July 2020

JULY 2020

Official Publication of SDCMS

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July 2020

Contents JULY

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

VOLUME 107, NUMBER 6

OFFICERS President: Holly B. Yang, MD President-Elect: Sergio R. Flores, MD Secretary: Toluwalase (Lase) A. Ajayi, MD Treasurer: Nicholas J. Yphantides, MD Immediate Past President: James H. Schultz, MD GEOGRAPHIC DIRECTORS East County #1: Heidi M. Meyer, MD (Board Representative to the Executive Committee) East County #2: Rakesh R. Patel, MD Hillcrest #1: Kyle P. Edmonds, MD Hillcrest #2: Steve H. Koh, MD (Board Representative to the Executive Committee) Kearny Mesa #1: Anthony E. Magit, MD Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Preeti Mehta, MD La Jolla #2: David E.J. Bazzo, MD, FAAFP North County #1: Patrick A. Tellez, MD North County #2: Christopher M. Bergeron, MD, FACS North County #3: Kelly C. Motadel, MD, MPH South Bay #2: Maria T. Carriedo, MD AT-LARGE DIRECTORS #1: Thomas J. Savides, MD #2: Paul J. Manos, DO #3: Irineo “Reno” D. Tiangco, MD #4: Miranda R. Sonneborn, MD #5: Stephen R. Hayden, MD (Delegation Chair) #6: Marcella (Marci) M. Wilson, MD #7: Karl E. Steinberg, MD #8: Alejandra Postlethwaite, MD ADDITIONAL VOTING DIRECTORS Young Physician Director: Brian Rebolledo, MD Retired Physician Director: Mitsuo Tomita, MD Resident Director: Nicole Herrick, MD Medical Student Director: Lauren Tronick CMA TRUSTEES Robert E. Wailes, MD William T-C Tseng, MD, MPH Sergio R. Flores, MD AMA DELEGATES AND ALTERNATE DELEGATES District 1 AMA Delegate: James T. Hay, MD District 1 AMA Alternate Delegate: Mihir Y. Parikh, MD At-large AMA Delegate: Albert Ray, MD At-large AMA Delegate: Theodore M. Mazer, MD At-large AMA Alternate Delegate: David E.J. Bazzo, MD, FAAFP At-large AMA Alternate Delegate: Kyle P. Edmonds, MD At-large AMA Alternate Delegate: Robert E. Hertzka, MD At-large AMA Alternate Delegate: Holly B. Yang, MD CMA DISTRICT I DELEGATES Karrar H. Ali, DO Steven L.W. Chen, MD, FACS, MBA Susan Kaweski, MD Franklin M. Martin, MD Vimal I. Nanavati, MD, FACC, FSCAI Peter O. Raudaskoski, MD Allen Rodriguez, MD Kosala Samarasinghe, MD Mark W. Sornson, MD Wayne C. Sun, MD

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

features:

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4

We’re All Top Doctors Now

by James Santiago Grisolia, MD

6

COVID-19 NYC: A San Diego Doctor’s Experience

by Karrar Ali, DO, MPH

11

COVID Crisis in Tijuana: San Diego Medical Community Responds

by James H. Schultz, MD, MBA, FAAFP, DiMM, FAWM

14

San Diego Model for Community Collaboration: Leaning In for Pandemic Planning

by Holly Yang, MD, MSHPEd, HMDC, FACP, FAAHPM, Paula Goodman-Crews, MSW, LCSW, David Bazzo, MD, FAAFP, CAQSM, James H. Schultz, MD, MBA, FAAFP, DiMM, FAWM, and Asha Devereaux, MD, MPH, FCCP

Departments

2

Briefly Noted Racial Inequities • Professional Development and Education • Practice Management

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Physician Classifieds

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This Is Our Time. The World Has Been Waiting for Us

By Helane Fronek, MD, FACP, FACPh

Surgery During COVID-19 Times

By Adama Dyoniziak SanDiegoPhysician.org 1

BRIEFLY NOTED

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July 2020

RACIAL INEQUITIES

A M CK AT L T E IV E R S

SDCMS Issues Statement on Racial Injustice THE SAN DIEGO COUNTY Medical Society Executive Committee, under the leadership of President Holly B. Yang, issued the following statement: “The events in the week after George Floyd’s murder at the hands of police officers in Minneapolis have once again brought to light the deep distress in our country caused by repeated incidents of mistreatment of people of color by law enforcement and the criminal justice system. While we commend the dedication, sacrifice, and values of the profession of law enforcement, we cannot ignore the issues of racism and police violence and their traumatic impact on the wellbeing and health of our black and brown community members.

“We acknowledge that racism, bias, and inequity are not isolated to the criminal justice system. They exist in all aspects of our society including public safety, healthcare, education, and access to resources and economic opportunity. The San Diego County Medical Society (SDCMS) is committed to working with the community and within the healthcare system to address bias, systemic racism, and inequality and their serious health consequences. The wellbeing of our community depends on our collective action.

“We join with the leaders of the California Medical Association and the American Medical Association in calling for change.

“We encourage people who choose to gather to peacefully protest, or to seek solace, to continue to take measures to protect themselves from the COVID pandemic, which disproportionally affects people of color. The collective trauma of these overlapping crises is unmatched in our recent history. We demand that the press be able to report on these issues freely, and that scientists and healthcare professionals are listened to in guiding research and health policy.

“We hope that people are able to find some comfort among friends, family, faith communities, and trusted healthcare professionals. SDCMS stands with all people who are suffering from this tragedy and the reverberations of those from our past.”

Resources for support: www.211sandiego.org www.up2sd.org

PROFESSIONAL DEVELOPMENT AND EDUCATION

CDA Extends Physician Licensing Waivers ON JUNE 1, 2020, the Department of Consumer Affairs (DCA) extended DCA Waiver DCA-20-13 that defers any CME or examination requirements for the renewal of licenses and allows up to six months after the state of emergency declaration is lifted for licensees to make up these requirements.

Under the new waiver extension, physicians with licenses that expire between March 31, 2020, and July 28, 2020, will have six months after the public health emergency is lifted to complete their required CME. This waiver applies to physicians licensed by the Medical Board of California and the Osteopathic Medical Board of California.

DCA Waiver DCA-20-13 also gives residents who were enrolled in an approved postgraduate training program in California on Jan. 1, 2020, two extra months to obtain a postgraduate training license from the Medical Board of California. Affected residents now have until Aug. 31, 2020, to obtain their postgraduate training license.

PRACTICE MANAGEMENT

CMA Publishes Templates for Communicating with Patients About Reopening AS MEDICAL PRACTICES begin the process of reopening after the COVID-19 shut down, one of the more difficult parts of the process may be communicating with patients and others.

Patients, who have spent months at home hearing about the dangers of the pandemic, may not know that it is OK to come to the practice for routine, non-COVID check-ups and treatments. They may also be afraid of the risk of infection that could come from interacting with the healthcare system.

The California Medical Association (CMA) has developed sample communications to help physicians inform and educate patients that it is safe to resume routine and non-urgent medical visits, and to notify patients what their practices are doing to keep patients and staff safe.

These templates — available free to all physicians — are intended to be general guides, and should be adjusted based on the needs of an individual practice or patient group.

CMA is also developing video PSAs and other materials as part of a larger campaign on this issue. Stay tuned for more details.

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WE’RE ALL TOP DOCTORS NOW

By James Santiago Grisolia, MD

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July 2020

PANDEMIC. IN A HAZY, CEREBRAL WAY WE PHYSICIANS

knew it would come someday, but none of us were truly prepared in our hearts. The eerie emptiness of streets, rush hour melting away overnight, even the sudden hush of hospital corridors stilled by the evaporation of elective cases and our first days of fear. While we heard of early swells and crashes in Wuhan, then Milan, Teheran, Madrid, and New York, we waited for the wave to hit us here. he first seiche did not overwhelm us. Early aggressive isolation orders in California and San Diego dampened the onslaught as everyone talked about “flattening the curve.” Dr. Nick Yphantides, chief medical officer for San Diego County HHS and SDCMS treasurer, has ably emceed online town halls jointly sponsored by the County, SDCMS and the Hospital Association of San Diego & Imperial Counties. These regular conferences provided critical early healing and emotional bonding in a time of crisis, while informing physicians as our knowledge rapidly evolved. Nick and his colleagues at the County succeeded in bridging the gaps to major health systems (Kaiser, Scripps, Sharp, UCSD) through the common mediator of SDCMS, facilitating critical collaboration during the early stages. Currently our wave of new cases is moderating in northern and central San Diego, giving way to a steady flow from border communities. Anglo expats living in Mexico join with janitors, nurses, and other essential workers who work in San Diego but found affordable housing in Baja. When seriously ill, all who can will line up at the border to return to San Diego or Imperial Valley for care.

We’ve just had our first taste of battle, far from the trench warfare of the Bronx and Queens. Now we must brace for the second and third waves, as the human need for social contact overwhelms our initial fear. Will the next wave of cases overwhelm us? SDCMS is helping to convene stakeholders countywide to coordinate plans for managing resources if they become scarce, as has happened in New York, New Orleans, and other cities. Building on ethics work from many centers, we hope to be fair and do the greatest good for the greatest number of people.

“Not overwhelmed” at the system level differs from the overwhelmed feeling many of us feel at ground level. As the tired ICU hospitalists and intensivists sign out, they sometimes churn in futility, when each ARDS seems exactly alike, the progress small, the complications many, the families angry because they can’t enter the hospital. Past SDCMS president Dr. David Bazzo continues to lead our Wellness Committee process, with multiple Zoom groups meeting for support and hotlines for providers needing individual help. Wellness tries to colonize our despair and reclaim it for sanity. But doctors, nurses, and other providers struggle to handle the extra stress, the extra hours, or the new anxiety of personal danger. hysicians and other providers thrive on helping others, including life-and-death situations. But this pandemic brings a new sense of risk, of unpredictable death or disaster, of maybe bringing SARS-CoV-2 home to your loved ones. Only our colleagues treating Ebola or working in a war zone regularly risked their lives for others, and rarely close to family.

COVID-19 brings economic perils as well. According to MGMA, 97% of practices across the nation have suffered economic impacts from COVID, with small groups most affected. In early April, practices averaged a 60% loss of patient volume and a 55% decrease in revenue. Each physician must assess personal and

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financial risks. Former SDCMS and CMA president Dr. Jim Hay decided to leave practice early for both reasons. “I was sent home by my partners due to my age on March 6, working from home since then. Recognizing potential financial problems for the group, I decided to save them six months’ worth of salary and quit earlier. So I guess you can say there was a financial nudge,” he said. Other colleagues face similar decisions.

According to the California Healthcare Foundation, some 23% of San Diego physicians are over age 60, at greater risk for COVID-related complications. or more than 15 years, SDCMS collaborated with San Diego Magazine in producing the annual Top Doctors survey, recognizing local physicians who were most likely to be recommended by their colleagues. While an imperfect process in which it’s impossible to create a level playing field, nevertheless these awards captured something vital about the intangible personal impact on quality of care.

Physicians critical of the Top Docs survey typically failed to recognize that San Diego Magazine was going to do the survey anyway, as a profit center, with or without SDCMS on board.

At least by participating, we could guide the process, assure selected physicians had active medical licenses, and otherwise bring quality to a subjective process. Many valued colleagues have won the Top Doc kudos, many on multiple occasions. The annual gala was always a delightful opportunity to get together in those halcyon, pre-pandemic days.

Sadly, COVID-19 hits businesses across the board, sparing almost nothing. San Diego Magazine looks like a potential casualty, although its publisher plans to revive the magazine in the near future. In this year the Top Doctor survey is laid to rest.

So we are left to celebrate and cherish each other. Truly, in this year of stress, turmoil, and personal hazard, the SDCMS Executive Committee feels that each and every practicing physician qualifies to be a Top Doctor. It’s stirring to drive or walk through our denser neighborhoods at 8 p.m. each evening when our community claps, clangs, and shouts support for us.

But we must accept kudos with great humility, knowing that the applause is not only for us but for the nurses, the ambulance drivers, the respiratory and other therapists who also put their lives on the line daily, often at greater risk than ours. Beyond that, one hopes society will better recognize and reward the other essential workers: security guards, bus drivers, fire and police, grocery checkers and stockers, janitors, and so many more. Just as COVID-19 disproportionately hits the African-American and Latino communities, those same communities provide many of our most underpaid and at-risk essential workers.

Like many others, I reread Camus’ The Plague near the start of the pandemic. The protagonist, Dr. Rieux, cares for plague victims despite personal risk, simply because he sees what needs to be done. The doctor concludes, “He knew that the tale he had to tell could not be one of a final victory. It could only be the record of what had had to be done, and what assuredly would have to be done again in the never ending fight against terror and its relentless onslaughts, despite their personal afflictions, by all who, while unable to be saints but refusing to bow down to pestilences, strive their utmost to be healers.”

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Dr. Grisolia is the editor of San Diego Physician, a 28-year member of SDCMS, and a neurologist.

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NYC A SAN DIEGO DOCTOR’S EXPERIENCE

BY KARRAR ALI, DO, MPH

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n 2019, I helped lead resiliency workshops for my emergency medicine partners at Vituity with the focus of learning mindfulness techniques, finding our center during chaos, and growing positive habits around sleep, diet, and experiencing joy in and out of work. The skills we taught were almost a foreshadowing and preparation for what was to come in 2020: a global pandemic that would test and challenge the skills and resilience of healthcare workers around the world.

There is much to discuss about this tragedy that many thought leaders including Bill Gates predicted would happen as epidemics and the widespread occurrence of disease have been a part of the world’s history going back to HIV, influenza, cholera, and the Bubonic Plague, which have killed millions of people worldwide . Pandemics can be sudden and chaotic, and require a quick response — a tough combination. There is death, confusion, anger, and panic while there is also the beauty of the human spirit that comes forward. There were 76,000 healthcare workers who volunteered when New York Governor Andrew Cuomo made the call for help, and I was one of these workers. We knew little about the illness at that time except what heard from the Italians and Chinese. Much of the focus has been on looking back and giving blame for why we weren’t better prepared as a nation and as a world, how we could have responded more quickly, and how can we take care of these patients now.

I believe in looking forward, and my perspective for this article is of one San Diego emergency medicine physician who was compelled to help our brothers and sisters in NYC. I’ve taken excerpts from my 14-day journal and shared my learnings and observations in the Intensive Care Unit of a New York City hospital (Jacobi Medical Center in The Bronx) and the city during the COVID-19 pandemic.

Agility, Connection and Learning on the Go in Crisis When serving in crises and high-pressure situations, agility is an attitude and lens that will empower you to assess a situation and use your judgment to start creating order out of chaos. This is one of the characteristics of disasters. When I helped out in Pakistan following the devastating 2005 earthquake, I had no idea what I was going to find when I got there. There was no welcoming committee at the airport, to say the least. I had to come up with a plan, get transportation, befriend an arrogant army officer, and assemble a team to go into the base of the Himalayas to see patients.

I think this experience is no different. The ability to come to a different state, a different hospital system, a different unit and to offer some value is not an easy task. I wondered, “Would my training from years ago serve me? Would I be able to walk into an ICU, introduce myself, and start giving orders and changing ventilator settings?”

Learn on the go: An ER doc serving as an ICU doc I listened to lectures online, reviewed procedures on YouTube, and watched a five-part series on ventilator management from one our intensivists at Palomar Hospital, sitting at my tiny desk in my tiny room in my tiny hotel in a desolate Midtown Manhat-

tan. I also learned about subtle differences in ventilator management for COVID patients.

As I talk to the ICU attendings, they told me how vent management hasn’t been easy for COVID patients. As the patients develop ARDS [Acute Respiratory Distress Syndrome], they become increasingly difficult to manage.

Some of the rules for ARDS management apply, but others do not. Lung compliance varies from patient to patient, and the fact they they require an immense amount of sedation makes things even more complicated.

Life in the ICU: Masks, PPE and the Art and Science of Medicine The staff scene: Traveling healthcare workers behind masks and the cumbersome PPE As I walked around the hospital floors, learning my way around and observing how this pandemic had affected so many people, I’m also learning that there are travelers from everywhere. As I introduced myself, I meet nurses from Tampa, Santa Monica, Little Rock, and almost every other part of the country. Most are here through one agency or another. There are OR nurses, peds ICU nurses, neuro ICU nurses, and everything in between. The nursing shortage is the issue because nurses are the highest exposed.

They’ve done the smart thing of putting all the IV pumps outside the room, but they still need to go in and check on the patient. Wearing the personal protective equipment (PPE) is so cumbersome. I’m so used to wearing it on a seldom occasion where I suspect a meningitis or a TB patient. Here, every single patient has COVID; and if they don’t, they still have it or will have it. It’s so easy to miss a step. Every time you go in, you have to gown up, and then every time you come out, you have to gown off. Do it again for the next patient. And now you have to sit on a computer and use a mouse or a keyboard. You may have cleaned it off at the beginning of your shift, but it’s not just your computer, so you need it clean it again and again and again. This is not the place for a germaphobe.

Two objectives: Keep the patients alive and don’t call the attending at home After I sign out, the attending thanks me again for coming and that Dr. Joshi is on call if there are any questions. My two objectives tonight are to keep the patients alive and not to call the attending at home. They have worked

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continuously for two months, and we are here to give them a break. Won’t make much sense if we keep waking them up to ask questions.

Blurred lines: Distinguishing between the art and science of medicine Even after 15 years into my career, it is still difficult to distinguish between the art and science of medicine. To me, COVID-19 is just another example where we really don’t know what we are doing. We’re trying a little of this and then a little of that. And we are using some empirical data, but every case I have seen has been different. As many articles I have read and lectures I have listened to over the past few weeks stated, the final play is based on clinical judgement. There isn’t a protocol or formula here. There’s no real algorithm. Maybe a few suggestions on what may have worked on COVID patients in Italy.

Sometimes proning, sometimes high flow O2, sometimes just intubating the patient. I think places like here or Italy where there have been so many cases will have to one day sit down and figure out what really worked. Thus far, we only have the “New York experience” or the “Italian experience.”

On the vent for weeks, without a trach … One thing that is working is to delay intubation. Glen [pulmonary fellow] told us that initially they tried intubating early because of the profound hypoxia. It soon became evident that they would run out of vents. But more importantly, once the patient was on the vent, the mortality was very high.

And after a few weeks, you would start getting complications from the endotracheal tube or just being on the vent. At least at this hospital, the ENT surgeons were very reluctant to perform a tracheostomy since the exposure risk was too high. I’d never seen patients on the vent for weeks without having a trach.

The art of proning patients 1900: As I’m finishing my rounds, I notice in bed 6 they are proning someone. Cool!

I can finally see what they do. Here, they have a proning team. It is run by the Army and includes several members, including a respiratory tech, a few nurses, and a few other solid hands, seven people in all.

The maneuver is to recruit more alveoli to help oxygenate the patient. They put a flat sheet under the patient. Then, they have another flat sheet on the patient. Then, they lay

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chucks [square padding that looks like a flat diaper] from neck to ankles. Followed by pillows on top of the chucks. Then, another flat sheet on the pillows. The Foley [urinary catheter] and rectal tube are tucked between the legs. Arms to the side. IV lines are out of the way so they don’t form pressure ulcers. Eyes are taped shut. There is one guy at the head of the bed, and several on each side. They roll the sheet on the side. In unison, they slide the patient to one side of the bed. On the leader’s count (always the guy holding the endotracheal tube), they rotate the patient 90 degrees on his side. Making sure the bed has no wrinkles or tubes or anything that will embed into the skin, on the leader’s count they rotate him again to make him prone. The head is slightly rotated so the ET tube is coming out of the side.

Seeing this all happen was one of the coolest things, and especially since it was done by the Army. They had this thing down to a science. I almost think that it could only be done by people who are so disciplined … I wish I could’ve taken a movie of this.

What if the family could see what we see?

This is where the pandemic hit me the hardest. I remember calling the family of a patient before we intubated him and discussing the severity of his disease. I remember talking to the daughter and explaining the poor prognosis if we did intubate him. I remember her being very emotional but reasonable. The problem is that she never saw how her dad really looked. His wife only spoke Spanish and was too scared to leave the house, and so her knowledge was only based on the conversation between me and the daughter. I wonder if the loved ones actually saw these patients in the ICU on four drips, breathing from a straw, often on a paralytic, that they would think differently on how we should manage their condition. Would the patients be on the ventilator for four weeks? Would they be intubated, then extubated, only to be re-intubated a day later?

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The Helping Spirit Everywhere I looked, the helping spirit of humans showed up.

Hospital food delivery every day. Though the hospital staff and volunteers like myself were tired, anxious, and doing our best, one thing we did not have to worry about was food. Jacobi treated everyone with care as they served food from local restaurants. This small act brought everyone together and nourished their bodies and souls.

Humbling and giving colleagues. The Army Corps of Engineers serving boxed lunches and, in fact, one major from the Army, a dentist from Cleveland, is happily one of the servers.

Unbelievable! He has a thriving practice back at home, yet he is so happy and honored to be here. Humble and kind, he ends every statement with “sir” and keeps thanking us for being here.

Life around me: NYC during a pandemic My grass is greener … if I pay attention … I come home a little exhausted and mostly overwhelmed. The hotel room is small. I’m sure adequate by New York standards, but small enough that I’m wondering how I’ll manage for two weeks. The concerning thing is nothing is open. NOTHING. Not a coffee shop, a restaurant, a bar, a lounge, or even our lobby downstairs. It’s basically quarantine in a shoebox. We humans are interesting creatures — we balk at small inconveniences because we are constantly comparing things to something better. I’m comparing this to my home: sunny, 78-degree San Diego, where Sherry [my wife] and Sky [my Siberian husky] are my comfort, joy, and cheerleaders. While I’m thinking about this, I am told that the concierge/manager of our hotel (Ahmed) has been living here for over five weeks! And he doesn’t know

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when he’ll go home. He says that they sent almost the entire staff home and a few brave volunteers decided to stay and take care of the hotel. They don’t have regular maid service but they offer whatever they have. I feel silly … I go back to my room and embrace the high ceilings, the comfortable bed, and the infinitely spacious dorm fridge. A sort of peace descends within me and knocks me to sleep.

Never appreciated a park so much … I’m back at Blank Slate again [café down the street from the hotel] getting my cappuccino and a lox and bagel. It seems that most parks are open, so I take my food to Bryant Park. It’s sunny and warm, and there are people all over the place. Of course, everyone is about 20 feet from each other, but at least they’re enjoying their coffee or playing a game of cards, or just taking pictures to show people what life in Bryant Park is like during COVID. I get it … I don’t want to leave from this park either.

Funny how even something so small like sitting on a park bench could be so wonderful. Just staring at the grass in front of me or listening to birds in the background has become so meaningful.

I’m starting to appreciate the mindfulness exercises that I’ve been teaching. It’s positive gratitude on a whole different level.

Back in the ICU: The end: We won’t prolong his suffering 0530: I walk in to the unit and bed 11 is hypotensive. His pressure is 58/30. Yep … that’s low. He’s got an arterial line and it’s correlated to the BP cuff on his arm. This is the guy who came in last week that I was desperately trying to save from being intubated. He is 72 years old. He was admitted last week for COVID pneumonia with a presumed pulmonary embolism.

He was on heparin for the few days after. He did well, and was extubated yesterday and just put on 2L of oxygen. All I had to do was babysit him and hopefully in the morning, transfer him to the floor. And now, his pressure is tanking! Why?? I get the ultrasound at bedside. Eesh! Fluid in the belly. Call surgery!!

The surgical intern arrives. He seems tired and bewildered so I get him up to speed and just give him the diagnosis. “Bro, he’s bleeding his belly.” As he tries to figure out how to turn on the ultrasound machine, the chief resident comes in. Definitely a chief resident and definitely a surgeon. He starts calling out orders… “need 3 units of blood STAT”… “What’s the hemoglobin?” … “Need a hemoglobin STAT!” He has the confidence of a surgeon yet the humility of a resident: A good combination. Lucky for him, I’ve already made the diagnosis and ordered all the labs and units of blood. I also added protamine [antidote for heparin overdose].

In walks the attending surgeon. She’s young, looks like a kindergarten teacher, but when she opens her mouth, she’s definitely the boss. She discusses the case with the surgery team.

It seems that opening him up will kill him because we don’t know the source of the bleeding. He needs a CT of the abdomen/ pelvis. He’s too unstable to go down to CT. As the transfusion unit finishes, his pressure drops again.

It’s time to call the family …

0730: It’s my last 30 minutes at this hospital. My only goal is to talk with the daughter and try to explain the disease course and

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prognosis of her father. She is crying on the phone and even though I’ve never met her or the wife, I can feel her pain. I sense a heaviness in my chest and feel the tears welling up in my eyes. She asks me, “Do you think you can save my dad?” My reply is, “ … probably not.”

Time to go home 0930: I’m exhausted. I’m in my hotel putting my remaining N95 masks in my suitcase. My flight is in a few hours so I need to get some rest. I’m still a little shaken from what happened a few hours before. Interesting thing is that I have had this type of encounter countless times throughout my career, but it seemed a little different this time because it’s a microcosm of this pandemic. We have tried to save as many lives as possible, but we still haven’t been able to address the management of those in the ICUs. When do we throw in the towel? When do we determine that the suffering is enough?

When do we allow families to take the risk of exposure and have them come in the ICU to see their loved ones suffering for weeks on end? These are some of the questions that go through my mind on my plane ride back.

As I land in San Diego, it’s 8:30 at night. I am so excited to see Sherry and little Sky. I feel like she has been with me much of the time I’ve taken her on many of my walks on FaceTime and shared so many stories. I think we are both ready to be still, reflect and enjoy our home and time together. I’ve never had such an experience in my life, but something tells me this won’t be the last. What New York has endured is hard to explain in a journal or a TV interview. My conversations with the heroes of Jacobi will stay with me forever.

Dr. Ali is an emergency medicine physician and a senior partner with Vituity.

COVID-19

COVID CRISIS IN TIJUANA:

SAN DIEGO MEDICAL COMMUNITY RESPONDS

By James H. Schultz, MD, MBA, FAAFP, DiMM, FAWM

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s I write this in early June I am almost overcome with a hurricane of emotions about what has transpired over the past three to four months. A mutant virus from central China has changed the world and almost everything we do. A tempest in a teapot has become a whirlwind, stirring up public health and sociological issues that have been too-long ignored.

A few emotions keep rising to the top for me. This article is about pride and gratitude — pride in the selflessness and generosity of my colleagues, and gratitude to our entire medical community for stepping up and stepping out even past our borders in a time of need.

The public health efforts in San Diego and the generally excellent response of our citizens have undoubtedly saved any thousands of lives. As time goes on and more data come in, we see around the world that the better the response to masking and social distancing has been, the fewer people have died.

In the middle of April, this was still not certain but we were doing our best to do what could be done and our infection rate remained low.

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COVID-19 However, it was becoming apparent by the now-deferred tax day in mid-April that something was happening in Northern Baja California. Testing positivity rates in our southern zip codes were outpacing the rest of the county, and Sharp Chula Vista and Scripps Chula Vista were filling with sick COVID-19 patients. Despite some federal efforts at reducing the number of people crossing the border, 40,000–80,000 people were still crossing daily. There were predominately U.S. citizens and legal residents with jobs in San Diego County, including as essential workers in hospitals, medical offices, food processing plants, and with defense contractors. n April 19 we sent a letter to the county expressing concern and outlining some possible way to assist.

Part of the rationale was altruistic and part of it was selfish; we did not want this virus raging through our neighbors and friends to the south and we did not want a virus so blatantly disrespectful of the international border to erupt here. Reports were surfacing of patients being turned away from full hospitals, at-home deaths increasing, whole households getting sick with COVID-19, healthcare personnel falling ill, and temporary hospitals being established. It was starting to sound like Italy and New York City.

Two proposals were put forth to the County for consideration: Proposal 1: SDMCS/SD County work together to coordinate a volunteer effort to provide physician volunteers to N Baja Proposal 2: Stop essential worker cross-border travel.

Should we, with proper notice, close the border to all personal

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movement? Give essential workers time and a place (county hotel space) to stay here until N Baja quelled? (Proposal 2 was deemed by the county to be not within their jurisdiction or control. However, county officials had already been in touch with the federal government and ultimately high-ranking DHS officials came on multiple occasions to explore border-crossing response options.)

Under Proposal 1, we would work together with N Baja officials to determine if there was a need for PPE, ventilator supplies, and ventilators, volunteer physician support, and/or structural items. To the extent we were to lend people to the effort, we would need to ensure licensing/malpractice issues were addressed and that security to and from the border was in place as well as transportation, food and lodging for prolonged stays. Adequate PPE and testing would also be necessary.

Communications channels would need to be established. And, most importantly, roles would need to be well-defined. We also wanted to investigate the potential of establishing physicianto-physician telemedicine support lines. SDCMS had already enrolled about 200 physicians willing to volunteer here for a possible surge event on this side of the border so we had a potential pool of local heroes to tap already.

Initial inquiries from our county officials to some Tijuana and N Baja officials provided information that the medical community required no assistance yet.

By April 30, our South Bay hospitals’ censuses continued to explode while most of the rest of the county maintained a steady but lower volume of Covid-19 cases. More stories were coming across the border with our daily border-crossing neighbors about a worsening situation south of the border. SDCMS members Drs. Linda Hill, Jess Mandel, and Lucy Horton from UC San Diego reached out to the county and offered assistance to the Tijuana medical community and the county cross-border team made contact again.

By May 4 we had determined that there was not much help needed and our efforts were going to cease; literally within a few hours of that decision a request for help was received from physicians and government representatives in Northern Baja.

Dr. Andres Smith from Sharp Chula Vista (also a SDCMS member!) sits on the Board of one Tijuana hospital, Cruz Roja, and is a director of the Cruz Roja EMS service, is a N Baja native and has many connections there. With his coordination and connections and through the County cross-border team we established an emergent evening call with political and medical leadership the night of May 4.

With a flurry of activity and a herculean effort from Dr. Smith, a delegation was formed and went to Tijuana early May 6. The delegation consisted of Drs. Mandel, Smith, Horton, and me, and Kelly O’Connor, RN from the UCSD ICU team. We were honored with a behind-the-curtains comprehensive tour of Hospital General de Tijuana and a brand-new lower-acuity temporary hospital in the Zonkeys’ basketball arena across town. This was to be staffed mostly by MSF and local physicians and nurses.

Tijuana General looked like images and descriptions of some Italian and New York hospitals. Two things stood out the most for me. One, and the more mundane, was their excellent PPE and the diligence of their nurses making sure we donned and doffed appropriately. I was a little envious of their PPE — it was much better than what I had available as a hospitalist here. he second thing that stood out for me, and something I will remember forever, is the dedication and courage of the physicians. This hospital had really sick patients — many on ventilators boarding in the ER for days, four people in a space designed for one, more people coming and each one sicker than the last. The volume of patients they were handling and the acuity was overwhelming to me; I will never again whine when my Palomar ER colleagues give me a chest pain, a DT, and a syncope to admit all at once. Young physicians were heroically acting with limited resources in a fairly austere environment and doing it with passion and purpose. You could see the fatigue in their eyes but also the determination.

The hospital itself was also adapting. We witnessed the process of creating negative pressure wards where there were none, new ICU beds in use, and temporary but effective personnel movement controls designed to keep the virus in isolated sections of the facility.

The leadership at Tijuana General has requested specifically a narrow focus on some collaboration in the care of the critically

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ill COVID-19 patients. As a result, Drs. Mandel and Smith, along with Dr. Tim Morris (intensivist and ventilator expert from UCSD) and nurses from Sharp and UCSD have been present on a daily basis exchanging ideas with our colleagues there. The nurses have helped share best practices and experience gained in the U.S. on patient positioning and care of COVID-19 patients and critically ill patients in general. Drs. Morris and Mandel have ensured that either one of them or another volunteer is present at Tijuana general seven days a week for four weeks; this effort is ongoing. Other physicians from Sharp, UCSD, and even Community Health Centers have gone to act as interpreters and to provide any other help requested. And Dr. Smith continues to pave the way and be present with this effort. And we are exploring how collaboration might continue using technology.

Back to those emotions — this is why I am so proud of and so grateful for my colleagues. It’s not as if people aren’t busy enough already and aren’t dealing with an upended world on many fronts already. In the face of so much change, uncertainty, and stress, our physicians are finding the time, will, and fortitude to go above and beyond in helping others: physicians at their best in a time of crises once again!

Dr. Schultz is chief medical officer for Neighborhood Healthcare and immediate past president of the San Diego County Medical Society.

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Seeking FM/DO/IM/ Psychiatrist in San Diego County Position: Full-time and part-time. Full benefits package and malpractice coverage is provided by clinic.

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SanDiegoPhysician.org 13

COVID-19

SAN DIEGO COUNTY MODEL FOR COMMUNITY COLLABORATION: LEANING IN FOR PANDEMIC PLANNING

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riage is a battlefield process used to prioritize patients and casualties from mass injury events according to those who need medical attention and would benefit from interventions in order to save the most lives possible. This concept is now commonly used during mass disasters in the community and separated into three categories: Primary triage determines the appropriate destination for patients via the ambulance transport system. Secondary triage occurs in emergency rooms, and Tertiary triage is the process of allocating resources in the intensive care units to those most likely to benefit. Tertiary triage is the course of action that we take when we have exhausted our ability to expand our critical care resources to surge. Triage requires us to accept the fact that, in a crisis situation, some individuals will not receive critical care resources that might have been dedicated to their care under normal circumstances, while some individuals will have critical care interventions withdrawn if they are unable to improve. (Maves et. al.) As the world witnessed overwhelmed healthcare systems from China to Italy with reports of triage implementation filtering to the United States, surge capacity preparations and the potential for scarce resource allocation planning suddenly became relevant. We describe the process by which more than 150 members from San Diego’s medical community have coalesced to prepare for an unimaginable event in order to facilitate sharing of scarce resources with the hope of avoiding scarce resource allocation situations.

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In early February, the first cases of COVID-19 came to San Diego with evacuees from Wuhan China who were quarantined at Marine Corps Air Station Miramar, with some requiring hospitalization. Later, evacuees from the Diamond Princess (Japan) and Grand Princess (San Francisco) also underwent quarantine.

Our first documented case of COVID in a San Diego County resident was on March 9. Physicians in San Diego, like the rest of the world, were anxiously watching the events in China and Italy. News of shutdowns, infected healthcare workers, and overwhelmed hospital systems raised the level of concern in our community from worry to alarm.

Members of the San Diego County Medical Society (SDCMS) expressed concern for our own healthcare system and its ability to withstand a surge. Contingency plans of preserving personal protective equipment (PPE) and extended use were implemented as shortages of PPE contributed to the anxiety of healthcare workers. Our physician community prepared to care for an unknown number of patients with a peak of disease that might arrive within weeks. Physicians began asking about what would happen if our system became overwhelmed as they watched reports of overcrowded hospitals in Italy and rapid spread of the illness in a nursing home near Seattle.

SDCMS put out a call to its members to begin social distancing on March 11. On March 12, Mayor Kevin Faulconer issued a State of Emergency for the City of San Diego, and restrictions on gatherings soon followed. On March 19, Governor Gavin

By Holly Yang, MD, MSHPEd, HMDC, FACP, FAAHPM, Paula Goodman-Crews, MSW, LCSW, David Bazzo, MD, FAAFP, CAQSM, James H. Schultz, MD, MBA, FAAFP, DiMM, FAWM, Asha Devereaux, MD, MPH, FCCP

Newsom issued a statewide stay-at-home order.

In the midst of our community undergoing some of the most important and consequential public health interventions of our lifetime, SDCMS leadership began to reach out to understand our community’s preparedness in case of overwhelming surge.

On March 11, SDCMS reached out to County leadership. Realizing the need for specific allocation protocols around ventilators and other scarce critical care resources, and after reaching out to staff at the Assistant Secretary for Preparedness and Response Technical Resources, Assistance Center, and Information Exchange (ASPR TRACIE) and understanding that a federal framework would not be forthcoming, leaders from the SDCMS Bioethics Commission began to form a coalition of experts to help develop them. During this phase that it was learned that the Taskforce on Mass Critical Care (TFMCC), an international group of critical care experts, was working on recommendations for the COVID-19 pandemic, which was important, as much of the existing literature was focused on pandemic influenza.

When the recommendations came out, while very helpful in concept, they were not a practical tool for hospitals and clinicians in triage decision making. t this point, members of the SDCMS Executive Committee and Bioethics Commission leadership joined with members of the Medical Operations Center for San Diego County and local TFMCC members to rapidly pull together medical and bioethics experts to create regional

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consensus guidance for allocation of scarce resources. With the assistance of the Hospital Association of San Diego and Imperial Counties (HASDIC), representatives from all San Diego County hospital systems came together to form two workgroups: critical care physicians and bioethics. At the same time, a central Crisis Care Committee formed comprised of medical and community members from the following sectors: pulmonary and critical care specialists, acute inpatient care/hospitalists, outpatient primary care, community health center/federally qualified health center, County Health and Human Services Agency, clergy, community advocates, City of San Diego, emergency medical services, hospital administration, emergency medicine, pediatrics, SDCMS, behavioral health, healthcare workforce wellness/mental health, nursing, bioethicists, palliative care, hospice, post-acute and long-term care, veterans, homeless, clinical/community linkages, patient advocacy, and legal services. Several members represented more than one sector.

Organizers encouraged representation from healthcare systems throughout the county. rom March 27 to April 4, these three groups met virtually for long hours to create consensus for fair and ethical distribution of resources to save the most lives possible and to be used only if demand outstripped supply. These groups drew from previously published work and learned from emerging work nationally and internationally as other states and countries developed and refined their own triage protocols. It was unknown at this time if California would be developing any statewide guidance. Two additional groups also contributed during this time period. The triage tool workgroup was formulated from representatives from hospitals whose organizations extend outside of San Diego County and grappled with how to reconcile differences in state, regional, and national organization guidance.

The other was the preexisting San Diego Extracorporeal Membrane Oxygenation (ECMO) Consortium, which collaborated with our larger effort to provide recommendations on this very specific part of critical care. All of the groups worked to create crisis standards of care that would save the most lives possible and avoid discrimination as outlined by the Office of Civil Rights guidance (issued March 28).

In early April, people were dying in horrifying numbers and refrigerator trucks were filling with bodies outside hospitals in New York. In San Diego, our COVID-19 numbers were rising. The non-pharmaceutical interventions of the stay-at-home orders and public education on minimizing infection were helping to flatten the curve, although it was not totally clear yet where on the curve we were. During this time, a small test virtual tabletop exercise was done via Zoom, followed by a countywide tabletop exercise with a simulated crisis scenario for all hospitals’ triage officers.

After the initial tabletop exercise, feedback from participating triage officers and team members as well as the CMOs of hospitals helped to refine the triage tool to remove an item that was deemed to be too subjective. The existing workgroups updated the triage tool, created a draft patient education handout, and updated tiebreakers. Three additional tabletop exercises were completed to train the triage teams with the new draft of the consensus document.

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hese tabletop exercises were critical, as to ensure that decisions about resource allocation are not made by the physicians directly caring for the patient, but rather by a triage team led by a triage officer who is a critical care or emergency medicine physician. A treating physician’s role is to act in their patients’ best interest and advocate for them. In times of scarcity, it requires a shift of perspective from individual benefit and first-come first-served, to a public health perspective of giving critical resources to those who require them and are most likely to survive. The triage officer tasked with making these decisions with the support of the triage team would make decisions based on objective data and a scoring system, but blinded to the patient and their detailed medical chart to avoid potential for bias. Clearly, the decision making in this situation is different from our norm in medicine, so these tabletop exercises were necessary for education and practice using the tool.

Another reason for educating teams from across the county all at once was to create a shared understanding and method of allocating resources consistently across our region. It is critical to ensure fairness in the setting of scarcity that all systems in a region consider resource allocation the same way. This prevents a scenario in which a patient who arrives at hospital A would be denied a ventilator, when by chance if the ambulance had brought them to hospital B across the street they would have received one because of different criteria. It was also important to gather as a community to ask questions and gain ideas from other hospitals, consider difficult and/or unclear scenarios, and to build trust.

Areas that have been identified as strengths of our process: 1. Highly engaged medical experts across systems who worked together in difficult circumstances (e.g., compressed timeline, short notice and lengthy meetings, virtual meetings) 2. Collaboration between SDCMS, HASDIC, and the County of San Diego Emergency and Medical Operations Centers 3. Willingness to modify protocols based on feedback and tabletop exercises Areas that we have identified for continued development: 1. Education about and refinement of communication within and between health systems and the county and community partners according to their chain of commands.

2. Inclusion of a representative from the CMO group on the Crisis Care Committee for their perspective and to aide in real-time communication during crises.

3. Situational awareness with real-time data tracking tools transparent to all hospitals.

4. Community input into the draft of the San Diego consensus crisis standards of care: This will be critical to ensure a

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transparent and unbiased process as possible.

5. Renal replacement therapy allocation: This is of special concern given the significant scarcity of dialysis that occurred during the April peak of the pandemic in New York and New Jersey.

6. Pediatric guidance: While not as significantly affected with severe COVID-19 disease, it is important to also plan for potential scarce resources that may impact children.

7. Ongoing refinement of the triage tool as data about COVID-19 continues to emerge.

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e are proud to be a part of planning for an event that we hope never occurs. In fact, it is precisely this planning, this coming together across organizations, that is critical in avoiding the situation. By working at cooperation rather than competition, valuing medical expertise, and grounding in ethical principles, we will hopefully prevent uneven distribution of resources across our region. Crisis care would be something declared at a government level, not one institution, and only after all available avenues for getting resources rapidly are exhausted. We each have learned and continue to learn in this ongoing process. We are grateful to the more than 150 healthcare professionals who have helped us to date, and to the community members of our Crisis Care Committee who will ensure we are hearing concerns and questions from outside of medicine. We are also grateful to the staff and physicians at San Diego County, especially in the Medical Operations Center, the support from Be There San Diego, and the collaboration with HASDIC.

Dr. Yang is president of SDCMS, Paula Goodman-Crews is Bioethics Commission co-chair, Dr. Bazzo is a former president of SDCMS, Dr. Schultz is immediate past president of SDCMS, and Dr. Devereaux is an SDCMS member, TFMCC executive committee member, and past co-chair.

References: Maves RC, Downar J, Dichter JR, et al. On behalf of the ACCP Task Force for Mass Critical Care, Triage of scarce critical care resources in COVID-19: an implementation guide for regional allocation an expert panel report of the Task Force for Mass Critical Care and the American College of Chest Physicians CHEST (2020), April 2020 https://doi.org/10.1016/j.chest.2020.03.063 HHS Office of Civil Rights in Action. BULLETIN: Civil Rights, HIPAA, and the Coronavirus Disease 2019 (COVID-19) https:// www.hhs.gov/sites/default/files/ocr-bulletin-3-28-20. pdf?fbclid=IwAR351WokrC2uQLIPxDR0eiAizAQ8QXwhBt_0asYiXi91XW4rnAKW8kxcog

CHAMPIONS FOR HEALTH

Left: Noel M. with his son, Alan, and their dog.

Center: Dr. Adam Fierer. Right: Evelyn Penaloza, Project Access care manager

Surgery During COVID-19 Times

By Adama Dyoniziak “I WAS SO WORRIED AND ANXIOUS about getting COVID and about the surgery.” These thoughts were running through Noel M’s mind constantly. Noel was referred to Project Access for general surgery to treat his right inguinal hernia.

His originally scheduled April surgery was rescheduled for the end of May due to COVID-19.

Noel suffered from his hernia condition for almost two years and it was affecting his daily life. He would get sent home from his job at the car wash. “I was in unimaginable pain,” he says. He was unable to run, go to the gym, or go hiking or bicycling with his son, Alan, and

partner, Martina. Then as the surgery date neared, Noel expressed concerns about having the surgery with everything that was going on with COVID-19. Evelyn Penaloza, Project Access care manager, reassured Noel that the hospital and staff were taking all the necessary precautions.

“We talked over the phone every day for a week up until his surgery,” Penaloza says. “Noel really needed someone to talk to because he felt like his family would make fun of him for being scared.”

Project Access staff participated in a training on managing anxiety during COVID-19 for patients and providers.

Focusing on the present and using grounding techniques helped Noel. “I told Noel we had to take it one step at a time, and he could call me whenever he needed help with anything,” Penaloza says. “Acknowledging how he was feeling and telling him it was normal for him to feel worried and anxious helped him. He used breathing techniques and even started doing some yoga. He was worried about being exposed to COVID-19 and complications that could occur from surgery.” His physician, Dr. Adam Fierer, and his staff were very helpful in answering all his questions, and Noel felt better prepared for surgery. “I want the

patient experience to be everything they could hope for,” Dr. Fierer says. “We make sure that patients feel welcome, and are provided all the information they need to feel comfortable with their upcoming surgery. My goal is for each patient to get every benefit of early recovery and less pain.”

Noel has recovered and the doctor has cleared him to return to normal activities.

“I’d like to thank Project Access, Dr. Fierer, and his staff for helping with my surgery,” Noel says. “It has changed my life. I am very happy and grateful.” Dr. Fierer has been a Project Access volunteer for many years. “It is incredibly satisfying to change somebody’s life for the better,” he says.

Now, Noel wants to start his own business of a mobile car wash.

For more information on how you can share your time and talent for Project Access’ uninsured or very lowincome patients, please contact Adama Dyoniziak at (858) 300-2780 or adama. dyoniziak@championsfh.org. Join us for our Virtual Sunset 5K kickoff on June 20, and in effect until Aug. 22 by registering at www.cfh5k.org.

Adama Dyoniziak is executive director of Champions for Health.

SanDiegoPhysician.org 17

CLASSIFIEDS CLINICAL TRIAL VOLUNTEERS NEEDED PARTICIPATION IN CLINICAL RESEARCH TRIALS: Physicians in the following specialties are needed for participation as Principal or SubInvestigator in Pharmaceutical sponsored Clinical research trials involving COVID-19 vaccine, RSV vaccine, Flu vaccine, Migraine, Multiple sclerosis, Parkinson’s disease, Asthma, COPD, NASH, Diabetes studies. Prior Clinical Research Experience is preferred but not essential. Our team of Clinical Research Professionals will conduct the clinical trials under your supervision.

Financial incentives and scientific publication opportunity. Will not take time away from your practice or increase liability. Primary care; Internal medicine; Pulmonology; Dermatology; Neurology; Gastroenterology. Please contact jsaleh@paradigm-research.com or anguyen@ paradigm-research.com or Afalconer@paradigmresearch.com PHYSICIAN OPPORTUNITIES INTERVENTIONAL PHYSIATRY/PHYSICAL MEDICINE SPECIALIST POSITION AVAILABLE: Practice opportunity for part time interventional physiatry/physical medicine specialist with well-established orthopaedic practice. Position includes providing direct patient evaluation/care of spine and musculoskeletal cases, coordinating PMR services with all referring providers. Must have excellent interpersonal and communication skills.

Office located near Alvarado Hospital. Onsite digital x-ray and emr. Interested parties, please email lisas@sdsm.net CARDIOLOGIST WANTED: San Marcos cardiology office looking for a part-time cardiologist. If interested, send CV to evelynochoa2013@yahoo.com or via fax to (760) 510-1811.

CHILD HEALTH OFFICER (MEDICAL DIRECTOR): The County of San Diego Health & Human Services Agency (HHSA), Medical Care Services (MCS), is seeking online applications and résumés from qualified individuals for Child Health Officer/Medical Director. This unclassified management position plays a key leadership role in our medical care system by supporting the planning, directing, and coordinating of all forensic and clinical functions specific to Medical Care Services. In accordance with Federal, state, and local policies and regulations, the Child Health Officer will have significant responsibility for monitoring and/or evaluating medical assessments of child abuse and/or neglect, pediatric care, and an array of services. Regular Full time $240,000.00 - $250,000.00 Annually.

Please visit the County of San Diego website for more information and to apply online.

PEDIATRIC POSITION AVAILABLE: Grossmont Pediatrics, a private pediatrics practice with Commercial HMO, PPO, Tricare, Medi-Cal patients, provides family-focused individualized care in East San Diego. Clinical cases include ADHD, asthma, adolescent behavioral health. Average 2.5 clinic patients per hour, 1-in-3 light call & newborns at one hospital. With Epic HER, access real-time care at Rady’s and area hospitals. Working 24 or 28 hours weekly, you will earn $130-150,000 annual compensation, upto 3 weeks PTO plus holidays, and future share in practice. Direct professional

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expenses are paid, Health, Dental, 401K, etc.

Contact venk@gpeds.sdcoxmail.com or 619-5045830 with resume in .doc, .pdf or .txt.

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

Great opportunity to work in a multidisciplinary setting in a private non-profit agency that serves persons with developmental disabilities. Must be licensed to practice medicine in California and certified by specialty board such as Neurology, Neurodevelopmental Disabilities, Developmental Behavioral Pediatrics, Pediatrics or Internal Medicine. Experience in the field of developmental disabilities and administrative or supervisory experience required. Please visit our website at www.sdrc.org for more information and to submit an application.

DEPUTY PUBLIC HEALTH OFFICER: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a California licensed or license eligible physician to work for County of San Diego Public Health Services, nationally accredited by the Public Health Accreditation Board. Regular - Full Time: $220,000 - $230,000 Annually. For more information and to apply: https://www. governmentjobs.com/careers/sdcounty/ jobs/2359704/deputy-public-health-officer19092204u?keywords=Deputy%20Public%20 health%20&pagetype=jobOpportunitiesJobs TEMPORARY EXPERT PROFESSIONAL (TEP) MEDICAL DOCTORS (MDs) NEEDED: The County of San Diego Health and Human Services Agency is seeking numerous MD positions to work in a variety of areas including Tuberculosis Control, Maternal and Child Health,

Epidemiology and Immunizations, HIV, STD & Hepatitis, and California Children’s Services.

Applicants (MD or DO) must hold a current California medical license. Applicants must be proficient in either Opioid Abuse Prevention and Treatment Strategies, Communicable Diseases and/or Healthcare Systems, and willing to minimally work three days a week. Hourly rate is $103/hour. If interested, please e-mail CV to Anuj.

Bhatia@sdcounty.ca.gov or call (619) 542-4008.

PRACTICE OPPORTUNITY: Internal Medicine and Family Practice. SharpCare Medical Group, a Sharp HealthCare-affiliated practice, is looking for physicians for our San Diego County practice sites. SharpCare is a primary care, foundation model (employed physicians) practice focused on local community referrals, the Patient Centered Medical Home model, and ease of access for patients. Competitive compensation and benefits package with quality incentives. Bilingual preferred but not required. Board certified or eligible requirement. For more info visit www. sharp.com/sharpcare/ or email interest and CV to glenn.chong@sharp.com.

PHYSICIAN POSITIONS WANTED PAIN MANGEMENT POSITION WANTED: Pain Management Physician Position Wanted: Fellowship-trained at MD Anderson Cancer Center, pain management with anesthesia background physician looking for a private practice, hospital, or academic position. Skilled in basic and advanced procedures, chronic pain and cancer pain management. Have CA, DEA, and Fluoro licenses. Please call/text (619) 977-6300 or email Ngoc.B.Truong@dmu.edu.

PRACTICE FOR SALE PRACTICE FOR SALE IN ENCINITAS: A GYNonly practice for sale in Encinitas with a majority of the patients in North County. Insurance accepted are PPO, cash and some Medicare patients. Could be turnkey or just charts.

Practicing is closing December 31st, 2019. Please call Mollie for more information at 760-943-1011.

CLINICAL RESEARCH SITE/MULTI-SITE SPECIALTY PHYSICIAN PRACTICE COMBO FOR SALE: Great opportunity for a Group Practice. Clinical Research offers a way for physicians to continue to practice medicine the way they like and provide an additional source of income that is compatible with their goal of providing great care and options for their patients. Patients will have the opportunity to participate in the research of new treatments.

Current site has staff and facilities for research, physician suites, and X-Ray. Use as a primary location or as a satellite office with research site.

Current physicians and staff willing to train and work alongside physicians new to research.

Contact E-Mail: CL9636750@gmail.com PRACTICES WANTED PRIMARY OR URGENT CARE PRACTICE WANTED: Looking for independent primary or urgent care practices interested in joining or selling to a larger group. We could explore a purchase, partnership, and/or other business relationship with you. We have a track record in creating attractive lifestyle options for our medical providers and will do our best to tailor a situation that addresses your need. Please call (858) 832-2007.

LA JOLLA OFFICE FOR SUBLEASE OR TO SHARE Scripps Memorial Medical office building at 9834 Genesee Ave. Amazing location by the main entrance to the hospital between I-5 and I-805. Multidisciplinary group available to any specialty. Excellent referral base in the office and on the hospital campus.

Great need for a psychiatrist.

We have multiple research projects.

If you have an interest or would like more information, please call 858-344-9024 or 858-320-0525.

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 MEDICAL SUITE AVAILABLE: Modern and luxurious medical suite located in the Scripps Ximed Building, on the campus of Scripps Memorial Hospital available for sublease/ space sharing. The lobby is spacious, and there is a large doctor’s office, staff room and 4 exam rooms. Terms are flexible, available to share parttime, half days or full days 4 exam rooms. Rent depends on usage. For more information, call 858-550-0330 extension 106.

ESCONDIDO MEDICAL OFFICE TO SHARE: Medical office space available at 1955 Citracado Parkway, Escondido. Close to Palomar Medical Center-West, Two to three furnished exam rooms, 2 bathrooms, comfortable waiting room, lab space, work area, conference room, kitchen.

Radiology and Lab in the medical building. Ample free parking. Contact Jean (858) 673-9991.

MEDICAL OFFICE SPACE FOR SUBLEASE: Brand new medical office space available for sublease in La Jolla near UCSD. 8950 Villa La Jolla at The Campus, easy access from I-5.

Perfect for specialist, includes one exam room and one procedure room. Brand new flooring, paint, furniture etc. Please send your email to eferrermd@gmail.com if interested.

MEDICAL OFFICE LEASE: We currently have a small medical office ready to lease.

The office is located in Imperial county and is approximately 910 sqft. Please email us at info@ carlsbadimaging.com with any with further questions or needed details.

NORTH COUNTY MEDICAL SPACE AVAILABLE: 2023 W. Vista Way, Suite C, Vista, CA 92083. Newly renovated, large office space located in an upscale medical office with ample free parking. Furnishings, décor, and atmosphere are upscale and inviting. It is a great place to build your practice, network and clientele. Just a few blocks from Tri-City Medical Center and across from the urgent care. Includes: Digital X-ray suite, multiple exam rooms, access to a kitchenette/break room, two bathrooms, and spacious reception area all located on the property. Wi-Fi is NOT included.

Contact Harish Hosalkar at hhorthomd@gmail.com or call/text (858) 243-6883.

MEDICAL OFFICE AVAILABLE FOR RENT: Furnished or unfurnished medical office for rent in central San Diego. Can rent partial or full, 5 exam rooms of various sizes, attached restroom. Easy freeway access and bus stop very close. Perfect for specialist looking for secondary locations. Call 858-430-6656 or text 619-417-1500.

MEDICAL OFFICE SPACE FOR SUBLEASE: Medical office space available for sublease in La Jolla-9834 Genesee Avenue, Suite 400 (Poole Building). Steps away from Scripps Memorial Hospital La Jolla. Please contact Seth D. Bulow, M.D. at 858-622-9076 if you are interested.

LA JOLLA OFFICE FOR SUBLEASE OR TO SHARE: Scripps Memorial Medical office building at 9834 Genesee Ave. Amazing location by the main entrance to the hosptial between 1-5 and 1-805. Multidisciplinary group available to any specialty. Excellent referral base in the office and on the hospital campus. Great need for a psychiatrist. We have multiple research projects. If you have an interest or would like more information, please call 858-344-9024 or 858-320-0525.

SHARED OFFICE SPACE: Office Space, beautifully decorated, to share in Solana Beach with reception desk and 2 rooms. Ideal for a subspecialist. Please call 619-606-3046.

OFFICE SPACE/REAL ESTATE AVAILABLE: Scripps Encinitas Campus Office, 320 Santa Fe Drive, Suite LL4 It is a beautifully decorated, 1600 sq. ft. space with 2 consultations, 2 bathrooms, 5 exam rooms, minor surgery.

Obgyn practice with ultrasound, but fine for other surgical specialties, family practice, internal medicine, aesthetics. Across the hall from imaging center: mammography, etc and also Scripps ambulatory surgery center. Across parking lot from Scripps Hospital with ER, OR’s, Labor and Delivery. It is located just off Interstate 5 at Santa Fe Drive, and half a mile from Swami’s Beach. Contact Kristi or Myra 760-753-8413.

View Space on Website:www.eisenhauerobgyn. com. Looking for compatible practice types.

OFFICE SPACE FOR RENT: Multiple exam rooms in newer, remodeled office near Alvarado Hospital and SDSU. Convenient freeway access and ample parking. Price based on usage. Contact Jo Turner (619) 733-4068 or jo@siosd.com.

OFFICE SPACE / REAL ESTATE WANTED MEDICAL OFFICE SUBLET DESIRED: Solo endocrinologist looking for updated bright office space in Encinitas or Carlsbad to share with another solo practitioner. Primary care, ENT, ob/ gyn would be compatible fields. I would ideally have one consultation room and one small exam room but I am flexible. If the consultation room was large enough I could have an exam table in the same room and forgo the separate exam room. I have two staff members that will need a small space to answer phones and complete tasks. Please contact 858-633-6959.

MEDICAL OFFICE SPACE SUBLET DESIRED NEAR SCRIPPS MEMORIAL LA JOLLA: Specialist physician leaving group practice, reestablishing solo practice seeks office space Ximed building, Poole building, or nearby. Less than full-time. Need procedure room. Possible interest in using your existing billing, staff, equipment, or could be completely separate. If

interested, please contact me at ljmedoffice@ yahoo.com.

MEDICAL EQUIPMENT / FURNITURE FOR SALE FOR SALE: Nuclear medicine equipment including Ge Millennium MG system, hot lab, and sources Cs-137. Rod Std 2. Cs-137. DCRS 3. Cs-137.

Spot 4. Co-57. Flood sheet. Please contact us at 760-730-3536 if interested in purchasing, pricing or have any questions. Thank you.

NON-PHYSICIAN POSITIONS AVAILABLE EXECUTIVE DIRECTOR, STUDENT HEALTH AND COUNSELING SERVICES: California State University San Marcos (CSUSM) has announced a national search for a visionary and collaborative leader to serve as Executive Director of Student Health and Counseling Services. Selected candidate will be appointed into an Administrator III OR Administrator IV. Appointment will be determined by education and experience. Selected candidate with an M.D. will be appointed as Administrator IV, and selected candidate without an M.D. will be appointed as Administrator III. For position specifications, benefits summary and to apply, please visit our website at https://apptrkr.com/1852486 FINANCE DIRECTOR San Diego Sports Medicine and Family Health Center is hiring a full-time Financial Director to manage financial operations. Primary responsibilities include monitoring of income, expenses and cash flow, reconciling bank statements, supervision of accounts payable, oversee billing department, oversee accounts receivables, payments and adjustments, prepare contracts, analyze data, prepare financial reports, prepare budgets, advise on economic risks and provide input on decision making. MBA/ Master’s and 5+ years relevant work experience preferred. Excellent references and background check required. Salary commensurate with skills and experience. To apply, please send resume to Jo Baxter, Director of Operations jobaxter@ sdsm.com.

NON-PHYSICIAN POSITIONS WANTED MEDICAL OFFICE MANAGER/CONTRACTS/ BILLING PERSON: MD specialist leaving group practice, looking to reestablish solo private practice. Need assistance reactivating payer contracts, including Medicare. If you have that skill, contact ljmedoffice@yahoo.com. I’m looking for a project bid. Be prepared to discuss prior experience, your hourly charge, estimated hours involved. May lead to additional work.

PRODUCTS / SERVICES OFFERED DATA MANAGEMENT, ANALYTICS AND REPORTING: Rudolphia Consulting has many years of experience working with clinicians in the Healthcare industry to develop and implement processes required to meet the demanding quality standards in one of the most complex and regulated industries. Services include: Data management using advanced software tools, Use of advanced analytical tools to measure quality and process-related outcomes and establish benchmarks, and the production of automated reporting. (619) 913-7568 | info@rudolphia. consulting | www.rudolphia.consulting.

SanDiegoPhysician.org 19

PERSONAL & PROFESSIONAL DEVELOPMENT

This Is Our Time. The World Has Been Waiting for Us

By Helane Fronek, MD, FACP, FACPh THIS YEAR’S UCSD SCHOOL OF MEDICINE GRADUATION was distinctive. The virtual ceremony prevented our joining together to celebrate the new doctors’ accomplishment and the significance of becoming physicians. Yet technology allowed us to witness on screens the joy of graduates and their families as each name was announced. The transformation of medical student to doctor is always breathtaking to me. And the commencement speaker’s message, set against the backdrop of protests against racial injustice throughout our country, made 2020’s graduation even more poignant.

Mona Hanna-Attisha, MD, the pediatrician who bravely persisted in sounding the alarm about toxic drinking water in Flint, Michigan, and its impact on children living in lower socioeconomic neighborhoods, used her speech to call the graduates to action. “This is your time. The world has been waiting for you,” she beseeched, reminding us that the power we hold as physicians can inspire significant change.

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July 2020

I was taught that African-Americans with chronic medical conditions — diabetes, heart disease, hypertension — have worse prognoses, ostensibly due to genetic or other underlying organic factors. More recently, we’ve seen the disproportionate outcomes from Covid-19 in people of color. Now we know that social factors are significant determinants of health and can be modified to improve those dire futures. Unfortunately, distrust in our health system and sometimes less effective treatment of African-Americans and other communities of color was born of medical experimentation on them, implicit biases, our unwillingness to understand and integrate their culture and important beliefs into the care we offered, and the barriers to entry into our profession that kept healthcare providers from reflecting the racial and ethnic makeup of our patients.

PRIME-Health Equity programs offered by UC medical schools constitute an important step in changing that reflection and should be expanded: We need doctors who look like and understand all groups within our multicultural society. All physicians and students will benefit from exploring our own implicit biases and from education on the importance of culture in communicating and formulating treatment strategies and plans. Attention must be directed to correcting inequities in education, access to nutrition, earnings, and opportunities at all levels. As Ibram X. Kendi, PhD, shares in his enlightening book How to Be an Antiracist, we cannot cut the shackles of people kept in captivity for years, place them on the starting line of a race, and expect them to compete as if conditions are now equal for all. We must first assist them in acquiring skills, knowledge, support, and confidence so they can perform at their best and have a fair chance of competing in the world.

What does this mean to us, as physicians, the people tasked with caring for our patients and community? Each of us will have to decide.

For me, it means educating myself about the experiences of groups that have felt unseen, misunderstood, and mistreated.

Acknowledging when I was blind to their pain or turned away, pretending it didn’t involve me. Being open to hearing, painful though it is, the ways in which they felt abandoned by our country, the medical profession, and me. Seeking ways to correct inequities in our world by increasing diversity in government, communities and organizations, and improving causative determinants such as education and healthcare. And most of all, increasing my sensitivity to injustice and speaking out against it.

I invite my fellow physicians to join me as we, who have willingly taken on the role of caring for the health of our community, honestly look at what we can do to correct the injustices that lead to inequities in our society and the care we deliver. Our time truly is now. The world has been waiting for us. Together, we can make a difference.

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

7th Annual Champions For Health Virtual Sunset 5K Benefits Project Access San Diego

Cham

h ealt

ns For H o i p

Virtual Sunset 5K

August 22, 2020 $40 Adult • $25 Children Under 12 Join us with your pets, family, friends, co-workers or individually as you walk, run, bike, swim or even treadmill our virtual sunset 5K.

www.CFH5K.org Everyone who registers receives a T-shirt which will be mailed directly to you.

Presented by

5575 Ruffin Rd., Ste 250, San Diego, CA 92123 • www.SB5K.org • 619.381.1632

$5.95 | www.SanDiegoPhysician.org San Diego County Medical Society 5575 Ruffin Road, Suite 250 San Diego, CA 92123 [ Return Service Requested ]

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Delivering the best imaginable service and unrivaled rewards is at the core of who we are. As an organization founded and led by physicians, we understand the value of superior care. Because for us, it’s not just a best practice, it’s in our unique code. Join us at thedoctors.com

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