildren: Alexandra de Jong, Taylor Martin (Bobby), Paige Heising, Sean Heising, Owen Heising, and Olivia Heising, and four great grandchildren: Aria de Jong, Landon Martin, Vale Martin, and Rory Martin, along with several nieces and a nephew.

His passing has left a big void in the lives his family, who will endeavor to make new memories while never letting go of their cherished memories of him.

A private memorial is planned. Dr. Heising will be interred at Fort Rosecrans National Cemetery with military funeral honors. Please contact the family for more information.

Superior Court Upholds CMA Legislation Mandating Reimbursement for COVID-19 Testing and Vaccination

IN A RULING ISSUED IN MAY, THE LOS ANGELES SUPERIOR COURT upheld the constitutionality of a state law requiring health plans to fairly reimburse healthcare providers for the costs of COVID-19 testing during the COVID-19 state of emergency.

Senate Bill 510, which the California Medical Association (CMA) sponsored, mandates that health plans and health insurers reimburse healthcare providers, regardless of network status, for COVID-19 testing and vaccination services. The law requires that health plans and insurers cover testing and vaccination without any cost-sharing or prior authorization requirements. SB 510 extended those provisions retroactively to March 4, 2020, the date Gov. Gavin Newsom declared a state of emergency for the pandemic.

In his ruling, judge Mitchell L. Beckloff dismissed the arguments made by the California Association of Health Plans (CAHP) challenging the constitutionality of SB 510’s requirement that CAHP’s health plan members pay healthcare providers for COVID-19 testing rendered during the period from the March 4, 2020, state of emergency declaration through Dec. 31, 2021. Recognizing that health plans do not operate as a matter of right, but rather must comply with state law, the court found it improper for those health plans to force healthcare providers to shoulder the responsibility for the cost of COVID-19 diagnostic testing through unfair contracting practices.

Judge Beckloff found that SB 510 was passed “to combat COVID-19 and its community spread by ensuring access to and encouragement for… screening and testing [and to] protect access to COVID-19 diagnostic and screening testing by ensuring the overall financial stability of the healthcare system.” His order further states that the health plans’ attempt to impose unreasonable contract terms on healthcare providers could frustrate this purpose by “diminish[ing] access to quality care.”

“CMA was proud to sponsor SB 510 when it was introduced by then-Senator Richard Pan, MD, and we’re thrilled to see it’s been rightly upheld in court,” said CMA President Donaldo Hernandez, MD. “SB 510 is a vital, life-saving bill that ensured all Californians were able to access COVID-19 testing throughout the duration of the pandemic and will require coverage for testing and vaccination during future public health emergencies.”

Prior to the passage of SB 510, CMA asked the California Department of Managed Care and the California Department of Insurance to investigate concerns that certain payers were illegally impeding patients’ access to COVID-19 testing and profiting at the expense of treating physicians.

CMA sponsored SB 510 to ensure that those barriers to testing were removed, physicians were reimbursed fairly by health plans, and patients did not have to incur out-of-pocket expenses for testing.

A Call for Viral Hepatitis Elimination for the U.S. and the World

By Dr. Robert G. Gish, Dr. Christian Ramers, MD, MPH, Dr. Binh Tran, PharmD, MS, MBA, and Scott Suckow

Background

Every minute, two individuals die of hepatitis B globally and the number of hepatitis B deaths in the U.S. is in the thousands each year.1 As we move forward with viral hepatitis elimination goals for the U.S. and for the world, we need to take some very important steps for hepatitis B virus (HBV) elimination.

Hepatitis B remains a major issue, and two important steps have taken place in the last 12 months to try to achieve elimination goals set by World Health Organization (WHO) and the US before 2030. In 2022, The American College of Immunization Practices (ACIP) advised HBV vaccination for all adults up to age 59 and optional for those over 59 if “at risk” or “upon request.” More recently, within the last few weeks, the Centers for Disease Control and Prevention (CDC) recommends testing all adults for hepatitis B with the triple panel of hepatitis B surface antigen (HBsAg), antibody to hepatitis B core antigen (anti-HBc; total) and hepatitis B surface antibody (anti-HBs).2

Hepatitis B has more impact than just causing cirrhosis, liver cancer, liver transplant, and death. On a day-to-day basis, individuals have to face stigma from hepatitis B in both social and employment settings, and it has a negative effect on their quality of life — including discrimination. Additional reasons to test and treat include a number of extrahepatic manifestations and associated conditions as diverse as skin rashes, kidney ailments, diabetes, and even some nonliver malignancies. And, importantly, this is a vaccine-preventable disease, unlike hepatitis C virus (HCV) or HIV.

You have probably heard about the Biden administration’s plans for HCV elimination by 2030, with an $11.5 billion budget request moving through Congress. It was covered in the September 2022 San Diego Physician focused specifically on hepatitis C, with local elimination planning efforts convened by the Liver Coalition of San Diego. It’s important for HBV elimination to be paired with HCV elimination, and vice versa, to markedly increase the efficiency of provider,

patient, and advocate efforts.

The epidemiology of HBV is well defined, with up to 2.4 million individuals being HBsAg-positive today. The prevalence is focused in immigrant populations, but also the general unvaccinated adult population (and a major overlap with people who inject drugs [PWID]). To date, the performance of “targeted” screening strategies for HBV has been poor with <20% tested and thus <20% knowing they are infected.

Figure: Incorporating HBV screening and testing into a clinic workflow, by age ACIP, American College of Immunization Practices; anti-HBc, antibody to hepatitis B core antigen; anti-HBs, hepatitis B surface antibody; HBV, hepatitis B virus; HBsAg, hepatitis B surface antigen; HepB, hepatitis B. Reprinted with permission from the Morbidity and Mortality Weekly Report.2

INFECTIOUS DISEASES

Treatment Modalities

In stark contrast to HCV and HIV where there are no vaccines, there are four very highly effective HBV vaccines and an opportunity to protect everyone from chronic HBV infection. There are still more than 1,000 babies born with chronic hepatitis B each year in the U.S. We have seen great success with universal maternal HBV screening, and these low rates of mother-to-child transmission in the US can be improved further with full implementation of our current test and vaccinate algorithms. We must capitalize on this amazing opportunity aimed at HCV elimination to create an HBV-free generation and also prevent onward transmission of HBV in intimate and household settings as well as high-risk HBV transmission prevention. We must start to identify all those individuals with HBV infection and link them to proper care. There is a major move underway to treat all individuals who are HBV-DNA-positive, just as we do with HIV-positive and HCV-RNA-positive patients. The current but outdated and complex U.S. HBV guidelines have not expedited elimination, and the guidelines (in the opinions of these authors) have formed a barrier to treatment due to their complexity. Future iterations of HBV guidelines are likely to move toward simplicity, decentralization to the primary care level, and task sharing. However, these must be accompanied by increases in public and provider awareness of the scope of the problem, and need for universal screening. We must also recognize that insurance plans use the HBV guidelines to deny patients access to treatment. Only 20% of patients fit the guidelines’ strict rules for alanine transaminase (ALT) and HBV DNA levels.

Call to Action

There are practical clinical realities that we must face together as providers, patients, and advocates to implement the HBV 5-Line Guideline (HBV test all, vaccinate all who are triple panel-negative, treat all who are HBV DNA-positive, and initiate surveillance for those with liver cancer or active HBV disease). We must first teach the basics of HBV screening and the triple panel test interpretation, such as:

• Do not vaccinate if a patient is anti-HBc

• There is no need for HBV boosters with current data showing HBV protection for up to and beyond 35 years after the 2-dose or 3-dose vaccine protocol.

It is important for all providers to review the recent Morbidity and Mortality Weekly Report (MMWR) on HBV testing and the response algorithms (as shown in the figure on page 5).2

We need the San Diego County Medical Society (SDCMS) to bring a forward-looking “call to action” directed at the providers in San Diego County to implement the ACIP and CDC recommendations across all types of practice. We need

to recognize that currently most patients are not receiving oral therapies over the long-term. There are many exciting new treatments for HBV in development and we no longer use the term “lifelong treatment” for HBV. We need to emphasize hope as we have more than 30 new HBV drugs in development — a marked improvement in functional cure rate (HBsAg loss and DNA negative), with complete cure and sterilizing cure on the horizon to clear covalently closed circular DNA (cccDNA) and HBV integrated virus in the liver genome. We are on the verge of a revolutionary change in HBV care, and now is the time to step up screening and linkage to vaccine and care to prepare for the new treatments coming soon to the clinic. Please keep your ear to the news for upcoming clinical trials as well.

Local Resources

We would also like to recognize the Asian Pacific Health Foundation (APHF) and other county nongovernmental organizations who have been and are working diligently to screen for HBV and HCV in the Asian and other high-risk populations alongside general health care screenings. The APHF and its former Asian Pacific Health Center have been in San Diego for the past 22 years, providing education and screening services for hepatitis B and C, hypertension, diabetes, lipid disorders, and osteoporosis for underserved populations at community health centers in San Diego County.

With Dr. Robert Gish as medical director since 2010 and chairman of the board more recently, APHF has increased its sphere of activity in the Asian Pacific Islander communities and beyond. Alongside the network of federally qualified health centers that include La Maestra and Family Health Centers, APHF partners with the University of California, San Diego, Skaggs School of Pharmacy and Pharmaceutical Sciences, and UCSD Medical School, among many others, to provide skilled and experienced staff and volunteers at twice-monthly community outreach events. With the National Task Force on Hepatitis B, and the Hepatitis B Foundation joining the Association of Asian Pacific Commu-

nity Health Organizations as Hep B United, APHF addresses viral hepatitis locally and throughout the U.S. A recent member of “Live Well San Diego,” APHF is in the second year of collaboration with Champions for Health from the San Diego County Medical Foundation and the County of San Diego Health and Human Services to add tuberculosis (TB) and latent TB infection prevention strategies in San Diego.

References

1 Hepatitis B Facts and Figures. Hepatitis B Foundation. Accessed May 9, 2023. https://www.hepb.org/ what-is-hepatitis-b/what-is-hepb/facts-and-figures/

2 Conners EE, Panagiotakopoulos L, Hofmeister MG, et al. Screening and testing for hepatitis B virus infection: CDC recommendations — United States, 2023. MMWR Recomm Rep. 2023;72(1):1-25. doi:10.15585/ mmwr.rr7201a1

Dr. Gish is an adjunct professor of medicine at the University of Nevada Schools of Medicine in Las Vegas and in Reno. He serves as an adjunct Professor of pharmacy at Skaggs School of Pharmacy and Pharmaceutical Sciences at UCSD, and a clinical professor of medicine at Loma Linda University. In addition, he is also medical director of the Asian Pacific Health Foundation in San Diego and of the Hepatitis B Foundation in Doylestown, Penn. In 2013, he founded Robert G. Gish Consultants, LLC to provide consultative support to pharma, nonprofits, hepatology centers, and liver transplant programs that wish to start or grow their programs. Dr. Ramers is a specialist in infectious diseases and the chief of population health at the Family Health Centers of San Diego. He also serves as the medical director of the Laura Rodriguez Research Institute and holds faculty appointments at UC San Diego School of Medicine and the San Diego State University school of Public Health. Since 2018 he has held the role of senior clinical adviser for the Clinton Health Access Initiative’s global viral hepatitis program, working on HBV and HCV elimination worldwide. Binh Tran is co-founder and program director of Asian Pacific Health Foundation in San Diego, and clinical professor of pharmacy (Vol.) at the UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences. Tran’s work on Hepatitis B began in 2003 with the Hepatitis B Prevention Project for Asians and Pacific Islanders in San Diego funded by The California Endowment. In 2012, APHF collaborated with the Antiviral Research Center in partnership with UCSD in a CDC funded grant on Hepatitis B on foreign-born populations in San Diego. APHF is currently providing education and screening of at-risk populations for Hepatitis B & C and metabolic diseases, and linking the affected people for follow-up care.Scott Suckow is chair of Patient Advocates United in San Diego County. Nationally he is the board chairman of the Hepatitis C Mentor & Support Group and chair of Global Liver Institute’s Liver Action Network. Scott is a national ambassador for the Center for Patient Advocacy Leaders (CPALS) and in the LEAD San Diego class of 2009. Scott has raised more than $35 million to fund research, direct services, support educational programs, and plan advocacy campaigns in his nonprofit career.

The House of Medicine Raises Its Voice for the Planet

By David Neison, MD, Vi Thuy Nguyen, MD, and Rachel Abbott, MD

AS CLIMATE-RELATED DISASTERS, FOOD AND water shortages, and extreme weather impact our world, the climate crisis has emerged from the shadows of scientific inquiry to what the UN Secretary-General Antonio Guterres calls a “code red for humanity.” In an unprecedented joint oped in September of 2021, over 230 medical journals from across the world, including The New England Journal of Medicine and the British Medical Journal, called upon world leaders ahead of the COP26 meeting in Scotland to take bold action. Amid the

crucible of the COVID-19 pandemic, the authors identified the climate crisis as the “greatest threat to human health.”

Only recently has the healthcare community turned its gaze to this threat, recognizing its role

in both cause and effects.

The healthcare sector is estimated to contribute 8.5% of global greenhouse gas emissions and is expected to triple its carbon footprint by 2050 under business as usual. If it were a country, healthcare would be the fifth largest climate polluter in the world.

Bound by our Hippocratic Oath to heal and protect the communities we serve, physicians must confront this crisis as leaders, trusted messengers, and agents of change.

Kaiser Permanente (KP) has long been a leader in environmental stewardship and achieved carbon neutrality in 2020. KP seeks to expand its use of renewable energies and invest in carbon offsets such as nature conservancies, tree planting, and cooktop stoves in developing nations. KP recognizes its immense purchasing power and is currently launching a full-scale evaluation of emissions related to its supply chain, including manufacture of pharmaceuticals, food, imaging, and medical devices, as well as the transportation of goods and people.

But within this massive effort, we noticed the lack of physician engagement.

As key players in our community and healthcare framework, we recognized that this absence was a significant missed opportunity. We felt the call to make changes on a local,

regional and national level. We recognized that our role as physicians in society and our medical groups afforded substantial influence and ability to effect change.

Partnering with our existing Green Team, we have been able to address energy use in our buildings, support sustainable food practices, and join our local product council. We also promoted the LEED Platinum recertification for our medical center’s building, design, operations, and management. Through this work, we hope to lean on our non-clinician partners to foster an environment of climate adaptation and resiliency.

Within the KP Southern California Region, we also leveraged our partners in other service areas to do much of the same work in their communities and to inspire us with work of their own. Physician Green Team Leaders across the Region meet monthly to connect and collaborate. Through this venue, we are currently introducing a Climate For Health Ambassador training through EcoAmerica. Having participated in the training three years ago, we hope it provides the tools for our medical group to advocate for their communities, from Kern County to Otay Mesa.

In the medical tradition of “see one, do one, teach one,” we also started the discussion about the

public health crisis of climate change within the KP family medicine and emergency medicine residencies. We developed a longitudinal curriculum to introduce the basic health effects of the climate crisis, including heat-related illness, cardiovascular complications, air pollution and allergen proliferation, extreme-weather-related injuries, expansion of infectious diseases, malnutrition, obstetrical outcomes, mental health impacts, civil conflict and forced migration. Through our work, we hope to also offer guidance for patients and providers on healthier habits to reduce greenhouse gas emissions, as well as discuss disaster preparedness and healthcare delivery, reduction of healthcare’s own footprint, and the notion of environmental justice. We were pleased to see that younger generations of medical students and trainees more readily acknowledge the intersection of climate change, health, and equity. As they will feel this burden to a greater extent throughout their career, it is imperative that they are well-versed and equipped to address this with their patients, colleagues, and administrators. The climate crisis is too daunting for any single organization. We do not pretend that we are alone in this fight. In 2019, we partnered with Dr. Bruce

Bekkar, a retired KP ob-gyn and now full-time climate and health advocate, and Nicole Capretz, founder and CEO of the Climate Action Campaign, to establish a Public Health Advisory Council (PHAC). This dynamic and diverse group of physicians and public health experts spans the gamut of the healthcare sector in San Diego, including KP, Sharp Healthcare, UCSD Health, and Scripps Healthcare. For the past three years, we have inspired one another to address the climate crisis with our patients and communities, hold elected officials accountable, and drive change within our individual organizations: A little friendly competition and cross-pollination for the sake of the planet.

Through public testimony, op-eds, and signed letters of support, members of the PHAC were able to successfully assist in building electrification ordinances in Encinitas, Solana Beach, and San Diego Unified School District, in an effort to remove methane gas from homes, schools and commercial buildings. Our continued work also aims at updating and implementing the City of San Diego’s Climate Action Plan and the County of San Diego’s Regional Decarbonization Framework.

Under the leadership of the KP Green Team, members of the PHAC from all healthcare systems collaborated to host the first Climate and Health Symposium for approximately 80 residents and faculty throughout San Diego in April of 2022. In addition to the KP family medicine and emergency medicine residency programs, we invited Family Health Centers, Scripps, and UCSD Family Medicine programs. The symposium featured didactics, simulation and cooking demonstrations from family medicine, emergency medicine, pediatrics, obstetrics and gynecology, and culinary medicine physicians, as well as advocacy and social justice experts, and the chief of staff for County Supervisor Terra Lawson-Remer. In preparation for future symposia, we hope to include a broader range of medical specialties and public health experts.

As we enter the summer months, our attention turns to the extreme heat that now affects much of San Diego County. Members of the PHAC from all healthcare organizations, as well as the County of San Diego, American Academy of Pediatrics, League of Women Voters, and the Tribal Health Climate Project, will host H3 SD: San Diego’s Heat and Human Health Summit. Readers are invited to attend the event on Aug 12, from 9 a.m. to 2 p.m. at UCSD School of Medicine. https://www.eventbrite.com/e/h3-sd-san-diegos-heat-andhuman-health-summit-tickets-630537242867 Public health experts, clinicians, and elected officials will address the effects of extreme heat events, which account for more deaths and hospital visits than all other climate-related and natural disasters combined.

There is much work to be done, as the medical community raises its collective voice to the climate crisis. The immediacy of our warming planet and its devastating downstream effects do not afford us complacency or the time to rest on our laurels. As COVID-19 held a mirror up to the inequities in health outcomes, we specifically intend our current and future efforts to advocate for the most vulnerable communities among us.

Gary Cohen, president and founder of Healthcare Without Harm, put it best when he said, “The

healthcare sector occupies a unique position in U.S. society, both as an economic behemoth and as a profession with an ethical commitment to ‘do no harm.’ That power and purpose can be leveraged to take on the twin crises of climate change and inequity. To that end, we must expand the health sector’s mission beyond patient care to include healing communities and the planet. This is the new social contract between the health sector and the communities they serve. This is the new Hippocratic Oath.”

WHOSE INTERESTS

does your malpractice insurer have at heart?

The authors are co-chairs of the Kaiser San Diego Sustainability/Green Team. Dr. David Neison is an emergency physician and is currently assistant chief of his department at Kaiser Permanente. He served as disaster chair for six years at KP, including throughout the pandemic. His background in disaster preparedness propelled him to turn his attention to the climate crisis and education. Dr. Vi Thuy Nguyen is a general pediatrician who practices at the Otay Mesa area and currently serves as the American Academy of Pediatrics California chair of the Expert Committee on Environmental Health. As @ drplasticpicker on Instagram, she shares her story of emerging from professional burnout after starting to pick up plastic on the beach! Dr. Rachel Abbott is a family medicine physician at Kaiser Permanente San Diego, with positions as women’s health and equity & climate change curriculum director for the family medicine residency and director of physician education. Dr. Abbott spent the formative years of her medical school and residency training working in underserved communities. She is passionate about addressing climate change via advocacy and education.

Yet another of California’s medical liability insurers has transitioned from focusing on doctors to focusing on Wall Street. This leaves you with an important question to ask: Do you want an insurer that’s driven by investors? Or do you want an insurer that’s driven to serve you— one that’s already paid $140 million in awards to its members when they retire from the practice of medicine?

Join us and discover why delivering the best imaginable service and unrivaled rewards is at the core of who we are.

Mind the Gap

By Helane Fronek, MD, FACP, FASVLM, FAMWA

archaic as we rush from patient to patient, knowing we have more to do than time to do it during each patient encounter.

And yet, gaps are plentiful and valuable — if we take a moment to notice and utilize them.

Before walking into each patient’s room, we can take a breath in and notice what emotions are still clinging to us after our last interaction. Are we bringing frustration, anger, or worry that doesn’t belong to this next patient we’re about to care for? As we breathe out, we can imagine those emotions flowing out of our body. This will help us ready ourselves for the new situation we’re about to encounter.

beautiful or interesting. The French composer Claude Debussy said, “Music is the space between the notes.” Similarly, it’s wise to pay attention not only to what is said in a conversation, but also to what is not being said. Wondering and inquiring about what is being left out in the discussion and why, can often be a bridge to really getting to know someone. It’s been my experience that, when one asks about these things, the conversation immediately becomes deeper and more meaningful.

I BELIEVE THE FIRST TIME I HEARD THE PHRASE

“Mind the gap” was while boarding a subway. Gap? What gap? I wondered. Then, I looked down and noticed the space between the platform I was standing on and the train car I was aiming to board. “Mind the gap” seemed to be an efficient way of cautioning people to step carefully across that gap lest they trip or get caught in the unexpected space.

In our overly busy lives, gaps are not something we are often aware of, are we?

It seems we rush from one activity to another, racing to arrive in time for our next obligation. Yesterday I narrowly avoided three accidents in which cars sped past other cars that were not moving fast enough for them, and a man suddenly ran behind my car as I was slowly backing out of our driveway. At work, relaxed encounters with colleagues seem

Another benefit of minding gaps is that their emptiness helps delineate and highlight spaces in our lives that are filled, just like the negative spaces on a photograph. Quiet times provide opportunities to appreciate the liveliness and periods of interaction in our lives. Stark or desolate views make vistas filled with colors, plants, or contrasts seem even more

Throughout each day, we have countless opportunities to create meaningful gaps. When stopped at a red light, waiting to cross a street, before entering our homes at the end of each day. Even at the top of each in breath and bottom of each out breath, a pause is available to us. A momentary gap to become aware of what our minds are thinking, to sense what we’re feeling, or to set our intention for the next part of our day. A precious gap to reconnect with ourselves — one very worthy of minding.

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

State Lawmakers Eye Forced Treatment to Address Overlap in Homelessness and Mental Illness

By April Dembosky, Amelia Templeton, and Carrie Feibel

MANY OF THE UNHOUSED PEOPLE IN PORTLAND,

Ore., live in tents pitched on sidewalks or in aging campers parked in small convoys behind grocery stores.

Mental illness can be part of the story of how a person ends up homeless — or part of the price of survival on the streets, where sleep and safety are scarce. Homeless people in Multnomah County, which includes Portland, die about 30 years earlier than the average American. These grim realities have ratcheted up the pressure on politicians to do something.

High housing costs and financial adversity are among the root causes of the burgeoning population on the streets.

About 1 in 3 people who are homeless in Portland report

having a mental illness or a substance use disorder, and the combination of homelessness and substance use or untreated mental illness has led to very public tragedies.

People with schizophrenia, for example, have died of hypothermia on the city’s streets. One resident gave birth in a snowstorm to a stillborn infant. Methamphetamine, cheaper and more potent than it used to be, is creating a heightened risk of overdose and psychosis.

In Oregon, some politicians, including Portland Mayor Ted Wheeler, have proposed changing the civil commitment law so doctors have more leeway in compelling treatment for patients too sick to know they need care. Without such changes, they argue, people with untreated addictions or

mental illnesses are stuck cycling between the streets, county jails, and state psychiatric hospitals.

“I think we can do better by people than allowing them to flounder,” said Janelle Bynum, a state legislator who represents suburbs southeast of Portland.

Bynum, a Democrat, signed on to a pair of bills, introduced by Republicans this year, that would expand the criteria for involuntary commitment in Oregon.

“My intention was to signal how cruel I think our current system is,” she said.

Half of the country’s unsheltered people live in California, and though only about a quarter to a third of homeless people are estimated to have a serious mental illness, they

are the ones other residents are likely to encounter in California’s cities. Mayors from San Francisco, San Jose, and San Diego have all expressed frustration that the threshold for psychiatric intervention is so high.

‘Why Aren’t You Doing Something?’

“When I’m often asked, ‘Mayor, why aren’t you doing something about this person who is screaming at the top of their lungs on the street corner?’ and I said, ‘Well, they’re not a threat to themselves or to others,’ that rings hollow,” said Todd Gloria, mayor of San Diego.

Now, state lawmakers in Sacramento, backed by mayors, have introduced laws and bills that would help bring more people into treatment, even against their will.

Last year, legislators approved a new approach to mental health care — called CARE Court — that allows judges to issue treatment plans for people with certain diagnoses. That program begins on a pilot basis this fall in seven counties, including San Diego and San Francisco counties, with the rest of the state expected to join next year.

This year, a bill moving through the legislature would expand who qualifies for a conservatorship or involuntary psychiatric hold.

The bill is gathering support and sponsors are optimistic that Democratic Gov. Gavin Newsom will sign it if it passes. But it’s been controversial: Opponents fear a return to bygone policies of locking people up just for being sick.

Half a century ago, California policymakers shuttered state psychiatric institutions, denouncing them as inhumane. Involuntary commitment was de-emphasized, and state laws ensured that it was used only as a last resort. The thinking was that the patient should have autonomy and participate in their care.

But politicians across California are now reconsidering involuntary commitments. They argue that not helping people who are seriously ill and living in squalor on the streets is inhumane. Psychiatrists who support the bill say it would constitute a modest update to a 56-year-old law.

The shift is dividing liberals over the very meaning of compassion and which rights should take precedence: civil rights like freedom of movement and medical consent, or the right to appropriate medical care in a crisis?

“The status quo has forced too many of our loved ones to die with their rights on,” said Teresa Pasquini, an activist with the National Alliance on Mental Illness. Her son has schizophrenia and has spent the past 20 years being “failed, jailed, treated, and streeted” by what she called a broken public health system.

“We are doctors who have to watch these people die,” said psychiatrist Emily Wood, chair of the government affairs committee of the California State Association of Psychia-

trists, a sponsor of the conservatorship bill, SB 43. “We have to talk to their families who know that they need that care, and we have to say we don’t have any legal basis to bring them into the hospital right now.”

Under current California law, a person can be held in the hospital involuntarily if they are a danger to themselves or others or if they are unable to seek food, clothing, or shelter as a result of mental illness or alcoholism. Doctors want to add other substance use disorders to the criteria, as well as an inability to look out for one’s own safety and medical care. (The state law defines what is known as “mental health conservatorship,” which is separate from the probate conservatorship that Britney Spears was under.)

Wood, who practices in Los Angeles, gave two examples of people she and her colleagues have tried, but struggled, to care for under the current rules. One is a man who doesn’t take his diabetes medication because he’s not taking his schizophrenia medication and doesn’t understand the consequences of not managing either condition.

Wood explained that even if he repeatedly ends up in the emergency room with dangerously high blood sugar, no one can compel him to take either medication under current law, because poorly managing one’s health is not a trigger for conservatorship.

Another man Wood described has a developmental disability that went untreated in childhood. He developed an addiction to methamphetamine in his 20s. Wood said the man is now regularly found sleeping in a park and acting inappropriately in public. His family members have begged

doctors to treat him, but they can’t, because substance use disorder is not a trigger for conservatorship.

To Wood, treating these people, even when they’re unable to consent, is the compassionate, moral thing to do.

“It’s essential that we respect all the rights of our patients, including the right to receive care from us,” she said.

But other advocates, including some of those working for Californians with mental illnesses, see the issue very differently.

Lawyers from the nonprofit Disability Rights California said the proposed expansion of conservatorship and the ongoing rollout of CARE Courts are misguided efforts, focused on depriving people of their liberty and privacy.

Instead, they said, the state should invest in better voluntary mental health services, which help maintain people’s dignity and civil rights. The group filed a petition in January to try to block the implementation of CARE Courts.

These advocates are particularly concerned that people of color, specifically Black residents, who are overrepresented in the homeless population and overdiagnosed with schizophrenia, will now be disproportionately targeted by more forceful measures.

“When people are told that they have to go to court to get what they should be getting voluntarily in the community, and then they get a care plan that subjugates them to services that still do not meet their cultural needs, that is not compassion,” said Keris Myrick, an advocate who has schizophrenia and has experienced homelessness.

More Housing: Another Badly Needed Prescription

Under current state law in Oregon, a person can be held for involuntary treatment if they are a danger to themselves or others or are at risk of serious physical harm because they cannot provide for their basic personal needs due to a mental illness.

Oregon, like California, does not include substance use disorders as grounds for commitment.

But its law is slightly broader than California’s, at least in one respect: Legislators amended it in 2015 to give doctors more leeway to step in if a person’s psychosis or other chronic mental illness is putting them at risk of a medical crisis.

Terry Schroeder, a civil commitment coordinator with the Oregon Health Authority, said that, before the change, a person would have to be nearly comatose or within a few days of death to meet the criteria for doctors to forcibly treat them for their own welfare.

The law now allows care providers to intervene earlier in an ongoing medical crisis.

In Oregon and California, the lack of adequate treatment options is frequently invoked in the ongoing debates over

forced commitment and conservatorship.

“Expanding conservatorships doesn’t solve for those structural issues around the lack of housing and the lack of funding for treatment services,” said Michelle Doty Cabrera, executive director of the County Behavioral Health Directors Association of California.

Cabrera’s group also questions the premise that forced treatment works, and there is indeed little evidence that compulsory treatment for substance use disorder is effective, and some evidence that it could even be harmful.

Critics of involuntary commitment have questioned the California Legislature’s objectives. If the ultimate goal of forced treatment is to reduce homelessness — and ease the moral failing of ill people sleeping on the street or using drugs in the open — then lawmakers are writing the wrong prescription, they said.

“The problem of homelessness is that people don’t have housing,” said primary care physician Margot Kushel, director of the University of California-San Francisco’s Benioff Homelessness and Housing Initiative.

“If you had all the treatment in the world and you didn’t have the housing, we would still have this problem.”

Supporters of involuntary commitments say both are needed. Many of the California lawmakers backing expanded conservatorship and CARE Courts are also backing efforts to increase the housing supply, including a $3 billion bond measure for the construction of small, neighborhood-oriented residences for people with mental illness.

Nationwide, rents have risen more quickly than people’s incomes in the past 20 years, particularly impacting people who rely on a fixed income, such as monthly disability payments.

April Dembosky is a health correspondent for KQED public radio and a contributor to NPR. Amelia Templeton is a reporter for Oregon Public Radio. Carrie Feibel is a senior editor with National Public Radio and collaborates with Kaiser Health News, where this article first appeared. This article is part of a partnership that includes KQED, OPB, and KFF Health News.

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Hundreds of physicians, residents and medical students gathered in Sacramento on Wednesday, April 19, 2023, for the 49th annual California Medical Association (CMA) Legislative Advocacy Day.

This year’s event was by all accounts a wildly successful endeavor. CMA welcomed nearly 400 attendees, representing 45+ specialties and 24 component medical societies. Attendees participated in a total of 120 legislator meetings as champions for patients and the practice of medicine.

“I think it is so important to advocate for our patients,” said Quinn Lippman, M.D., an ob-gyn who attended advocacy day with her peers from the San Diego County Medical Society. “There’s the one-on-one care we give in our offices every day, but [it's important that we] take a step back and look at the broader picture of who has access to health care, how that care is being delivered, what medications patients have access to.”

Attendees received updates from CMA President Donaldo Hernandez, M.D., and CMA’s chief lobbyist Stuart Thompson about key health care issues before

the legislature this year. Attendees then lobbied their legislators in support of CMA's priority issues, including:

+ SB 598: Prior Authorization Reform, which would significantly reduce the administrative burden physicians must bear because of prior authorization.

+ AB 765: Truth in Advertising, which protects patients AND physicians against allied health professionals who use terminology to misrepresent themselves as physicians.

+ Medi-Cal: While we have made sure that all Californians have health care coverage, it is meaningless if they can’t see a provider or get regular, timely care outside of the emergency room. Access to care is the last leg of the stool that holds this safetynet program up and is the key to unlocking quality health care for all and reducing disparities.

Legislative Advocacy Day attendees also enjoyed an engaging panel discussion from our keynote luncheon speakers, physician Assemblymembers Joaquin Arambula, M.D.; Jasmeet Bains, M.D.; and Akilah Weber, M.D.

To see all the photos from this year’s advocacy day, see our Flickr album at bit.ly/2023legday.

Physicians gather in Sacramento as champions for patients and the practice of medicine!

And the Golden Gavel Goes to….

The CMA Political Action Committee (CALPAC) concluded its three-week Golden Gavel contest in conjunction with Legislative Advocacy Day, with a fundraising total of just over $13,800. The $13,800 raised represents a historic record for fundraising at Legislative Advocacy Day.

CALPAC Chair Damodara Rajasekhar, M.D., is excited to congratulate the physicians of the San Bernardino County Medical Society as winners of the Golden Gavel – with the highest fundraising total of any medical society.

The Golden Gavel contest challenged physicians from each county medical society to make a new donation or upgrade their current level of giving to CALPAC. At the end

of the three-week contest period, the medical society that had the highest level of giving won the Golden Gavel. The contest has now taken place three times, with a different CMA component medical society winning each year. Donations to CALPAC are crucial for supporting the campaigns of political candidates who share CMA’s health care policy vision. The importance of CALPAC’s work, the core of which is electing legislators and maintaining positive relationships thereafter, was on full display at CMA’s Legislative Advocacy Day.

CALPAC is excited to build on this success and physicians are encouraged to give to CALPAC in support of CMA’s advocacy efforts by visiting calpac.org/donate

See You Next Year!

We are grateful for the time everyone took out of their busy schedules to speak with legislators on the issues impacting the delivery of health care in California. Next year will mark CMA's 50th Legislative Advocacy Day. We hope to see you in Sacramento on April 10, 2024!

Curbside Consultations: Patient Safety and Legal Risks

By Richard Cahill, JD

INFORMAL, OR “CURBSIDE,” CONSULTATIONS

among healthcare practitioners represent an important part of clinical practice and help to promote a collegial relationship in both the clinic and hospital settings. These types of informal consultations can increase knowledge among practitioners and may also improve the care and treatment of patients who present with complex comorbidities, often resulting in more favorable outcomes. Informal consultations do, however, include inherent risks for the consulting practitioner. This article answers questions that our patient safety risk managers routinely address about the potential liability of unofficial professional consultations.

Do Practitioners Who Provide Curbside Consultations Risk Being Sued?

Risks are involved if the expectations between the practitioners are not clearly communicated at the outset of the dialogue. In a classic scenario, the consulting practitioner is sued by a patient the practitioner has neither met nor examined — and certainly doesn’t remember months or years later after a problem has developed and litigation has been initiated.

Invariably, the consulting practitioner who offered the informal advice made no written record of the encounter that could later support the basis for the recommendations. As a result, the consulting practitioner has little evidence to defend the care other than possibly relying on an established routine or habit and practice when attempting to explain the recommendations discussed. The risk of being named in litigation increases significantly if the requesting practitioner identifies the consulting practitioner by name in the patient’s record and summarizes the general nature of the conversation.

What Are the Legal Issues Raised by Curbside Consultations?

A consulting practitioner who provides informal advice could be named in a lawsuit if a patient suffers harm because the requesting practitioner relied on the consultant’s information to make a treatment decision. Both practitioners could be liable if the information failed to conform to community standards and was a proximate cause of the patient’s injury. The probability that both would be named

as defendants would depend on the content of the documentation made regarding the consultation, the nature and extent of the patient’s injury, and the information revealed during litigation.

The preliminary legal questions to be evaluated in cases involving curbside consultations are: (1) Did a practitionerpatient relationship exist between the consulting practitioner and the patient, and (2) did the consulting practitioner, therefore, owe a duty of due care to the patient consistent with what similarly trained practitioners would have done under the same or similar circumstances?

For each affirmative response to the questions below, the likelihood increases that a curbside consulting practitioner could be named as a defendant and face possible monetary exposure for civil damages should the matter proceed to trial or arbitration:

• Did the requesting practitioner provide detailed facts that included the patient’s history, comorbidities, and laboratory data?

• Did the consultant personally review any portion of the patient’s record?

• Did the consultant speak directly with the patient or conduct even a cursory physical examination at bedside?

• Did the consultant recommend or order any specific tests, therapies, medications, or other treatment modalities?

• Did the consultant follow up with either the requesting practitioner or the patient?

• Most importantly, did the consultant submit a bill for services rendered?

What Kinds of Informal Consultation Cases Have Been Litigated?

Our closed claims analyses revealed multiple cases in which informal consultations took place between practitioners and the patient ultimately suffered serious cardiac, obstetric, neurologic, hemodynamic, or other untoward sequelae. Both practitioners were named in the subsequent malpractice action. In some cases, the consulting practitioner shared in liability for the final outcome based on the degree of involvement. (See the factors outlined in the question above.)

Curbside Consults Have Also Moved to Electronic Communications. Does a Practitioner’s Professional Liability Insurance Cover Consulting With Other Practitioners Through Electronic Means?

It does not matter if the curbside consultation is electronic (via email, text, or telephone) or an in-person, face-to-face encounter. Due to the advent of metadata technology, the electronic footprint of the interaction exists virtually forever. The issues with informal consultations, regardless of the mode, remain the same. The fact that an email, text, or other electronic format allows practitioners who are miles — or states — apart to communicate can, however, also lead to other issues, such as privileging, credentialing, and licensure in the state where the patient resides. Professional liability insurance does not typically cover a practitioner for practice in a state where the practitioner is not licensed.

What Patient Safety Issues Are Raised by Curbside Consultations?

From a patient safety standpoint, a verbal or electronic exchange between practitioners may lack the patient’s complete clinical picture (which should include a detailed history, an explanation of presenting signs and symptoms, identification of prescription and nonprescription medications, comorbidities, findings on physical examination, and related issues).

By responding without having all the pertinent information, the consulting practitioner may provide advice that is not in the best interests of the patient. It may result in an incorrect diagnosis, the formulation of an incorrect treatment plan, or a delay in ordering and implementing appropriate therapies. If the patient is harmed as a result, the consulting practitioner could be named as a defendant in a claim.

In analyzing closed claims, we have learned that incomplete or poor communication among practitioners is one of the leading causes of bad outcomes. This represents a major risk with informal consultations: Communication of all the necessary information to obtain and provide good clinical advice is critical.

What Criteria Can be Used to Determine Whether a Situation Is Low Risk or One That Requires a Formal Consultation?

If the requesting practitioner’s questions go beyond the low-risk scenarios described below, a formal consult should be obtained instead.

• Questions are for the general education of the requesting practitioner and are not specific to the patient.

• No request is made to confirm or make a diagnosis.

• No record review is required.

• No questions are raised about ordering specific tests or studies.

• The questions are straightforward and require only simple answers and nonspecific advice.

What Can Practitioners Do to Protect Themselves?

At the outset of the encounter, clear communication must take place between the practitioners that identifies the nature of the inquiry and the type of guidance being solicited. Curbside consultations are tempting to busy practitioners because they are convenient and speedy — the very reasons to avoid engaging in this practice. Also, consulting practitioners are not compensated for the time, expertise, and potential liability exposure involved. If you decide to assume this risk, consider the following strategies:

• Clarify the nature of the consult; advise the requesting practitioner that a curbside consultation should not be considered a formal consultation.

• Consider the facts not provided.

• Keep the consultation brief.

• Make sure the requesting practitioner is aware that the advice given is not a treatment decision.

• Refrain from using email or text messages as a method of informal consultation. (For more information, see our article “Smartphones, Texts, and HIPAA: Strategies to Protect Patient Privacy.”)

If the requesting practitioner continues to insist that you render a treatment decision or makes serial inquiries about the same patient, we advise that you firmly but respectfully request making a formal and documented consultation instead. This approach helps to promote optimum patient care and protects the practitioners from possibly frivolous malpractice claims in the event of an unexpected or adverse outcome.

For additional information, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.

Note: The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Richard Cahill is vice president and associate general counsel for The Doctors Company.

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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

FAMILY MEDICINE/INTERNAL MEDICINE PHYSICIAN: San Diego Family Care is seeking a Family Medicine/Internal Medicine Physician (MD/DO) at its Linda Vista location to provide 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.

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.

TUBERCULOSIS CONTROL & REFUGEE HEALTH

CHIEF AND MEDICAL DIRECTOR: recruitment is attached and linked here - https://www.governmentjobs.com/ careers/sdcounty/jobs/3223044/chief-tb-control-refugeehealth-public-health-medical-officer-21412809uth

PUBLIC HEALTH SERVICES MEDICAL CONSULTANT

M.D., D.O: Medical Consultant-21416207 | Job Details tab | Career Pages (governmentjobs.com)<https://www. governmentjobs.com/careers/sdcounty/jobs/3148610/m-dd-o-medical-consultant-21416207?keywords=medical%20 consultant&pagetype=jobOpportunitiesJobs

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 PHYSICIAN: TrueCare is more than just a place to work; it feels like home. Sound like a fit? We’d love to hear from you! Visit our website at www.truecare.org. Under the direction of the Chief Medical Officer and the Lead Physician, ensure the provision of effective quality medical service to the patients of the Health center. The physician is responsible for assuring clinical procedures are continually and systematically followed, patient flow is enhanced, and customer service is extended to all patients at all times.

PUBLIC HEALTH LABORATORY DIRECTOR: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a qualified individual to work for a Level 3 Public Health Laboratory. The Public Health Services department, part of the County’s Health and Human Services Agency, is a local health department nationally accredited by the Public Health Accreditation Board and first of the urban health departments to be accredited. Public Health Laboratory Director-21226701UPH

NEIGHBORHOOD HEALTHCARE MD, FAMILY PRACTICE AND INTERNISTS/HOSPITALISTS: Physicians wanted, beautiful Riverside County and San Diego 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

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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 highdensity 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.

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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 500sq feet 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.