November/December 2021 by San Diego Physician

Official Publication of SDCMS NOVEMBER/DECEMBER 2021

A SEASON OF THANKS Gratitude in Tough Times

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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: Sergio R. Flores, MD President–Elect: Toluwalase (Lase) A. Ajayi, MD Secretary: Nicholas (Dr. Nick) J. Yphantides, MD, MPH Treasurer: Heidi M. Meyer, MD Immediate Past President: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM

Contents NOV./DEC.

VOLUME 108, NUMBER 10

GEOGRAPHIC DIRECTORS East County #1: Catherine A. Uchino, MD 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, MPH Kearny Mesa #2: Alexander K. Quick, MD La Jolla #1: Preeti S. Mehta, MD (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: Maria T. Carriedo-Ceniceros, MD AT–LARGE DIRECTORS #1: Thomas J. Savides, MD #2: Kelly C. Motadel, MD, MPH #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, FAAFP #8: Alejandra Postlethwaite, MD ADDITIONAL VOTING DIRECTORS Medical Student: Jimmy Yu Resident: Nicole L. Herrick, MD Young Physician: Brian J. Rebolledo, MD Retired Physician: Mitsuo Tomita, MD CMA OFFICERS AND TRUSTEES Robert E. Wailes, MD William T–C Tseng, MD, MPH Sergio R. Flores, MD Timothy Murphy, MD AMA DELEGATES AND ALTERNATE DELEGATES District I: James T. Hay, MD District I Alternate: Mihir Y. Parikh, MD 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 Alternate: David E.J. Bazzo, MD, FAAFP CMA DELEGATES District I: Karrar H. Ali, DO, MPH District I: Steven L.W. Chen, MD, FACS, MBA District I: Franklin M. Martin, MD, FACS District I: Vimal I. Nanavati, MD, FACC, FSCAI District I: Peter O. Raudaskoski, MD District I: Kosala Samarasinghe, 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 RFS: Rachel Buehler Van Hollebeke, 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 4 Schrodinger’s Cat Scan: Reflections on Clinical Uncertainty By Daniel J. Bressler, MD, FACP 8 A Season of Thanks: Gratitude in Tough TImes By Sergio Flores, MD

Departments 2 Briefly Noted: Practice Management • Prescriptions 10 Protect Access to Quality Healthcare: Oppose the Dangerous MICRA Measure on Next Year’s Ballot By Vimal Nanavati, MD, FACC, FSCAI

11 A Remarkable Career in Family Medicine By Karen Johnston Berger, EDD 12 Strategies for Effective PatientAssisted Telehealth Assessments By Sue Boisvert, BSN, MHSA 14 California Hits New Milestone With Over 500K People Screened for Adverse Childhood Experiences By California Medical Association Staff 15 Our Tiny Yet Mighty Team! By Adama Dyoniziak

16 Dementia Linked to Inflammatory Foods By Judy George 17 COVID Booster Shot Increases Protection in Cancer Patients By Mike Bassett 18 Finding the Magic of Gratitude in Difficult Times By Helane Fronek, MD, FACP, FACPH 19 TB or Not TB … Juntos! By Adama Dyoniziak 20 Classifieds

SanDiegoPhysician.org 1

BRIEFLY NOTED 2

BY CALIFORNIA MEDICAL ASSOCIATION STAFF

PRACTICE MANAGEMENT

CMS Issues Third Critical Care E/M Comparative Billing Reports In late November, the Centers for Medicare and Medicaid Services (CMS) issued a third letter in the Special Edition Comparative Billing Report (CBR) series on Part B claims for critical care evaluation and management (E/M) services. The CBR program was created by CMS as an educational tool for providers, intended to enhance accurate billing and/or prescribing practices and support providers’ internal compliance activities. CBRs reflect a specific provider’s billing and/ or prescribing patterns as compared to his/her peers’ patterns within a service area that may be prone to improper Medicare Part B payments. Each CBR is unique to a single provider, is disseminated only to that individual provider, and is not publicly available. Receiving a CBR is not an indication of or precursor to an audit, and it requires no response on a provider’s part. You should have received an email from cbrpepper.noreply@religroupinc.com to access your report. Update your email address in the Provider Enrollment, Chain, and Ownership System (PECOS) to ensure future delivery.

cians who haven’t submitted any MIPS data do not need to take any additional action to qualify for the automatic EUC policy. CMS will automatically identify and re-weight all 4 MIPS performance categories to 0% and apply a neutral payment adjustment for the 2023 MIPS payment year. Unfortunately, if a physician or small practice has submitted quality data codes on their 2021 Medicare claims, they will need to still file a 2021 MIPS Hardship EUC to avoid a 2023 payment adjustment and be exempt from the 2021 MIPS program. If a group practice that typically participates in MIPS as a group has not submitted 2021 data, then the automatic EUC policy will apply to the individual physicians within the group. If the group has submitted any 2021 data, then they will need to apply for the EUC to avoid a 2023 payment adjustment. Essentially, if the physician or practice has not submitted any 2021 MIPS performance data, then the automatic EUC will apply to the physician. PY2021 EUC Exception Applications can be submitted by signing in to qpp.cms.gov and clicking Exception Applications on the left-hand navigation. PRESCRIPTIONS

PRACTICE MANAGEMENT

Are You Ready for California’s Electronic Prescribing Mandate?

The Centers for Medicare and Medicaid Services (CMS) recently announced that it will again this year be granting automatic exceptions from reporting requirements for clinicians and providers participating in Medicare quality reporting programs due to the ongoing disruptions the COVID-19 public health emergency is having on physician practices. The Extreme and Uncontrollable Circumstances (EUC) Hardship Exception policy will be automatically applied to all MIPS-eligible clinicians who do not submit any MIPS data for the 2021 performance period (2023 payment year). Physi-

In 2018, the California Legislature passed a law (AB 2789) that created a state-level mandate that all prescriptions must be transmitted electronically by Jan. 1, 2022. The law applies to all physicians and almost all prescriptions, with very few exceptions. The California Medical Association (CMA) has compiled a frequently asked questions document (members-only) to help physicians understand their requirements under the new law. CMA also hosted a webinar so physicians and their staff can learn more about the electronic prescribing mandate, and how to make sure your practice is ready to go for next year. The webinar — Preparing for California’s Electronic Prescribing Mandate — is free for members and their staff, and $99 for all others. The webinar is available for on-demand viewing at cmadocs.org/webinars.

CMS to Hold Physicians Harmless from 2023 MIPS Penalties Amid COVID-19 Pandemic

November/December 2021

TRUST WORDS OF WISDOM

Listening to Your Patient BY STEVE BROZINSKY, MD

“Listen to your patient — he is telling you the diagnosis.”

IT WAS 1979. I WAS THE ATTENDING PHYSICIAN ON

the general internal medicine ward at the VA Medical Center in Brooklyn. One cold January morning, I led my team to the bedside of Mr. Jones, an elderly AfricanAmerican gentleman who had been admitted the night before, complaining of some chest pain and shortness — Dr. William Osler, 1900 of breath. Mr. Jones looked rather frightened when this sea of white coats marched into his room. I tried to put him at ease by introducing myself and telling him that it was routine for his intern to present his case to me. He looked up at the two interns and their medical resident and two third-year medical students who accompanied me into his room and quietly said, “OK.” Dr. Lewis started to present the case and mentioned that he had auscultated an S4 gallop when Mr. Jones was in the emergency room and that it was still present this morning. Perhaps to impress me, the intern put his stethoscope on the patient’s chest, closed his eyes, and quietly started repeating, “Tennessee, Tennessee, Tennessee.” The team’s resident physician, a very wise and empathetic Dr. Kathryn Warren, gently nudged her intern aside and said, “Dr. Brozinsky, actually I think it was an S3 gallop,” and she proceeded to place her stethoscope on his chest, closed her eyes and gently repeated, “Kentucky, Kentucky, Kentucky.” I had just completed my gastroenterology fellowship and was not about to put my stethoscope on Mr. Jones’s chest in an attempt to decide the issue. I did not have to. With a very broad smile, the patient looked up at me and stated, “They ‘re both wrong — it’s Nor Carlina!”

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SanDiegoPhysician.org 3

R EFL EC T I O N S O N MED I CINE

Schrodinger’s Cat Scan Reflections on Clinical Uncertainty By Daniel J. Bressler, MD, FACP

N THE LATE 1920S, THE LATEST

findings of theoretical physics were captured in a model of the behavior of subatomic particles. This model, called quantum mechanics, posed that aspects of such particles, including their location, could not be described definitively but only probabilistically. The model explained all known experimental observations about this dimension of the world. Despite that, two of the world’s most famous physicists, Erwin Schrodinger and Albert Einstein were uncomfortable with this strangeness of the quantum world being “neither this nor that.” In a series of exchanged letters they proposed various thought experiments to analogize their objection. The one that has stuck historically comes from Schrodinger and has come to be known as The Schrodinger Cat Paradox. Schrodinger imagined a cat in a box in which was located a vial of poison and a hypersensitive Geiger counter adjusted to detect a high energy electron coming from a specific atom. If the counter detected the electron, it would activate a hammer to break the vial which would release the poison and kill the cat. If no electron was detected, then no hammerstrike, no poison release, and the cat would be alive. Through this thought experiment, Schrodinger, with Einstein, was attempting to show the absurdity of the quantum view, which held that the electron’s location could only be said to have a known location once it was

November/December 2021

observed. Before that observation, the electron (and thus the cat) were supposed to be in a state called “quantum indeterminacy,” and thus the cat was both dead and alive. The locations of quantum objects, like the electron, are described in quantum theory as existing in multiple locations at once (called superposition). These multiple locations, according to the descriptive equations, “collapse” into one position once observed. Don’t worry if this is not intuitively obvious. Richard Feynman, the Nobel Prize-winning Caltech physicist, is widely quoted as saying, “If you think you understand quantum mechanics, you don’t understand quantum mechanics.” Clinical Uncertainty “versus” Quantum Uncertainty How is this relevant to clinical medicine? Like quantum physicists, clinicians are frequently dealing with the issue of uncertainty. A patient presents to us with puzzling symptoms. We conduct our investigations, including a focused interview, a physical examination, laboratory testing of various body fluids, imaging studies, and physiologic monitoring. Once we have sent the patient for a supposedly definitive test — let’s call it an old vernacular term, a “CAT scan” — we wait, a bit like Schrodinger, to find out if our patient “has something or doesn’t,” if their symptoms or signs correlate with a disease. Between the decision to order

the test and the time of the arrival of the results, the patient and the doctor are in a state of “clinical indeterminacy.” In many cases even after the scan results arrive, there remains a persistent level of such indeterminacy. We want (and our patients expect) a definitive answer, but so often the best we can offer them is a probabilistic one. We say things at this point like: You might have cancer. You may have had a stroke. There may be early signs of multiple sclerosis. Clinical indeterminacy is caused by a kind of superposition of clinical possibilities (the so-called “differential diagnosis”) encountering informational inadequacy or conflict. One obvious response is to simply do more testing. And yet, gathering more information has its own costs: money, time, pain, risk. A biopsy, for example, can solve a diagnostic dilemma, but often does not. With the Schrodinger Box, we open it and, voila — the cat is determined to be either alive or dead. With our patient, we do the test and sometimes — like stacking Russian dolls — there is simply another layer of more ambiguity. That said, one key difference between the Schrodinger Cat conundrum and a medical one is the iterative nature of clinical decision making. Repeatedly returning to a diagnostic or therapeutic dilemma allows additional and additive reconsiderations and adjustments. We use both different techniques and take advantage of time, per se, to reduce uncertainty. Uncertainty comes in many shapes and sizes. Prognostic: What will the outcome be with no intervention? How much can we improve upon that with treatment? Diagnostic: Might the results of the test give a false negative or false positive? How much to trust a positive

PET scan in a patient with a lung nodule or a negative treadmill test in a patient with chest pain? Might a biopsy cause new problems such as a pneumothorax or infection? Therapeutic: Might the standard treatment fail or result in an unacceptably severe side effect? How the Medical Profession Has Intellectually Responded to Clinical Uncertainty One helpful development that we as a profession have invented are clinical guidelines for dealing with uncertainty. Some of the more common ones include the Fleischner Society criteria dealing with pulmonary nodules; the BiRADS system interpreting breast imaging; American Urologic Association on using PSA to screen for prostate cancer; The American Heart Association guidelines for initiating statin therapy for hyperlipidemia; the American Academy of

Dermatology ABCDE criteria for deciding which pigmented skin lesions to biopsy. But remember, these guidelines create “rules of reasonableness” rather than absolute truths. There will always be patients whose clinical stories defy the guidelines: the benign appearing lung nodule that grows rapidly and metastasizes; the BiRADS Class 5 mammogram with innocent pathology; the low risk patient whose first presentation of coronary heart disease is sudden death; the low PSA prostate cancer; dark irregular skin lesion that turn out to be nothing but an irritated keratosis. If you practice long enough, you are bound to choose a reasonable clinical path with a deleterious outcome: choosing to treat a condition that would have behaved innocently if left alone; and doing watchful waiting

on a condition that exploded unexpectedly. We can take all the facts of the case into consideration, apply the best available data and guidelines, draw on Bayes’ Theorem to guide us with respect to pre- and post-test probabilities and still produce a bad outcome for our patient. Like Schrodinger’s Cat, we can be both right and wrong. The Challenges in Communicating Uncertainty Thinking probabilistically is much easier in the abstract than in the concrete case of your own patient’s health. Not only are there the cluster of clinical facts, there is also the dual communication variable that arises from the beliefs, experiences and personalities of the SanDiegoPhysician.org 5

doctor and the patient. What is each of their risk tolerances? How much do each of them approach uncertainty from a scientific perspective and how much from a religious or spiritual perspective? Are the doctor or patient more “aggressive” or more stoical? Does the doctor or the patient have in their memory an example of someone that did particularly well or badly with the proposed clinical pathway? How much do both of them tolerate waiting in a setting of uncertainty? We know that some patients, when sick, regress to a more infantile state and want the doctor to play the role of parent. They say, in other words: just tell me what to do, Doc. They want certainty the way a child, when she hears thunder, wants to be told, “Everything will be all right.” Other patients want us to be a “mere consultant” to their own role as the CEO of their own life. As the old Oslerian proverb advises, physicians need to try to understand both what sort of disease the patient has and what sort of patient has the disease. As doctors we have a complex role to play, doing our best to be as reassuring as the facts allow. We have to think in the language of probabilities and talk in a language that is appropriate to the patient’s personality, sometimes in stark statistical terms and sometimes with a softer (more reassuring) gloss. Uncertainty Is Inevitable. Expect It Uncertainty is woven into the fabric of clinical medicine and into reality itself. All the ways of knowing something are fraught with some degree of unreliability. Measurements can be mistaken, our senses can be fooled, our instruments can malfunction, artifacts can masquerade as facts and our inferences can be misled by a host of cognitive biases. If only it was as simple as Sherlock Holmes advised in his oft-quoted guide to logic: “When you have eliminated all which is impossible, then whatever remains, however improbable, must be the truth.” If only! The problem with trusting Sherlock in this regard is that it assumes that we have truly eliminated (or in medical terms “ruled out”) the entire universe of competing explanations. 6

November/December 2021

Schrodinger’s Cat Scan Inserting a needle for tissue inspection We hope it’s a target our probes can get at Dismayed that we haven’t gained further direction Not unlike the condition of Schrodinger’s Cat. The test came back fuzzy, more info is needed The stakeholders squabble for “this” over “that” Does the patient have patience to wait and repeat it? Can we live with that vagueness of Schrodinger’s Cat? The surgeon insists on an en bloc removal But the stubborn pathologist started a spat The treating oncologist seeks my approval I call on the spirit of Schrodinger’s Cat. The challenge of acting in hazy conditions Is to swing in the darkness when we’re up to bat That is the blessing and curse of physicians We share with the puzzle of Schrodinger’s Cat.

Uncertainty Is Intractable. Deal With It No matter how much progress we make at determining the best and most auspicious path for diagnosing and treating puzzling clinical problems, the idea that we will ever always get it right is a fantasy. The scientific method for separating out what is from what isn’t so, helps us by crossing off the list of possibilities those that have a high likelihood of being false and thus whittling away at the list. But there will always be stragglers. There will always be exceptions to the rules. Our algorithms will become increasingly accurate, but like any expert system, will have flaws both on the input and the output. Even in the best of scenarios we are always dealing with currently available information. Before angiotensin receptors were discovered, there were no ARBs for hypertension. Before PET scans, diagnostic biopsies and their attendant risk were much more common. For Schrodinger and Einstein, the Cat

Paradox was a thought experiment meant to challenge the strangeness of the quantum world. As doctors we can adapt it to be a rehearsal for approaching a certain kind of clinical scenario. There are limits to knowledge. Omniscience doesn’t exist. And however much we study and tap into networks of information, what we still don’t know is boundless. Medicine is a practical craft as well as a science. In our off-hours we might explore the theory of indeterminacy but in our on-hours we are called up to decide and act. Doing so in full awareness of uncertainty has the potential to make us dithering and indecisive but also has the potential to make us humble — and even, dare I say it, wise. Dr. Bressler, SDCMS-CMA member since 1988, is a former chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and a longtime contributing writer to San Diego Physician.

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S A N D IEGO CO UN T Y MED I C A L S O CIE T Y

A Season of Thanks Gratitude in Tough Times By Sergio Flores, MD

KNOW I SPEAK FOR MOST OF US when I say the past two years have been the most difficult and painful of my medical career. There has been so much pain, suffering, and loss. The struggles, the stress and the exhaustion that we have endured as medical professionals during a once-in-a-hundred-years pandemic have been unprecedented and unpredictable. Many of us have been pushed to the breaking point, but we have kept going because we did not want to fail our patients and our colleagues. The financial pressure caused by the pandemic has also been devastating to so many small medical practices, while our hospital system has too often been strained as well. The number of people lost to COVID-19 in San Diego County alone is well over 4,300, over 75,000 in California, approaching 800,000 for the United States, and over 5.2 million worldwide. These are staggering numbers. The saddest part to me now is these numbers are still growing when we have vaccines available that have been proven to be safe and effective to prevent hospitalization and death. I’ve experienced firsthand the tragedy of unnecessary loss by the death of a close relative who was the best man in my wedding but refused to get vaccinated. Dealing with — in terms of both persuading and treating medically — the vaccine-hesitant has now become our greatest challenge in the pandemic. Despite all the loss, there has also been

November/December 2021

so much and so many to be grateful for during this tough time. That is what I want to focus on. This holiday season — as we approach the two-year mark for this pandemic — is perhaps the most appropriate time to take stock of all the positive in our lives and to remind ourselves of the people and things that have not only sustained us during this time but will make it possible for us to come out on the other side. While obvious, the first thing we should all be thankful for are the incredible vaccines. It is truly a miracle of science that they were developed so quickly and have been proven so safe and effective. A study shows that they have already saved 140,000 lives in just the first five months of their use in the United States. They have been proven to essentially prevent hospitalization for the vaccinated who contract COVID-19 and will ultimately save millions of lives across the globe. They have been the key to moving forward and transitioning to a more normal daily life. We must also be grateful for the remarkable COVID-19 treatments such as monoclonal antibody infusions — and the most exciting development of all to date, Pfizer’s pill awaiting FDA approval that promises to reduce hospitalization and death by 90 percent! It likely won’t surprise you that I’m thankful for the San Diego County Medical Society and the incredibly positive difference it has made during the past two years. A debt of gratitude is owed by many

San Diego physicians to my immediate predecessors as SDCMS president: David Bazzo, Jim Schultz, and Holly Yang for their leadership and hard work to help other physicians and the San Diego medical community navigate the COVID-19 crisis. I’m also thankful for the incredible work of the SDCMS staff, led by CEO Paul Hegyi, to support, assist, and provide guidance to our county’s physicians. I know that others have noticed the important role that SDCMS has filled during COVID-19 because the number of physicians becoming new members of our organization has tripled over the previous year! During the past year, SDCMS worked to fill the gap in support for many physicians, particularly those from independent practices. The first vaccines for health workers began rolling out last December, with a huge gap immediately evident for physicians outside of the large hospitals. This was particularly worrisome for older physicians, and the private office staff of many. (Physicians with privileges could get vaccinated, but their office staff were initially unaccounted for.) SDCMS jumped into action, communicating with members, sharing updates, and working to find solutions for many. We advocated with the county to expand the vaccine network while also helping to set up the broader vaccination network when doses would become more readily available. We continuously pushed to make it easier for physicians to volunteer as vaccinators to help relieve the operational crush. SDCMS also helped physicians volunteer to provide patient care in areas experiencing COVID surges, give vaccines, and fight medical disinformation. We helped to raise awareness of COVID-related clinical trials and free monoclonal antibody therapies, and are now working with CMA to get COVID vaccines into practices that care for children. I’m also grateful for the leadership and tireless efforts of the San Diego County Health and Human Services Agency and for Dr. Wilma Wooten and Dr. Nick

Yphantides. SDCMS has worked closely with county government throughout the pandemic to get better information and support to the medical community in San Diego County. We continued our expanded advocacy role with the county, attending all board hearings covering COVID and regularly coordinating testimony where relevant to fight misinformation. As you know, many public health officers have been under constant attack during the pandemic. Several have resigned their positions due to threats, harassment, and the stress of the crisis. When threats and racist remarks were made in public testimony against Dr. Wooten, we issued a statement calling for a return to civility in procedures, and a stronger response and greater support from our elected leaders for our county public health officer. Consequently, we were gratified to see a new set of operating rules at County Board of Supervisor meetings adopted in response. Speaking for a community of more than 4,600 physicians, retired physicians, and medical students carries weight. In the early part of the pandemic and throughout 2020 and 2021, we partnered with San Diego County Health and Human Services and the Hospital Association of San Diego and Imperial Counties to provide virtual Clinical Town Halls to help physicians stay up to date on the newest information on the pandemic, hosting local experts as well as physi-

cians from New York and Italy to help us understand the crisis as it evolved. This filled an important role for all physicians — especially those in smaller practices. We have held them as needed to help inform physicians in the latter half of 2021, such as for the appearance of the Omicron variant. During the PPE shortage, SDCMS was grateful to be able to distribute more than 800 boxes containing a two-month supply of PPE to small and medium physician practices in partnership with the California Medical Association. I know this was a major help for countless physicians and their staffs. I’m also deeply grateful for Champions for Health, the nonprofit foundation for SDCMS, which focuses on providing healthcare access for underserved and minority communities throughout the county. It is these communities that have

suffered the greatest loss of lives from COVID-19. Champions, led by Adama Dyoniziak and coordinated by Andrew Gonzalez, has administered more than 22,000 COVID vaccination doses and more than 8,000 flu shots. I am joined by so many in offering the most profound appreciation for the sacrifice and service of my colleagues to the people of San Diego during this prolonged crisis. Above all else, I am grateful for the love, support, and sacrifice of our families and friends which have sustained us in the most difficult of times. May this holiday season remind us of all we have to be grateful for and help us show our appreciation to those in our lives whether it be our family, friends, patients, or colleagues. Dr. Flores is the president of the San Diego County Medical Society.

SanDiegoPhysician.org 9

MICRA PROTECTION

Protect Access to Quality Healthcare Oppose the Dangerous MICRA Measure on Next Year’s Ballot BY VIMAL NANAVATI, MD, FACC, FSCAI Dr. Nanavati with a patient.

EXT FALL, CALIFORNIA voters will be asked to vote on a new ballot measure that would drive up healthcare costs, restrict access to care for low-income patients, and decimate the protections afforded to patients across California as part of the Medical Injury Compensation Reform Act (MICRA). This initiative, bankrolled with millions of dollars from an Iowa-based trial attorney, would effectively eliminate the cap on non-medical damage awards in malpractice cases, substantially raising healthcare costs for all Californians while allowing attorneys to collect unlimited fees from medical malpractice awards. In an effort to make the measure even more punitive, the initiative sponsor included language that will hold physicians personally responsible to pay medical damage awards out of their own pocket. It would entitle plaintiff’s lawyers to target physicians’ personal assets. In short, this measure would provide new incentives for lawyers to file frivolous medical malpractice suits, creating a chilling effect on the practice of medicine and clearing the way for new financial windfalls for California’s trial lawyers at taxpayer expense. While current California law allows patients to recoup unlimited damages for medical expenses, lost wages and in

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cases of gross medical negligence, there is no cap on non-economic damages. The law was put in place to ensure injured patients receive fair compensation while also protecting doctors, hospitals, and other healthcare providers from frivolous, punitive lawsuits that drive up healthcare costs. This initiative would erase those protections and send taxpayers the bill. According to California’s independent Legislative Analyst’s Office, this measure would lead to “annual government costs likely ranging from the low tens of millions of dollars to the high hundreds of millions of dollars,” and will reduce access for those who need it most, including those who use Medi-Cal, county programs, safety net providers, and schoolbased health centers. County and state hospitals have to pay medical malpractice awards out of the budgets they receive from taxpayers. This means that if medical malpractice awards increase, government costs will increase too. Somebody has to pay, and that will be taxpayers through higher taxes and California citizens through higher healthcare premiums. According to one economic analysis, this measure would increase the average annual cost of healthcare for a family of four by $1,100. There are unintended consequences well beyond just the economics. If this attack on MICRA passes, patients will find themselves without critical access to their doctors as many physicians will be forced to retire early or even move out of state. Moreover, new graduate physicians will find it easier to work out of state rather than work in such a potentially hostile environment. This push to eliminate MICRA is led by Nicholas Rowley, a wealthy trial attorney from Iowa who has publicly said that he is willing to spend at least $20 million of his own money in support of the initiative.

For Rowley, the investment makes sense. Rowley has made his millions by winning big verdicts, and charging big fees, in personal injury and medical malpractice cases around the country. The California effort is just his latest attempt to eliminate malpractice award caps in other states so that he and his firm can profit. If he is successful, he and his law firm will be unshackled from current limits on attorneys’ fees, and stand to make millions while sending California taxpayers the bill. Physicians take an oath to protect patients — and this dangerous proposal would put patients at risk of losing access to quality medical care. In 2014, voters were clear when they rejected Prop. 46 and changes to MICRA that would have quadrupled the cap on non-economic damages because of the negative effects that it would have on their quality of care and pocketbooks at large. This measure goes well beyond what Prop. 46 would have done, and the cost to taxpayers would be far greater. The California Medical Association has joined Californians to Protect Patients and Contain Health Care Costs, a broad coalition of physicians, dentists, nurses, hospitals, safety net clinics, and other healthcare providers, to oppose this initiative. Together, we are vigorously fighting this initiative in order to protect access to quality healthcare for Californians across the state. This initiative is a direct attack on physicians that could have disastrous consequences for physicians and their patients. If this MICRA bill is allowed to pass, patients may lose access to their longtime physicians as many will be forced to retire or move out of state. While organized medicine is facing many challenges, there are none as important as the threat posed by this initiative. We need the support of all California physicians to help defeat this dangerous measure. To join the campaign, please visit cmadocs.org/micra. Dr. Nanavati is an interventional invasive cardiologist in San Diego, development chair of the California Medical Association Political Action Committee (CALPAC), and a member of the San Diego County Medical Society board of directors.

SDCMS MEMBERS

A Remarkable Career in Family Medicine BY KAREN JOHNSTON BERGER, EDD

SAN DIEGO PHYSICIAN

is retired this fall after 52 years in devoted service to local families. Dr. John A. Berger’s practice is remarkable because for the past decade, maybe longer, it has been one of the few remaining solo practices in San Diego. He took his own calls for all those years — never without the latest device, which started with a pocket pager and now has evolved to an iPhone. And, until a year ago, he was driving distances to make house calls — some of them to remote areas of San Diego County. Dr. Berger’s practice is remarkable

in other ways. As an Alpha Omega Alpha graduate of the University of Minnesota Medical School, at the time a top research institution worldwide, he was trained by some of the giants of medicine in the mid-’60s: Cecil Watson, Wesley Spink, A.B. Baker, C. Walton Lillihei, and Owen Wantensteen. It was a very complete training — medicine, neurology, surgery, psychiatry, pediatrics — in-depth and well-rounded. After medical school, he interned at Kings County Hospital, in Brooklyn, and took part of a neurology residency, again at the University of Minnesota, under A. B. Baker in his

junior year of medical school — an honor, before being drafted to Camp Pendleton during the Vietnam War. Settling in San Diego, Dr. Berger carried this education forward to benefit San Diegans. As president of the San Diego Medical Society in the mid-1980s, he pushed for increased coverage of mental health care — not popular at the time — as local medicine made the transition from fee-forservice to managed care. For years associated with the UCSD Family Practice department, he contributed to the clinical education of numerous physicians-in-training. In 2004 he was named a “San Diego Top Doctor” by San Diego Magazine. Over the years, Dr. Berger always incorporated “patient-as-person” into his care and medical considerations. He concentrated not only on the disease, but the individual before him, often devoting extended and repeated office visits to consultation. His training in neurology and psychiatry provided him the tools to distinguish the physical from the emotional aspects of illness and then to help him blend them in his treatment plan — never ignoring one for the other. He is also a skilled diagnostic clinician able to make the quick and hard calls on acute illness. His skill is evidenced by the regard in which he has long been held by local medical specialists. One said recently of Dr. Berger, “He is one of our premier clinicians; he will be missed.” Dr. Berger’s hallmark has been to send patients for emergency treatment with a definitive diagnosis over a spectrum of needs — medical, surgical, neurological, ophthalmological, cardiovascular, and in return to receive calls of admiration and appreciation from receiving specialists. So what does all this mean? Dr. Berger doesn’t have the thick resume of academic research papers that usually gains attention — only a room full of the charts of those he has helped to better health over his 52-year career. Hence his retirement will not be marked by the community — not that he has ever been one to seek acclaim for his quiet practice. His measure of success? The number of patients in all walks of life, some with him for more than 40 years, who made appointments at his Hillcrest office just to say, “Goodbye.” Karen Johnston Berger is the author of two books used in introductory medical and nursing courses. She and Dr. Berger have been married for 57 years. SanDiegoPhysician.org 11

TELEHEALTH

Strategies for Effective PatientAssisted Telehealth Assessments BY SUE BOISVERT, BSN, MHSA

HE MAIN DIFFERENCES

between telehealth visits and office-based patient visits are the location of the patient (geography), the insertion of technology between the provider and the patient, and the performance of the physical assessment. While much has been written about the challenges of geography and technology in telehealth visits, clinical literature and specialty society jour-

November/December 2021

nals are beginning to address patientassisted telehealth assessments. The strategies outlined in this article can help physicians perform a successful patient-assisted assessment. Physicians who practice telemedicine must carefully consider the components required to complete an effective remote assessment and plan ahead based on their specialty area and the patient’s presenting complaint. While many

patients may purchase a blood pressure cuff or a thermometer, accessing a more complex instrument — such as an otoscope, ophthalmoscope, or digital stethoscope — may be beyond the ability of a typical patient unless the visit occurs in a retail kiosk or pod. Either way, the patient (or caregiver) becomes an essential partner in the assessment process. The important role that assessment plays in the diagnostic process and the prevention of diagnostic error cannot be overstated, as illustrated in our recent analysis. The Doctors Company studied 286 primary care malpractice claims that closed between 2014 and 2018. Analysts found that 51 percent of the claims involved assessment failures. The top two contributing factors were failure to establish a differential diagnosis (16.7%) and failure to assess and address continued symptoms (14%). The standard of care remains the same whether the visit is in person or remote. It is the provider’s responsibility to ensure that information gleaned during a remote assessment is sufficient to determine the patient’s diagnosis and treatment. The following strategies can help providers better prepare patients to assist effectively with the remote assessment: 1. Previsit Preparation In addition to offering a technology test session, ensure that the patient telehealth previsit process includes instructions to patients for obtaining the equipment necessary to measure vital signs. Based on diagnosis and provider specialty, the instruction can be patientspecific — such as a blood pressure and oxygen saturation monitor — or general, such as a thermometer and scale. Advise the patient to practice using the equipment and to measure and write down the results over the course of several days, including on the morning of the telehealth visit. 2. Visit Initiation Establish rapport. Smile. Confirm audio and video function, and ask the patient how the sign-in process went. Introduce yourself and confirm the patient’s identity with two identifiers. Evaluate how the patient looks in order to determine if a telehealth visit is appropriate. Evalu-

ate the patient’s mental and physical status to determine if the patient can participate appropriately. In the case of children, frail elderly, and patients with special needs, determine if a caregiver is present and able to assist. Use the opportunity to evaluate the patient’s environment and address any distractions. For additional information on patient distractions in telehealth, read our article, “Telehealth’s Newest Safety Risk: Distracted Patients.” Confirm the patient’s medication list, or if necessary, conduct a virtual “brown bag” medication check. Ask the patient to give you the vital sign information collected. Document the information in the medical record as “patient self-reported.” 3. Physical Assessment Assessment during a virtual visit is, by necessity, a collaborative effort. The provider observes and directs the patient or caregiver to assist. Patients can be directed to position themselves to

facilitate visual inspection of head and neck structures. A willing patient can be guided through palpation of the neck and submandibular areas to examine for “lumps” and, if noted, to describe pain, induration, shape, and size. Patients can be asked to stand and take a few steps to assess balance and gait. Any joint pain can be further evaluated with range of motion and the use of a pain scale. Patients can be asked to palpate pulses, provide a heart rate, and describe what they are feeling. Respiratory function can be assessed by having the patient sit quietly and take deep breaths while the provider and patient listen for any wheezing or coughing. Abdominal assessment can be facilitated by having the patient stand and turn side to side as well as guiding the patient to palpate any areas of concern. Carefully document the portions of the assessment observed by the provider and those that were “patient assisted.” For example, “the patient assisted with

lymph node assessment.” Because of the limitations of patientassisted assessment, carefully consider the clinical conditions that can be evaluated using this approach versus conditions that require an in-person visit. For the comfort and consideration of both the provider and patient, this decision is best made at the time of scheduling as opposed to during the telehealth visit. For staff who schedule appointments, having clear guidelines and ready access to clinical decision makers will increase the chance of making an appropriate determination regarding the type of visit to be scheduled. When used appropriately, a patientassisted assessment during a telehealth visit is a wonderful opportunity to increase patient engagement in their own healthcare and further enhance the provider-patient relationship. Sue Boisvert is patient safety risk manager II for The Doctors Company.

PLACE YOUR AD HERE FEBRUARY 2020

Official Publication of SDCMS

Celebrating 150 Years

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. Requirements: California license, DEA license, CPR certification and board certified in family medicine. Bilingual English/Spanish preferred. Send resume to: hr@vistacommunityclinic.org or fax to 760-414-3702

Vista Community Clinic is a private, nonprofit outpatient community serving people who experience social, cultural or economic barriers to health care in a comprehensive, high quality setting.

www.vistacommunityclinic.org

MARCH 2020

Official Publication of SDCMS

NOVEMBER/DECEMBER 2019 Official Publication of SDCMS

Celebrating 150 Years

Artificial Intelligence and Medicine THE DEBATE

PREVENTION DIABETES Reversing the Risks

DEMENTIA Reducing the Burden How to Engaging Patients GUN SAFETY

BUILD TRUST

BREAST CANCER Preventing Deaths

in 15-Minute Office Visits

Contact Jennifer Rohr 858.437.3476 • Jennifer.Rohr@SDCMS.org

EEO/AA/M/F/Vet/Disabled

SanDiegoPhysician.org 13

ACES AND TOXIC STRESS

California Hits New Milestone With Over 500K People Screened for Adverse Childhood Experiences BY CALIFORNIA MEDICAL ASSOCIATION STAFF

DVERSE CHILDHOOD

experiences (ACEs) and toxic stress are a root cause of some of the most harmful, persistent, and expensive societal and health challenges facing the world today. With 62% of California adults having experienced at least one ACE and 16% having experienced four or more, California is taking aggressive steps to address ACEs and toxic stress through ACEs Aware, the first-in-the-nation initiative to establish routine screening in primary 14

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care and develop a network of care. ACEs Aware recently announced that, to date, more than 20,500 California clinicians have been trained and screened more than 500,000 children and adults across the state. “ACEs Aware continues to serve as an integral part of California’s response to the COVID-19 public health emergency and social and political stressors,” said California Surgeon General Nadine Burke Harris, MD. “ACEs Aware is giving providers the tools and resources they need to

help Medi-Cal beneficiaries identify and address stress-related physical and mental health concerns that can occur due to prolonged activation of the biological stress response.” Governor Gavin Newsom also recently signed into law Senate Bill 428, the ACEs Equity Act, which will significantly expand coverage for ACE screenings by requiring all health insurance plan contracts that provide coverage for pediatric services and preventive care to include coverage for ACE screenings. This includes Knox-Keene-licensed managed care plan contracts and health insurance policies issued, amended, or renewed on or after Jan. 1, 2022. Building upon these successes, ACEs Aware is moving into a new organizational home within the University of California. The newly created UCLA/ UCSF ACEs Aware Family Resilience Network (UCAAN) will leverage the substantial interdisciplinary resources of two public health science campuses — the University of California, Los Angeles and University of California, San Francisco — to develop, promote, and sustain evidence-based methods to screen patients for ACEs and advance evidencebased treatments for toxic stress. Receive ACEs Aware Training Today (Free!) The California Medical Association (CMA) is a proud ACEs Aware grantee and encourages all physicians, particularly Medi-Cal providers, to receive the free, two-hour training to learn how screening, risk assessment, and evidence-based care can effectively intervene on toxic stress. By screening for ACEs, providers can better determine the likelihood a patient is at increased health risk due to a toxic stress response, a critical step in responding with trauma-informed care that connects patients with a supportive network of care to mitigate the impact of ACEs. Physicians may receive 2.0 Continuing Medical Education (CME) and 2.0 Maintenance of Certification (MOC) credits upon completion — and can receive reimbursement for providing ACEs screening to Medi-Cal beneficiaries.

CHAMPIONS FOR HEALTH

Celene Salazar, Jeffrey Filice, Maribel Herrera, Adama Dyoniziak, Andrew Gonzalez, Evelyn Penaloza, Jaime Carrillo, Katy Rogers. Not pictured Gabriela Stichler

Our Tiny Yet Mighty Team! by Adama Dyoniziak

hampions for Health is the rebranded name for the San Diego County Medical Society Foundation. Founded in 2004 by the leadership of the San Diego County Medical Society, our efforts have provided a caring and efficient resource for patients in need, created a network of physician volunteers, reduced costs and stress on healthcare infrastructures, and established a healthier community and workforce through quality preventive and specialty care. As we have matured over the past 17 years, and as health has taken on a greater meaning than just healthcare, we have been blessed with a growing number of champions working with us to improve the health of our community. Health equity has been our cause before the term was popular. We have always provided prevention and specialty care services in high-priority-index zip codes, where low-income, low or no insurance coverage, and high rates of mor-

bidity intersect in San Diego County. We mobilize our network of dedicated physicians, hospitals, surgery centers, nurses, nursing associations, schools of nursing, pharmacy and medicine to provide non-duplicative, medically necessary services where San Diegans live, work, play, and pray. From 20,000-plus COVID doses and 8,000 flu shots to 485 Project Access patients with 1,232 consultations and 81 surgeries, the quality of medical and healthcare services provided meet the highest standards of care and are provided with responsiveness, urgency, and attention to detail. Access to care for all is our mission — it shouldn’t be a dream that is out of reach. Our physician volunteers and partners who support Champions for Health transform the lives of San Diegans from pain and dire medical diagnoses to health, renewed family involvement, and productive work and community life. When you donate to Champions for

Health, you contribute to the health and wellbeing of thousands of individuals in San Diego. For every $1 you donate, Champions for Health secures $10 in pro bono assistance through our Project Access San Diego program, equaling a 1,000% return on your donation. There are so many ways to help people in need. Choose the way that works best for you! You can donate once, become a major donor, or join our monthly giving program for consistent, ongoing support of people in need. It’s the end of the year: stocks and securities can be transferred to Champions for Health. Direct charitable distributions of IRA funds can be contributed up to $100,000. Shop online through AmazonSmile and select San Diego County Medical Society Foundation (dba Champions for Health) as your charity. AmazonSmile will donate 0.5% of the price of your eligible purchases to Champions for Health. Our tiny yet mighty team invites you to join us in our shared mission to do whatever it takes to answer the health equity gap in San Diego. Thank you for supporting us, your foundation, and your physician and nurse colleagues in making San Diego the healthiest place to live! www. championsforhealth.org/donate. Adama Dyoniziak is executive director of Champions for Health. SanDiegoPhysician.org SanDiegoPhysician.org 15 15

DEMENTIA DIET

Dementia Linked to Inflammatory Foods BY JUDY GEORGE

IETS WITH HIGHER

inflammatory potential were tied to an increased risk of incident dementia, a prospective observational study showed. Each unit increase in dietary inflammatory index scores was associated with a 21% higher risk of dementia over three years (HR 1.21, 95% CI 1.03-1.42, P=0.023), reported Nikolaos Scarmeas, MD, PhD, of Columbia University in New York City and the National and Kapodistrian University of Athens Medical School in Greece, and co-authors. Compared with participants with the lowest inflammatory diet scores, those with the highest scores were three times more likely to develop incident dementia (HR 3.01, 95% CI 1.24-7.26, P=0.014), the researchers wrote in Neurology. “A diet with a more anti-inflammatory content seems to be related to lower risk for developing dementia within the following three years,” Scarmeas told MedPage Today. Available dementia treatments are not very effective, he said — “it’s quite important that we find some measures to partially prevent it.” 16

November/December 2021

“Diet might play a role in combating inflammation, one of the biological pathways contributing to risk for dementia and cognitive impairment later in life,” he added. Evidence suggests certain foods, nutrients, and non-nutrient food components can modulate inflammatory status acutely and chronically. Earlier prospective research looked at dietary inflammatory potential and cognitive decline only in women, not in both sexes, the researchers noted. Scarmeas and co-authors analyzed data from 1,059 older adults in the Hellenic Longitudinal Investigation of Aging and Diet (HELIAD), a population-based study that investigates associations between nutrition and age-related cognition in Greece. People with dementia at baseline were excluded from the analysis. Participants had a mean baseline age of 73.1 and a mean 8.2 years of education; 40.3% were men. Dietary intake was evaluated through a semi-quantitative food frequency questionnaire validated for the Greek population and administered by a trained dietitian.

Foods and nutrients associated with the inflammatory biomarkers interleukin (IL)-1β, IL-4, IL-6, L-10, tumor necrosis factor (TNF)-α, and C-reactive protein in other studies were assigned a value and tallied to obtain a diet inflammatory index score. Higher dietary inflammatory index scores indicated a more inflammatory diet. People in the first tertile had the lowest scores (-5.83 to -1.76, indicating a more anti-inflammatory diet), which represented about 20 servings of fruit, 19 of vegetables, four of legumes, and 11 of coffee or tea a week, on average. People in the third tertile had the highest scores (0.21 to 6.01) and a more pro-inflammatory diet, with a weekly average of nine servings of fruit, 10 of vegetables, two of legumes, and nine of coffee or tea. Over an average follow-up of 3.05 years, 62 people were diagnosed with dementia. Higher dietary inflammatory index scores correlated with higher dementia risk. A gradual risk increase across higher tertiles suggested a dose-response relationship between the inflammatory potential of diet and incident dementia, Scarmeas and co-authors observed. The relatively short follow-up period in this study raised the possibility of reverse causality, but further analysis showed the findings were not moderated by the presence of mild cognitive impairment at baseline. Food frequency questionnaires may be subject to measurement error, the researchers acknowledged. Data about some dietary components, including eugenol, ginger, onion, turmeric, garlic, oregano, pepper, rosemary, and saffron, were not available. In addition, serum levels of inflammatory biomarkers were not obtained. “Our results are getting us closer to characterizing and measuring the inflammatory potential of people’s diets,” Scarmeas said. “That, in turn, could help inform more tailored and precise dietary recommendations and other strategies to maintain cognitive health.” Judy George covers neurology and neuroscience news for MedPage Today, where this article first appeared and where she writes about brain aging, Alzheimer’s, dementia, MS, rare diseases, epilepsy, autism, headache, stroke, Parkinson’s, ALS, concussion, CTE, sleep, pain, and more.

COVID AND CANCER

COVID Booster Shot Increases Protection in Cancer Patients Efforts Should Be Made to Get Additional Dose to These Patients, Researchers Say BY MIKE BASSETT

OVID-19 BOOSTER SHOTS

generated immune responses in cancer patients who had no detectable antibodies after primary vaccination, researchers said. Among seronegative patients, a third dose of vaccine achieved a 56% seroconversion rate, reported Balazs Halmos, MD, MS, of Montefiore Einstein Cancer Center in New York City, and colleagues. These findings call “for broad efforts to provide third vaccinations to such patients,” they wrote in Cancer Cell. In the study, 99 patients underwent repeat anti-SARS-CoV-2 spike antibody (anti-S) testing after completion of their primary vaccine series. While the majority of patients (94% with hematologic ma-

lignancies and 100% with solid tumors) maintained detectable anti-S IgG titers >50 AU/mL at 4 to 6 months, median titer levels fell significantly during this time period — from initial levels of 5,162 AU/ mL to 724.6 AU/mL at follow-up (P<0.001). Anti-COVID immunity before and after a booster vaccination was then assessed in 88 patients (median age 69) with a cancer diagnosis (31 with solid tumors and 57 with hematologic malignancies); 73% were on active treatment at the time of their booster. Of these patients, 70% received the Pfizer-BioNTech vaccine, 25% received the Moderna vaccine, and 5% received the Johnson & Johnson/Janssen vaccine as their primary shots. With the

exception of eight patients, all received a booster shot with the vaccine type received at baseline. Median time since last vaccination was 177 days. Sixty-four percent were seropositive prior to the booster shot, while the remaining 36% were seronegative. All seronegative patients, save one, had hematologic malignancies. Halmos and colleagues found that patients with hematologic malignancies had both a statistically significant lower pre-booster antibody response, as well as a smaller change in anti-S IgG mean titers post-booster compared with those with solid tumors (10,034 vs 22,686 AU/ mL; P=0.00263). Four weeks after booster vaccination, 70 of the 88 patients (80%) had antibody levels higher than before they received their booster. Of the 14 patients remaining seronegative after the booster, all had B-cell malignancies. Eight of these patients were on active therapy at the time of their booster vaccination. Even patients who received therapy within 30 days of booster vaccination had a statistically significant chance of seroconversion (P=0.02). Prior therapy with a Bruton tyrosine kinase inhibitor or anti-CD20 therapy, or both, was significantly associated with a decrease in both pre- and post-booster antibody seroconversion (P=0.01333) and titer (P=0.0000575). While this study showed that additional dosing can boost immunity in patients with cancer, it also demonstrated that some will not benefit from a third mRNA dose, “highlighting the need for continued efforts to develop valid laboratory correlates of anti-COVID-19 immunity and specific studies assessing the potential benefit of subsequent homologous vaccine doses, heterologous vaccinations, passive immunizations, and other unique approaches for these patients,” Halmos and colleagues wrote. Mike Bassett is a staff writer focusing on oncology and hematology for MedPage Today, where this article first appeared.

SanDiegoPhysician.org 17

PERSONAL AND PROFESSIONAL DEVELOPMENT

Finding the Magic of Gratitude in Difficult Times BY HELANE FRONEK, MD, FACP, FACPH

FTER THE MUTED HOLIDAY

season of 2020, we placed our hopes on 2021, anticipating a return to the joyful seasons of the past. Yet COVID still consumes our thoughts. Concerns about the Delta variant and other variants to follow, the many unvaccinated Americans, and the uncertainty of a future with the continued presence of COVID weigh on us. If we have lost loved ones, their absence further saddens us. And, if we are one of many in our ranks who are witness to the overwhelming illness and death, we may find positive emotions incongruous with the sadness and loss we experience daily at work. Many of us approach this holiday season reticent to feel any excitement. How might we find the joy and renewal of spirit that we yearn for at this time of year? The simple truth is that gratitude is the most reliable and powerful tool we have. Yes, gratitude is a tool. While not mechanical, it’s a means to dig ourselves out of our worries, to shift ourselves into a better state of mind and a healthier way of living. F-MRI images document changes in connectivity between our amygdala and other important brain structures after experiences of gratitude. Our heart and respiratory rates slow, our muscle tension decreases, and we feel a sense of spaciousness. In this relaxed and expanded state, we feel more hopeful. Another benefit of gratitude is that connecting with it is simple and quick! When Fred (Mr.) Rogers accepted his lifetime achievement Emmy award in 1997, he asked the audience to take 10 seconds to remember someone who played an important, positive role in their lives. The room

November/December 2021

instantly became silent as people, tears in their eyes, connected with their sense of gratitude. Each of us has access to this tool. We need only direct our attention to it. Keeping a gratitude journal is an effective way of harnessing this tool. Data shows that rates of burnout fall when physicians keep gratitude journals and that writing letters of gratitude (even if you don’t send them) improves mental health. By making gratitude practices a regular part of our lives, we utilize those neural pathways regularly and enhance

our ability to notice gratitude in real time, as it occurs in the moments of our lives. This leaves us with a more positive view of our days. And instead of perseverating on the frustrations of our day, we can spend our drive home thinking of all the things we are grateful for and walk into our homes feeling relaxed, calm, appreciative, and open to noticing the many positive experiences the evening holds. During this holiday season, let’s take stock of what we appreciate and are grateful for. Let your breathing slow, your muscles relax and your heart open to the beauty and hope around you. Then, give the gift that never goes out of season by sharing with the special people in your life the many ways in which you are grateful for them. Dr. Fronek is an assistant clinical professor of medicine at UC San Diego School of Medicine and a Certified Physician Development Coach.

CHAMPIONS FOR HEALTH

Andrew Gonzalez, Director of Community Health and the Gonzalez family of Northgate Gonzalez Markets.

TB, or Not TB … Juntos! by Adama Dyoniziak

hampions for Health is part of a unique private-public partnership to eliminate TB called Collaboration for Action to achieve Results toward the Elimination of TB (CARE TB). This group includes the San Diego County Tuberculosis and Refugee Health Branch, and is supported by the work of TB Free California, a partnership among the California Department of Public Health, community clinics and health departments throughout California. Together, we are a comprehensive, engaged response committed to reducing TB’s burden in local Asian Pacific Islander communities, specifically Filipino and Vietnamese individuals. During our first year, the CARE-TB advisory committee, consisting of API community members representing healthcare systems, service agencies, schools, Latent TB Infection/ TB patients, and business organizations, created the LTBI/TB outreach agenda, reviewed and approved all educational resources and activities, and the CARE-TB

Plan. This plan allows for integration of the CARE-TB advisory committee members and its program into the County of San Diego TB Elimination Initiative to facilitate San Diego County’s overall TB elimination plan. CARE-TB’s goal is to provide immediate and convenient opportunities for Filipino and Vietnamese individuals to receive TB education at CFH COVID/flu vaccine clinics in high-risk TB areas with low access to healthcare. TB risk assessments will be conducted using the five-question San Diego County TB Risk Assessment, translated into Tagalog and Vietnamese, and implemented by Filipino and Vietnamese community members, alongside the distribution of the TB prevention materials. Appropriate TB testing for those at risk via the risk assessment will be provided, with an exam and treatment offered to those testing positive. The CARE-TB program is part of the Community Wellness prevention activities coordinated by Andrew Gonzalez,

director of community health. In a beautiful and inspiring ceremony held at Northgate González Market headquarters, one of California’s largest Hispanic grocery chains, Andrew was introduced as one of the honorees of the second annual JUNTOS Award. Northgate González Market’s Hispanic Heritage Month campaign recognized 20 community leaders who are giving back to the community and awarded $40,000 to nonprofits in their name. The award is particularly special because of its title: Juntos means “Together” in Spanish. “When my family opened the doors to Northgate Market 41 years ago, we made a commitment to give back and place as a priority the health and wellness of the communities we serve,” says Miguel González, co-president of the company. “We continue to honor this legacy with the JUNTOS Award.” “I applaud the tremendous efforts and commitment of Northgate Market and everything they do for the community,” says Andrew Gonzalez. “I am honored to be recognized and included among this distinguished group of community leaders.” The dedicated physician volunteers of the San Diego County Medical Society envisioned being of service to the community, so they created the Foundation, which is now called Champions for Health. Join us in transforming lives juntos! www.championsforhealth.org/ volunteer. Adama Dyoniziak is the executive director of Champions for Health. SanDiegoPhysician.org SanDiegoPhysician.org 19 19

CLASSIFIEDS VOLUNTEER OPPORTUNITIES

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

RADY CHILDREN’S HOSPITAL - PEDIATRICIAN POSITIONS: Rady Children’s Hospital of San Diego seeking board-certified/eligible pediatricians or family practice physicians to join the Division of Emergency Medicine in the Department of Urgent Care (UC). Candidate will work at any of our six UC sites in San Diego and Riverside Counties. The position can be any amount of FTE (full-time equivalent) equal to or above 0.51 FTE. Must have an MD/DO or equivalent and must be board certified/eligible, have a California medical license or equivalent, PALS certification, and have a current DEA license. Contact Dr. Langley glangley@rchsd.org and Dr. Mishra smishra@rchsd.org. PER DIEM OBGYN LABORIST POSITION AVAILABLE: IGO Medical Group is seeking a per diem laborist to cover Labor and Delivery and emergency calls at Scripps Memorial Hospital in La Jolla. 70 deliveries/month. 24-hour shifts preferred but negotiable. Please send inquiries by email to IGO@IGOMED.com. MEDICAL CONSULTANT – SAN DIEGO COUNTY: The County of San Diego, Health and Human Services Agency’s Public Health Services is looking for a Board Certified Family Practice or Internal Medicine physician for the Epidemiology and Communicable Disease Division. Under general direction, incumbents perform a variety of duties necessary for the identification, diagnosis, and control of communicable diseases within the population. This position works closely with the medical and laboratory community, institutional settings, or hospital control practitioners. Learn more here: https://www.governmentjobs.com/ careers/sdcounty?keywords=21416207

November/December 2021

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.

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

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.

FULL-TIME CARDIOLOGIST POSITION AVAILABLE: Seeking full time cardiologist in North County San Diego in busy established general cardiology practice. EP or Interventional also welcome if willing to hold general cardiology outpatient clinic also at least 50% of time while building practice. Please email resume to jhelmuth1220@gmail.com. Immediate opening.

FAMILY MEDICINE OR INTERNAL MEDICINE PHYSICIAN: TrueCare is more than just a place to work; it feels like home. Sound like a fit? We’d love to hear from you! Visit our website at www.truecare.org. Under the direction of the Chief Medical Officer and the Lead Physician, ensure the provision of effective quality medical service to the patients of the Health center. The physician is responsible for assuring clinical procedures are continually and systematically followed, patient flow is enhanced, and customer service is extended to all patients at all times. PUBLIC HEALTH LABORATORY DIRECTOR: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a qualified individual to work for a Level 3 Public Health Laboratory. The Public Health Services department, part of the County’s Health and Human Services Agency, is a local health department nationally accredited by the Public Health Accreditation Board and first of the urban health departments to be accredited. Public Health Laboratory Director-21226701UPH NEIGHBORHOOD HEALTHCARE MD, FAMILY PRACTICE AND INTERNISTS/HOSPITALISTS: Physicians wanted, beautiful Riverside County and San Diego County- High Quality Family Practice for a private-nonprofit outpatient clinic serving the communities of Riverside County and San Diego County. Work Full time schedule and receive paid family medical benefits. Malpractice coverage provided. Be part of a dynamic team voted ‘San Diego Top Docs’ by their peers. Please click the link to be directed to our website to learn more about our organization and view our careers page at www.Nhcare.org. PHYSICIAN WANTED: Samahan Health Centers is seeking a physician for their federally qualified community health centers that emerged

INTERVENTIONAL PHYSIATRY/PHYSICAL MEDICINE SPECIALIST POSITION AVAILABLE: Practice opportunity for part time interventional physiatry/physical medicine specialist with well-established orthopaedic practice. Position includes providing direct patient evaluation/care of spine and musculoskeletal cases, coordinating PMR services with all referring providers. Must have excellent interpersonal and communication skills. Office located near Alvarado Hospital. Onsite digital x-ray and emr. Interested parties, please email lisas@sdsm.net. CARDIOLOGIST WANTED: San Marcos cardiology office looking for a part-time cardiologist. If interested, send CV to evelynochoa2013@yahoo. com or via fax to (760) 510-1811. GENERAL FAMILY MEDICINE PHYSICIAN: to provide quality patient care to all ages of patient in a full-time traditional practice. The Physician will conduct medical diagnosis and treatment of patients using medical office procedures consistent with training including surgical assist, flexible sigmoidoscopy, and basic dermatology. The incumbent must hold a current California license and be board eligible. Bilingual Spanish/English preferred. Founded as a small family practice in Escondido 1932 by Dr. Martin B. Graybill, today we’re the region’s largest Independent Multispecialty 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 fullservice 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 POSITIONS WANTED

SEMI-RETIRED MD AVAILABLE: Semi-retired MD- past San Diego County Medical Society Member with 10 years post retirement experience as part time, independent contract, medical director for Methadone/Opiate Addiction Clinics. Would like to continue work. Recent clinic was sold in pristine condition, unrestricted. CA MD Lice and same for DEA. DEA has suboxone rider, please email at mb9828@gmail.com or call 858-382-0552. PRACTICE FOR SALE

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

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) 4273328 or email at Feminacareo@gmail.com. UTC AREA MEDICAL OFFICE SPACE: 2000 sq. ft. Recently renovated corner office space in La Jolla Medical & Surgical Center. 8929 University Center Lane. Beautiful building with ample free parking. One mile from UCSD Jacobs Health Center and Scripps Memorial Hospital. Prime location. Competitive rent. Contact (858) 337-3768. Email: Marcekramer@me.com OFFICE SPACE FOR MENTAL HEALTH PRACTITIONER: Available June 1st, 2021, Mercy Medical Building, one large consultation room facing eastern mountains, large windows, recently remodeled. Includes waiting room,

plenty of storage, BR, parking for patients. Walking distance to UCSD medical center and Mercy Hospital and lots of restaurants. Freeway close. Contact Randall Hicks MD, at (619) 298-7135. TURNKEY MEDICAL OFFICE FOR LEASE IN BRAWLEY, CA: 6,504 SF medical office space available at 283 Main Street Brawley, CA. Office includes a large reception area, 10 exams rooms, 5 offices, 5 restrooms, X-ray room, lounge, lab space and nurses station. Located on the main road with easy access and abundant parking. Available for a short or long term lease. Please call Melissa at 310-471-2700 for more information. TURNKEY OFFICE SPACE FOR RENT NEAR ALVARADO HOSPITAL: Turnkey office space for rent. Modern, remodeled and clean. We have a little space available or a lot, depending on your needs. We are located near Alvarado hospital. Conference room, nurses station and many exam rooms, along with Doctors and Admin spaces.To inquire or to schedule a showing, please contact Jo Turner (619) 733-4068. OFFICE SPACE IN POWAY: Office in Poway. Centrally located. Close to pomerado hospital. Radiology, pharmacy next door. Fully furnished, WiFi included. Three exam rooms, reception area, waiting room. Half days to full time available. Ideal for specialist who wants to expand. Call Dr. Luna if interested: (619) 472-1914. KEARNY MESA OFFICE FOR SUBLEASE: Kearny Mesa area sublease in our orthopedic office which includes: onsite x-ray available, storage space, space for 1-2 employees and free parking. Can discuss internet, phones, fax line, access to printer/copier, and more. Please contact Kaye Spotz at kspotz@synergysmg.com for more information. SAN DIEGO OFFICE NEAR SHARP FOR SUBLEASE OR TO SHARE: Rady Children’s Hospital medical office building at 7910 Frost Street. Central location near to both Rady Children’s Hospital and Sharp Memorial Hospital, between HWY 163 and I-805. Available to any specialty. The space available includes access to one office, two exam rooms and a nurse’s station/ common area desk. Be close to excellent referral sources in the building and from the hospital campus. If you have an interest or would like more information, please call (858) 278-8300 x. 2210 or email nhughes@synergysmg.com OFFICE SPACE/REAL ESTATE WANTED

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

MEDICAL EXAM TABLES FOR SALE: Unfortunately for us, we are unable to utilize our medical exam tables which are in great condition. Our practice is going in a different direction, thus the need for us to provide these tables, which were barely used. The tables are approximately 70 x 30 inches and have black padding on top of a natural pine wood frame. Each table adjusts up and has a headrest with a pillow included. We are interested in moving these out of our office as soon as possible, since we are remodeling and need the space to complete the project. We can provide a picture and schedule time to see the tables between 9am - 5pm M-Th, or 9am–2:00pm Friday. Price is negotiable and we are just looking for a reasonable donation for the tables. We can sell individually as well, but will provide a greater incentive for taking both. Please contact Rick at (619) 795-6700 or email rick@manageyourage.com. OBGYN RETIRING WITH OFFICE EQUIPMENT FOR DONATION: Retiring from practice and have the following office equipment for donation: speculums, biopsy equipment, lights, exam tables with electric outlets, etc. Please contact kristi. eisenhauermd@yahoo.com or (760) 753-8413. MEDICAL EQUIPMENT FOR SALE: 2 Electric tables one midmark, 3 Ultrasounds including high resolution Samsung UG-HE60 with endovag and linear probes, STORTZ hysteroscopy equipment, 2 NOVASURE GENERATORS ,ENDOSEE OFFICE HYSTEROSCOPY EQUIPMENT : NEW MODEL, OLDER MODEL, Cynosure laser equipment:MONALISATOUCH (menopausal atrophy), TEMPSURE Vitalia RF (300 watts!) for incontinence, ENVI for face, Cynosure SculpSure with neck attachment for body contouring by warm sculpting. Please contact kristi.eisenhauermd@yahoo.com or (760) 753-8413. FOR SALE: Nuclear medicine equipment including Ge Millennium MG system, hot lab, and sources Cs-137. Rod Std 2. Cs-137. DCRS 3. Cs-137. Spot 4. Co-57. Flood sheet. Please contact us at (760) 730-3536 if interested in purchasing, pricing or have any questions. Thank you. 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. 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.

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