May 2008

“ P H Y S I C I A N S U N I T E D F O R A H E A LT H Y S A N D I E G O ”

THE RISE OF THESMART PATIENT

At the Crossroads ofEvidence-based Medicineand Consumer-directed

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2 S A N D I E G O P H Y S I C I A N . o r g | M A Y 2 0 0 8

Contents VOL. 95 | NO. 5

[ D E P A R T M E N T S ]

THE RISE OF THESMART PATIENT

4 CONTRIBUTORS:This Issue’s Contributing Writers

6 EDITOR’S COLUMN:Times Are Tough: You’ve Got a Friend

8 SEMINARS:SDCMS’ 2008 Seminars and Events

10 COMMUNITY HEALTHCARECALENDAR

23 TAKING IT OUT OF THE OFFICE:Recreation Prescriptions for the Underserved

34 THE COUNCIL OF COMMUNITYCLINICS

39 PHYSICIAN MARKETPLACE:Classifieds

44 CHRONIC CARE MADE EASIER:Taking Action on Many Fronts

VISIT

SANDIEGOPHYSICIAN.ORG

12 BRIEFLY NOTED: SDCMS Reference Guideto Health Plan Obligations, and More…

PAGE 24

The Rise of the Smart Patient: At the Crossroads of Evidence-based Medicine and Consumer-directedHealthcare By DANIEL FRIEDLAND,MD24“Evidence-based”: A Term in Search of a DefinitionBy BRIAN S. ALPER, MD, MSPH30

[ F E A T U R E S ]

20 WORKERS’ COMPENSATION 101:Overcoming PerceivedMisunderstandings

EVIDENCE-BASED MEDICINE:

36 NEW STROKE CARE SYSTEM:Coming Soon…

35 FAMILY HEALTH CENTERS OFSAN DIEGO

BRIAN S. ALPER, MD, MSPH Dr. Alper is the founder and manager of DynaMed, a point-of-care reference resource designed to providedoctors and medical researchers with the best available evidence to support clinical decision-making.

FRAN BUTLER-COHEN Ms. Butler-Cohen is CEO of Family Health Centers of San Diego.

DANIEL FRIEDLAND, MD Dr. Friedland is the author of Evidence-based Medicine: A Framework for Clinical Practice and founder ofSuperSmartHealth.com, which incorporates the principles of EBM into a vision of optimal health and well-being.

MARISOL GONZALEZ Ms. Gonzalez is your SDCMS physician advocate. She can be reached at (858) 300-2783 or at [email protected] any questions you may have about your practice or your membership.

EVALYN GREB Ms. Greb is a retired licensed clinical social worker.

BRUCE E. HAYNES, MD Dr. Haynes, an emergency medicine physician, is the medical director for the Emergency Medical Services Branchin the Division of Public Health Services of the County of San Diego Health and Human Services Agency, a position he has held since February2006.

STEPHEN R. O’KANE Mr. O’Kane is CEO of the Council of Community Clinics.

LAWRENCE S. POHL, MD, MPH Dr. Pohl received his medical degree from the University of Buffalo and his master’s degree in public healthfrom the Medical College of Wisconsin. He is board certified in both family and occupational medicine.

JOSEPH E. SCHERGER, MD, MPH Dr. Scherger is clinical professor of family medicine at UCSD. He is also medical director of Ameri-Choice, which administers San Diego County Medical Services. Dr. Scherger, along with editing San Diego Physician, is chair of the SDCMS Com-munications Committee.

CHRIS SEARLES, MD Dr. Searles is a family physician and a psychiatrist who works primarily with the underserved and uninsured of SanDiego County. He is on the clinical faculty at UCSD’s Department of Family and Preventive Medicine and is the co-director of the UCSD Com-bined Family Medicine and Psychiatry Residency Program.

WILMA WOOTEN, MD Dr. Wooten is San Diego County’s public health officer.


Contributors

Joseph Scherger, MD, MPHKyle LewisKetty La Cruz

EDITORMANAGING EDITORASSISTANT EDITOR

Adam Dorin, MDRobert Peters, MDDavid Priver, MDRoderick Rapier, MDJoseph Scherger, MDSandra Wilcox, MD

EDITORIAL BOARD

SDCMS EXECUTIVE COMMITTEE

Albert Ray, MDStuart Cohen, MD, MPHTheodore Mazer, MDSusan Kaweski, MDLisa Miller, MDJoseph Scherger, MD, MPHJeffrey Leach, MDRobert Wailes, MDSherry Franklin, MDRobert Hertzka, MDTom Gehring

Theodore Mazer, MDAlbert Ray, MDRobert Wailes, MD

Catherine Moore, MDDiana Shiba, MD

James Hay, MDRobert Hertzka, MD

Albert Ray, MDLisa Miller, MD

PRESIDENTPRESIDENT-ELECTPAST PRESIDENT

SECRETARYTREASURER

COMM. CHAIRDELEGATION CHAIR

BOARD REP.BOARD REP.

LEGISLATIVE CHAIREXECUTIVE DIRECTOR

SDCMS CMA TRUSTEES

OTHER CMA TRUSTEES

AMA DELEGATES

ALTERNATE DELEGATE

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 andlength 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 DiegoPhysician 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. Addressall editorial communications to [email protected]. All advertising inquiries can be sent to [email protected] . San Diego Physician is published monthly on the first of the month.Subscription rates are $35.00 per year. For subscriptions, email [email protected]. [SAN DIEGO COUNTY MEDICAL SOCIETY (SDCMS) PRINTED IN THE U.S.A.]

ACCOUNT EXECUTIVEPROJECT DESIGNER

ADVERTISING ART DIRECTORCOPY EDITOR

1450 Front Street • San Diego, CA 92101 • 619-230-9292 • Fax: 619-230-0493 • 800-600-CITY (2489) • www.sandiegomagazine.com

Published by Dari PebdaniJane HughesGeneen MontgomeryAdam Elder

PRESIDENTPUBLISHER

DIR., BUSINESS DEVELOP. & MARKETINGMARKETING & PRODUCTION MNGR.

Jim FitzpatrickMaureen SullivanHeather BackJennifer Rohr

EAST COUNTY DIRECTOR

HILLCREST DIRECTOR

KEARNY MESA DIRECTOR

LA JOLLA DIRECTOR

NORTH COUNTY DIRECTOR

SOUTH BAY DIRECTOR

AT-LARGE DIRECTOR

YOUNG PHYSICIAN DIRECTORRESIDENT PHYSICIAN DIRECTORRETIRED PHYSICIAN DIRECTORMEDICAL STUDENT DIRECTOR

William Tseng, MDWoody Zeidman, MDRoneet Lev, MDTom McAfee, MDAdam Dorin, MDSherry Franklin, MDSteve Poceta, MDWynnshang Sun, MDRobert Wailes, MDDouglas Fenton, MDTony Blain, MDVimal Nanavati, MDAnna Seydel, MDJeffrey Leach, MDRobert Peters, MDDavid Priver, MDWayne Iverson, MDPaul Kater, MDJohn Allen, MDKevin Malone, MDMihir Parikh, MDKimberly Lovett, MDGlenn Kellogg, MDLindsey Frost

SSeenndd yyoouurr lleetttteerrss ttoo tthhee eeddiittoorr ttoo EEddiittoorr@@SSDDCCMMSS..oorrgg

First Bank_SDP_0308:Layout 1 2/15/08 3:28 PM Page 1


do not need to say much abouthow tough being in medicalpractice is these days. Medicarecuts, Medi-Cal cuts, difficult in-

surance reimbursement, new reportingrequirements that would challenge anMBA, and a looming recession withmore people having less money tospend on healthcare. And the overheadcosts of practice continue to rise re-lentlessly. How do physicians survivetough times? In situations like this, Iam reminded of a line from The Beat-les: “I get by with a little help from myfriends.”When it comes to helping physicians

with medical practice issues, friends canbe hard to come by. This is where theSan Diego County Medical Society(SDCMS) comes in. SDCMS is here foryou, especially in tough times. Mem-

policies and critical information to nego-tiate timely payment. Again, the CMAON-CALL documents come to the res-cue, and having a local resource likeMarisol saves countless hours and pro-vides the reassurance of not being aloneworking with large payers.The office manager of a family prac-

tice group calls or emails about threetimes a week with questions about med-ical practice issues. These range fromhow physicians should report domesticviolence to what physicians can chargewhen they receive a subpoena or are giv-ing testimony in a deposition. Marisol isable to research these subjects and pro-vide up-to-date answers to her questions.SDCMS staff helps small and large

practices alike. Recently, one of SanDiego County’s largest medical groupsfaced a very expensive litigation action

I bership definitely has its benefits. Hereare some real examples of SDCMShelping members. These come fromMarisol Gonzalez, the full-time helperof SDCMS member practices (her titleis physician advocate):A pediatrician is starting up a new

practice. She has questions about manythings: the legalities of rest periods foremployees; information about sole pro-prietorships; incorporation; and herbusiness license. Using CMA’s ON-CALL documents as a resource, Marisolis able to guide her through the maze ofstarting and running an independentpractice. She also connects her with en-dorsed business partners at a discount,such as CHMB billing services.An internist is having reimbursement

problems with health plans. He needsan advocate to understand the billing

Times Are

Tough

Editor’s Column

by the state. SDCMS teamed up withCMA to help the group right from thebeginning. SDCMS and CMA wereable to provide the attorneys defendingthe group with critical documents andguidance that helped result in a suc-cessful defense. And remember, withprofessional liability insurance, TheDoctors Company gives a 5 percentdiscount to physicians who are SDCMSmembers.Unfortunately, some physicians or

office staff call SDCMS for help andare not members. They may decide tojoin only when they are in a crisis.

Since membership dues are used to em-ploy Marisol and the other greatSDCMS staff, only members can behelped in this way. Save yourself theembarrassment of waiting to joinSDCMS until you are in crisis. Youdon’t buy fire insurance when thehouse is burning.If you are not a member, join now

and take advantage of the many bene-fits of a staff ready and waiting to helpyou. As Carole King and James Taylorsang, “Ain’t it good to know thatyou’ve got a friend?”

M A Y 2 0 0 8 | S A N D I E G O P H Y S I C I A N . o r g 7

ABOUT THE AUTHOR: Dr. Scherger

is clinical professor of family medicine at

UCSD. He is also medical director of Ameri-

Choice, which administers San Diego County

Medical Services. Dr. Scherger, along with ed-

iting San Diego Physician, is chair of the

SDCMS Communications Committee.

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please contact Dari Pebdani for information and rates.

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If your medical license or privileges are on the line…

Members Of The Firm: David Rosenberg, J.D. Tomas A. Shpall, J.D.Annette Farnaes, J.D.

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• More than 50 years of combined experience inMedical License/Hospital Privilege Disputes

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SEXUAL HARASSMENT

TRAINING

Oct. 15, 6:30 p.m. - 8:30p.m.

SEXUAL HARASSMENT

TRAINING — OFFICE MAN-

AGERS FORUM Oct. 16, 11:30a.m. – 1:30 p.m.

2008 San Diego County Medical Society Seminars and Events

Along with its many social events held

throughout the year, theSAN DIEGO COUNTYMEDICAL SOCIETY

(SDCMS) strives to builda robust schedule of

ffrreeee sseemmiinnaarrss ffoorr oouurrpphhyyssiicciiaann mmeemmbbeerrss aanndd

tthheeiirr ssttaaffffss..

For further information about any of these seminars or events, watch your emails

and faxes, visit SDCMS’ websiteat www.SDCMS.org, call SDCMS

at (858) 565-8888, or email us at [email protected].

Details may change as semi-nars approach –contact

SDCMS to confirm. Thank you for your

membership!

OCTOBER

PRACTICE MANAGEMENT

SEMINAR “Financial Con-trol for Physicians: Prevent-ing Money Leaks” June 18,6:30 p.m. - 8:30 p.m.

PRACTICE MANAGEMENT

SEMINAR – OFFICE MAN-

AGERS FORUM “Treating Pa-tients Right: Tact, Courtesy,and Etiquette in the MedicalOffice” June 19, 11:30 a.m. -2:30 p.m.

JUNE

SDCMS NEW MEMBER SOCIAL

Aug. 29, 6:00 p.m. -9:00 p.m.

AUGUST

Seminars

LEGAL SEMINAR —

OFFICE MANAGERS FORUM

“HR Law” May 22, 11:30a.m. – 1:00 p.m.

CMA CEO JOE DUNN: DISCUS-

SIONS WITH PHYSICIANS

May 27 and 28, all day, bothdays at several different SanDiego County hospitals

YOUNG PHYSICIANS SOCIAL

Sep. 6, 3:00 p.m. - 8:00 p.m.

SEPTEMBER

“WHAT IS/ISN’T EHR/EMR?”

May 14, 4:00 p.m. - 8:00p.m.; May 15, 9:00 a.m. - 1:00p.m.

LEGAL SEMINAR “Contract

Law” May 21, 6:30 p.m.–8:30 p.m.

MAY

RISK MANAGEMENT SEMINAR

Nov. 13, 11:30 a.m. - 1:00p.m., Nov. 14, 11:30 a.m. - 1:00p.m.; Nov. 14, 6:30 p.m. - 8:30p.m.

RESIDENT AND NEW PHYSI-

CIAN SEMINAR “Preparingto Practice: What You Needto Know BEFORE You BeginYour Practice” Nov. 22, 8:30a.m. – 3:30 p.m.

NOVEMBER

Allscripts is pleased to announce that it will offer preferred pricing to SDCMS members on the award winning HealthMatics® Office Practice Management and Electronic Health Records solution. This integrated PM and EHR solution offers state of the art technology that includes:

For more information please contact Jamie Smolin at 619.955.6929 or at [email protected]. Visit us online at www.allscripts.com/healthmatics.

Announcing Allscripts as a Preferred Vendor of the San Diego County Medical Society

• Complete work flow management• P4P, clinical and financial reporting• Advanced Scheduling• Comprehensive Claims management

• E-prescribing with formularies• Electronic orders and results • Automated Health Maintenance • Online Patient Portal

Coastal Healthcare Consulting Group, Inc.

• Medical Group Contracting and Negotiation

• Health plan Contracting

• Revenue Enhancement

• Contracts Review

• Staff Training

CONTRACTING AND NEGOTIATION SERVICES FOR PHYSICIANS AND MEDICAL GROUPS

Reasonable Rates, Great Results! Kim Fenton, President

714-544-5488

www.HealthcareConsultant.org • [email protected]

Would You Like To Get Paid What You Are Worth?

YOUNG PHYSICIANS SOCIAL

Dec. 5, 6:00 p.m. -9:00 p.m.

DECEMBER

Project2:Layout 1 4/18/08 2:09 PM Page 1

ESSENTIAL TOPICS IN PEDIATRICS 2008: EXPLORING THE DEVELOPMENTAL SPECTRUM

WHAT: Experts in the field of autism will updateparticipants on early diagnosis and managementof this disorder through several lectures and an in-tensive workshop (designed with the generalist inmind).WHEN:May 15WHERE: Catamaran Resort Hotel and Spa, SanDiegoCOST: $250CME: 24.5 AMAINFORMATION: Call (858) 534-3940 or [email protected].

ALZHEIMER’S DISEASE: UPDATE ON RESEARCH, TREATMENT, AND CARE

WHAT: Expert faculty will address how we handlepsychiatric and behavioral issues, what medica-tions we see on the horizon, how we can help im-prove the quality of life for the Alzheimer’s diseasepatients and caregivers, and much more.WHEN:May 22–23WHERE: The Westin Horton Plaza Hotel, San DiegoINFORMATION: Visithttp://cme.ucsd.edu/alzheimers.

FRESH START’S 2008 SURGERY WEEKENDS

WHAT:Over 100 volunteers join together to providefree reconstructive surgery and related medicalservices to disadvantaged children with physicaldeformities caused by birth defects, accidents,abuse, or disease.WHEN:June 7–8; July 26–27; Sept. 13–14; Nov. 1–2WHERE: The Center for Surgery of EncinitasINFORMATION: Visit www.freshstart.org.

DELIVERING SAFE AND OPTIMAL CARE THROUGHEFFECTIVE TEAMWORK AND COMMUNICATION

WHAT: This seminar is ideal for anyone interested inbetter teamwork and communication in their health-care setting. Organizations are encouraged to sendgroups of people who work together in high-risk serv-ice lines, such as the operating room, intensive careunit, emergency department, and labor and delivery.WHEN:June 10–11WHERE: La Costa Resort and Spa, CarlsbadCME: AvailableINFORMATION: Visit www.ihi.org (click on “Pro-grams”).

GLUCOCORTICOIDS MOOD: CLINICAL MANIFESTATIONS, RISK FACTORS, AND

MOLECULAR MECHANISMS

WHAT: This conference will encompass many as-pects of the clinical effects of glucocorticoids in a va-riety of illnesses and in health. The topics addressedwill be of relevance to many medical specialties inwhich glucocorticoid therapy is widely used.WHEN:June 20WHERE: San Diego Marriott Del MarCOST: $425CME: 10.75 AMAINFORMATION: Call (858) 534-3940 or [email protected].

25TH ANNUAL SUPERFICIAL ANATOMY AND CUTANEOUS SURGERY

WHAT: This program is designed to provide thebasic information and principles of superficial headand neck anatomy and surgery for those interestedin dermatological surgery.WHEN:July 14

WHERE: San Diego Marriott Del MarCOST: $2,795CME: 44 AMAINFORMATION: Call (858) 534-3940 or [email protected].

25TH ANNUAL PRIMARY CARE MEDICINE: A PRACTICAL APPROACH

WHAT: The course will emphasize the practical as-pects of clinical practice.WHEN:August 1–3WHERE: Marriott Hotel and Marina, San DiegoINFORMATION: Call (858) 587-4404 or [email protected].

19TH ANNUAL CORONARY INTERVENTIONS

WHAT: This conference will discuss the state-of-the-art concepts and techniques of interventionalcardiology.WHEN:September 17–19WHERE: Hilton La Jolla Torrey PinesINFORMATION: Call (858) 587-4404 or [email protected].

ADVANCED WILDERNESS LIFE SUPPORT CME/CERTIFICATION COURSE

WHAT: Four-day CME and certification course inadvanced wilderness life support and wildernessmedicine. This course is designed to further edu-cate medical professionals in outback safety, sur-vival, diagnosis, and treatment.WHEN:November 12–15WHERE: Carlton Oaks Country Club, SanteeCME: AvailableINFORMATION: Visitfamilymedresidency.ucsd.edu/awlsconference.shtml.


Calendar

ADDRESS: 5575 Ruffin Rd., Ste. 250, San Diego, CA 92123TELEPHONE: Dareen Nasser, office manager, at (858) 565-8888 or [email protected]

FAX: (858) 569-1334CEO/EXECUTIVE DIRECTOR: Tom Gehring at (858) 565-8597 or [email protected]

COO/CFO: James Beaubeaux at (858) 300-2788 or at [email protected] OF MEMBERSHIP AND MEMBER SERVICES: Janet Lockett at(858) 300-2778 or at [email protected]

PHYSICIAN ADVOCATE:Marisol Gonzalez at (858) 300-2783 or at [email protected]

OFFICE MANAGER ADVOCATE: Lauren Woods at (858) 300-2782 or [email protected]

DIRECTOR OF EVENTS AND LEADERSHIP SUPPORT: Jennipher Ohmstede at(858) 300-2781 or at [email protected]

SDCMS FOUNDATION EVP: Aron Fleck at (858) 300-2780 or at [email protected] OF COMMUNICATIONS AND MARKETING: Kyle Lewis at (858)300-2784 or at [email protected]

ASSISTANT EDITOR AND WEBMISTRESS: Ketty La Cruz at (858) 565-7930 orat [email protected]

LETTERS TO THE EDITOR: [email protected] SUGGESTIONS: [email protected]

Get In TouchS D C M S

Alliant_SDP_0508:Layout 1 4/15/08 10:46 AM Page 1


NOTE: Thank you to the Alameda-Contra Costa Medical Association (ACCMA) and the California Medical Association for compiling this amazing member benefit!

Noted

he San Diego County MedicalSociety (SDCMS) is pleased toprovide our members with a

reference guide to health plan obliga-tions. This guide represents another ex-ample of the benefits and advocacy thatmembers of SDCMS-CMA receive tohelp them successfully practice medi-cine and meet the needs of their pa-tients. It provides essential informationto assist physicians when dealing withpayment disputes and contract issueswith health plans. Moreover, its verycontent exists because of successfulCMA advocacy on behalf of physiciansin the promotion of new laws, prece-dent-setting court actions, advocacywith regulatory agencies, and the class-action federal anti-racketeering (RICO)lawsuit against major health plans filedby CMA.

The guide comprises several sections:SECTION 1: A quick reference to health

plan obligations. Each obligation is de-scribed and identified as a state law, courtdecision, or a provision of the RICO set-tlement, and accompanied by a listing ofthe recourse physicians can utilize whenthe obligations are not met as well as thesource for further information.SECTION 2: Contact information for

SDCMS and CMA if assistance is neededin dealing with health plans as well as list-ings of the sources for further informationcited in Section 1.SECTION 3: Guidance for pursuing re-

course against health plans through the ap-propriate regulatory agency if obligationsare established by state law.SECTION 4: Guidance on seeking recourse

if the obligations are established pursuantto the RICO settlement terms.

SECTION 5: Model letters developed byCMA to send to health plans when theyfail to meet their obligations.SDCMS-CMA members can access this

guide in the “Member Physicians” sectionof SDCMS’ website at www.SDCMS.org.Please contact Marisol Gonzalez, yourphysician advocate at SDCMS, if you haveany questions regarding the informationcontained in this guide or if you need anyassistance in dealing with a health plan. Asyou use this guide, reflect on the fact thatit is made possible by the collective supportthat physicians provide as members. Andif you encounter colleagues who do nothave a copy because they are not a mem-ber, you might tell them how valuable youfind such membership benefits and thattheir support would enable SDCMS andCMA to do even more on behalf of themedical profession.

T

Reference Guide to Health Plan ObligationsFree SDCMS Members-only Benefit

Briefly

IHS_SDP_0508:Layout 1 4/15/08 10:18 AM Page 1


Briefly Noted

New SDCMS-CMA MembersNATASHA PRAKASH CHANDANANI, MDAnesthesiologySan Diego • (858) 565-9666

JOEL C. DIAMANT, MDInternal MedicineLa Jolla • (858) 554-7809

PHILLIP WILLIAM DICKINSON, MDSurgeryLa Mesa • (619) 464-4469

LAURA NORTON FAGERLUND, MDInternal Medicine and PediatricsCoronado • (619) 435-2234

LAURIE ANN FRAKES, MDInternal Medicine, Medical Oncology, and HematologyEncinitas • (760) 452-3340

BRIDGETTE BOGGESS FRANEY, MDFamily MedicinePoway • (858) 675-3210

CHARLES IRVING KNOLL, MDPhysicial Medicine and RehabilitationSan Diego • (619) 516-3992

MARK CUTLER NELSON, MDOrthopedic Surgery and Spine SurgerySan Diego • (858) 571-0606

CHRISTINE CYN NIEMAN, MDPediatric AnesthesiologySan Diego • (858) 565-9666

PATRICIA E. PARDO, MDAnesthesiologySan Diego • (858) 565-9666

SISSELA SAYEUN PARK, MDCardiac AnesthesiaSan Diego • (858) 565-9666

CARL A. POWELL, DOSurgeryCardiff • (760) 635-7507

XING-JIAN REN, MDInternal Medicine and GeriatricMedicineLa Jolla • (619) 245-2350

Rejoining SDCMS-CMAMembers

CHANDRAKANT V. SHAH, MDCardiovascular DiseaseCardiff by the Sea • (760) 633-3044

DEAN EDWARD SIDELINGER, MDPediatricsSan Diego • (619) 685-2539

ANTHONY JAMES STANZI, MDPediatric AnesthesiologySan Diego • (858) 565-9666

SARA ELIZABETH STEWART, MDAnesthesiologySan Diego • (858) 565-9666

DANIEL VERNON WHITE, MDNeurological SurgeryChula Vista • (619) 476-7958

ALICIA COLLINS BENJAMIN, MDInternal MedicineSan Diego • (619) 699-1645

BRUCE LEIGH BOWER, MDInternal Medicine and Diagnostic,Vascular, and Interventional RadiologySan Diego • (858) 565-0950

CARLOS M. GARCIA, MDPediatricsChula Vista • (619) 271-4059

JIM RAYBURN HARLEY, MDPediatrics and Pediatric Emergency MedicineSan Diego • (858) 966-8005

STEVEN A. ORNISH, MDPsychiatry and Forensic PsychiatrySan Diego • (619) 692-3222

EUGENE MICHAEL TACHUK, MDFamily MedicineSan Diego • (619) 222-5433

Welcome New and Rejoining SDCMS-CMA Members!Nonmembers: Join Today at www.SDCMS.org

SDCMS Physicians Honored As Health Heroes!On March 20, 2008, San Diego’s Combined Health Agencies (www.combinedhealth.org)

recognized three SDCMS members at its 14th annual Health Hero Awards, where each

of the 25 member agencies honors a local business, media professional/celebrity, med-

ical/health professional or scientific researcher who has contributed to the local health

industry through their community activism. The honorees, whose unique stories

demonstrate what it means to go above and beyond in their respective fields, stand out

in the San Diego County community by volunteering their time and talents on top of

the pressures of a demanding career. The SDCMS physicians honored this year are

Mitsuo Tomita, MD, M. Sandra Norton, MD, and Holly Yang, MD. Congratulations!


To run display advertising in San Diego Physician, please contact

Dari Pebdani for information and rates. 619-744-0528 or [email protected]

ADVERTISE HERE

Leslie Kane, editor of Medical Eco-nomics magazine, informed her read-ers in March that our own Joseph

Scherger, MD, San Diego Physicianeditor since 2004, had been added

to the Medical Economics editorialboard:

Joseph Scherger, MD, a family physi-

cian in San Diego, has joined our Edi-

torial Board. Scherger, a nationally

recognized healthcare IT expert, has

recently focused on using technology

tools and quality improvement meth-

ods to redesign the medical office. In

addition to being in the forefront of

information technology develop-

ments and having an impressive re-

sume of published articles, books,

and speaking engagements, Scherger

has been recognized as Family Physi-

cian of the Year (AAFP, 1989); re-

ceived the Thomas Johnson Award

for family medicine education (1994);

and served on the IOM (Institute of

Medicine of the National Academies)

Committee on the Quality of Health

Care in America (1998-2001). We are

delighted to have Scherger’s guid-

ance in informing our coverage.

Congratulations, Dr. Scherger!

San Diego Physician Editor Appointed to Medical Economics Editorial Advisory Board


Briefly Noted

SDP: HAVE YOU ALWAYS WANTED TO BE A PHYSICIAN?

DDRR.. WWAAIILLEESS:: Ever since high school. During mysenior year, I joined a group called Medical Ex-plorers, which allowed me to follow a doctoraround for a day. He was a neurosurgeon, andI just thought it was the coolest thing in theworld. From that point on, I was pre-med.

SDP: WHAT IS YOUR SPECIALTY AND MODE OF PRACTICE?

DDRR.. WWAAIILLEESS:: I’m a pain medicine specialist. I’mpart of a small group called the Pacific PainMedicine Consultants, located in NorthCounty. Our practice consists of three physi-cians and two physician assistants. We do a fullrange of services dealing with pain manage-ment. We like to think of ourselves as a mul-tidisciplinary program that treats just aboutany type of pain problem.

SDP: WHAT IS YOUR OPINION ON EVIDENCE-BASEDMEDICINE?

DDRR.. WWAAIILLEESS:: It’s a wonderful concept, but evi-dence-based medicine only covers a fraction ofthe choices we have in our day-to-day prac-tices. It’s a shame, but it’s a reality that we don’thave good research outcome data on most ofwhat we do. In my field, many of the things Icome across are extremely difficult to study. Itis nearly impossible to do double-blinded re-search on topics like spine fusion. Also, many

studies require a large number of participants,and it’s just not practical to get the researchdone. So, while I’m a big believer in evidence-based medicine, I also know there are very se-vere limitations in its application.

SDP: WHAT ARE THE CHALLENGES OR FRUSTRATIONS YOUEXPERIENCE IN YOUR PRACTICE?

DDRR.. WWAAIILLEESS:: The biggest challenge is having todeal with insurance companies. Oftentimes,we are limited in the care we want to provideour patients because it conflicts with the in-surance companies’ guidelines. This has to dowith everything from the selection of medica-tions to certain procedures that are chosen. It’sfrustrating because we want to do the best forour patients with the least harm, but we can’talways practice that way because of insurancerestrictions. We see examples where insurancecompanies opt for the bigger, more expensive,more complicated, and frequently less-satisfy-ing procedures that are the least cost-effective,but have been around for a long time.

SDP: WHEN DID YOU JOIN SDCMS-CMA AND WHY?

DDRR.. WWAAIILLEESS:: I joined SDCMS-CMA in 1993. Ijoined for one big reason: The fact that organ-ized medicine is our only hope to producechange. I wanted to be a contributor, and Iknew that I needed to be a part of the team.I’ve always been interested in the economics

and finance of healthcare and in the politics ofhealthcare legislation. After a while of beinginvolved on the county level as I have been, itjust tends to grow on you.

SDP: WHY SHOULD OTHER DOCTORS BECOME INVOLVEDWITH ORGANIZED MEDICINE?

DDRR.. WWAAIILLEESS:: I believe it’s our responsibility asphysicians to support our patients and ourchosen profession. It’s only through organizedmedicine that we have the format and abilityto make effective change in the quality of careand access to care for our patients. It is also ourresponsibility to promote a supportive careerpath for the providers that give patients care.

SDP: WITH WHAT THOUGHTS WOULD YOU LIKE TO LEAVEYOUR CONSTITUENTS IN THE ENCINITAS/CARLSBAD AREA?

DDRR.. WWAAIILLEESS:: Be part of the team; be part of thesolution. I hope you’re all concerned about theissues that confront us every day. You can restassured that there are a number of organiza-tions, from the county to the state to the na-tional level, that are working to improve theissues that trouble most physicians. Organizedmedicine is the best format to present youropinions, to be persuasive, and to work for yourgoals. What better way to achieve your goalsthan with the support of an entire medical as-sociation behind you. That’s why it’s importantfor all doctors to be part of the team.

Robert Wailes, MDNorth County Director, SDCMS Board of Directors

PROJECT ACCESS SAN DIEGO (PASD)Connecting Uninsured and Underinsured San Diegans With Volunteer Physicians

PHYSICIANS WANTED:• Primary care physicians to provide a “medical home” for one or more people.

• Specialty care physicians to provide one or more specialty consult(s) and procedure(s).

For more information about PASD or to let us know how you would like to help, contactAron Fleck, SDCMSF executive director, at (858) 300-2780 or at [email protected].

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Evidence-based Medicine Research Websites

• Centre for Evidence-based Medicinewww.cebm.net

• Super Smart Healthwww.supersmarthealth.com

• Netting the Evidencewww.shef.ac.uk/scharr/ir/netting

• DynaMedwww.ebscohost.com/dynamed

• Duke University Medical Centerwww.mclibrary.duke.edu/subject/ebm

• Evidence-based Medicine Resource Centerwww.ebmny.org

• University of Marylandwww.hshsl.umaryland.edu/resources/evidence.html

• WebMDwww.emedicine.com

• SUNY Downstate Medical Centerhttp://library.downstate.edu/resources/ebm.htm

• The Society for Clinical Trialswww.sctweb.org

• The James Lind Librarywww.jameslindlibrary.org

• PubMedwww.ncbi.nlm.nih.gov/PubMed

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“ P H Y S I CI A N S U N

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HEALTH INFORMATION

TECHNOLOGY

Transforming Care

Ask Your Physician Advocate!By Marisol Gonzalez

How Long to Keep Medical Records?

Can I Charge to Copy Medical Records?

How Can I Place a Classified Ad?

UESTION: I am a pediatrician;how long do I need to keep mymedical records?

ANSWER: CMA ON-CALL document#1160 gives three different recommendedretention periods. Under option two, it isrecommended that physicians retainrecords for at least 10 years after the lastdate a patient is seen, with exceptions.Minors’ records should be kept longer inthose cases where the 10 years elapse be-fore the minor has reached the age of 18.In no event should a minor’s records bedestroyed until at least one year after theminor has reached the age of 18. In addi-

tion, the records of pregnant womenshould be retained long enough to assessthe effects of medication or treatment re-ceived on the fetus, requiring retention atleast until the child reaches the age of ma-jority.

UESTION: A private attorneyrepresenting one of our pa-tients is requesting a copy of

the patients’ medical records for a SocialSecurity benefits trial. This attorney hasstated that because it’s for a trial regard-ing Social Security benefits, they are enti-tled to these records for free. Is this true?

ANSWER: Yes, but they are only allowedone free copy. California Health & SafetyCode §123110 (d) (1) states: “Any pa-tient or former patient or the patient’srepresentative shall be entitled to a copy,at no charge, of the relevant portion ofthe patient’s records, upon presenting tothe provider a written request, and proofthat the records are needed to support anappeal regarding eligibility for a publicbenefit program.” Although a patientshall not be limited to a single request, thepatient or patient’s representative shallbe entitled to no more than one copy ofany relevant portion of his or her recordfree of charge. (Health & Safety Code

§123110 (d) (2)) This subdivision shallnot apply to any patient who is repre-sented by a private attorney who is payingfor the costs related to the patients appeal,pending the outcome of that appeal. Forpurposes of this subdivision, “private at-torney” means any attorney not employedby a nonprofit legal services entity.(Health & Safety Code §123110 (d) (3))

UESTION: I would like toplace a classified ad in SanDiego Physician as well as

on SDCMS’ website. What is the cost andhow can I do this?

ANSWER: SDCMS members can place aclassified ad in San Diego Physician and onwww.SDCMS.org free of charge. For non-members, the charge is $100 for the first75 words and $0.50 for every word there-after. Contact Ketty La Cruz at (858) 565-7930 or at [email protected].

QQ

MARISOL GONZALEZ

Q

ABOUT THE AUTHOR:Ms. Gonzalez isyour SDCMS physician advocate. She canbe reached at (858) 300-2783 or [email protected] with any ques-tions you may have about your practice oryour membership.

DOES YOUR OFFICE MANAGER HAVE A QUESTION TOO?Lauren Woods, your SDCMS office manager advocate, is on staff and ready to help your officemanager with any questions they may have! Feel free to contact Lauren at (858) 300-2782 orat [email protected], and make sure your office manager is signed up to receive SDCMS’ newoffice manager e-newsletter.


Your Physician Advocate Has the Answers!

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MEDICAL PROTECTIVE1/2 PAGE HORIZONTAL AD


he topic of workers’ compensa-tion has different connotations tothe employer, the injured em-

ployee, and the doctor. Many doctors at-tribute a negative feeling toward thisdiscipline, and this is often due to misun-derstanding and stereotypes that are per-ceived.Early workers’ compensation laws were

a trade-off between employer and em-ployee. The laws provided benefit to theinjured worker, regardless of fault, in ex-change for the employer’s limited liability.The employer could no longer use tradi-tional defenses, while the worker gave uphis or her right to sue for potentially largepain and suffering damages. Providingworkers’ compensation benefits by theemployer has become mandatory and is asignificant cost and responsibility of con-ducting business in California. Employersmay purchase workers’ compensation in-

surance through a private insurance com-pany or elect to be self-insured if theymeet certain qualifications. The employeedoes not contribute to the cost. The Di-vision of Workers’ Compensation, withinthe California Department of IndustrialRelations, regulates the California Work-ers’ Compensation System. The Califor-nia Workers’ Compensation AppealsBoard (WCAB) is the judicial body thatmakes rulings for disputed issues withinthe system.Treating patients with work-related in-

juries can be challenging, given the vari-ous rules within the system, but can bevery rewarding as we see an injuredworker return to his or her usual and cus-tomary duties. Work-related injuries canbe specific or acute, such as a lumbosacralstrain, or cumulative, such as tendonitisor carpal tunnel syndrome. There alsomay be a work-related illness, such as a

hypersensitivity pneumonitis from in-halation of dust particles, tuberculosis,from work exposure to active TB, or dis-eases such as asbestosis or pleuralmesothelioma, which often can have a la-tent period of 30 or more years.When the injured worker presents to

the physician, the first priority is to de-termine if the particular injury is work-re-lated. For an injury to be consideredwork-related and thus fall under the ju-risdiction of the California workers’ com-pensation laws, the injury must arise outof and in the course of employment (legalabbreviation is AOE/COE). There mustbe a causal relationship between the em-ployment and the injury sustained. Therealso must be a relationship of time andplace between the injury and employment— that is, while the employee was per-forming an activity related to his or herjob.

T

Workers’ Compensation 101Overcoming Perceived Misunderstandings and Stereotypes

By LAWRENCE S. POHL, MD, MPH


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Sometimes, the injury is straightfor-ward and clearly work-related, such as apatient bending over at work and, in theprocess of lifting a heavy item, straininghis or her back. Other instances are not asclear, such as a mechanic who lifts, bends,and stoops at work on a regular basis, butcannot remember a specific incident lead-ing to this injury. Another example is if aworker suffers a myocardial infarctionwhile at work, he or she has suffered aninjury in the time and place of employ-ment, but for there to be compensation,the heart attack would have to be causedby the work. In our state, for firefightersand police officers, there is a presumptionwithin the law that the heart attack iswork-related. This is not the case in mostother occupations, and causation must beproven.When the doctor determines that the

injury or illness is work-related, he or shemust fill out a Doctor’s First Report of In-jury Form. In this form, the doctor mustdescribe the injury, present the subjectiveand objective findings, the impression,whether he or she feels it is work-related,

and if there are other factors that wouldinhibit healing or if there were prior sim-ilar injuries that have not resolved at thistime. The doctor also must document atreatment plan, estimate when the patientwould be cured of his or her injury/illness,and make a determination if the patientmay return to regular duties, be on mod-ified duty with specific restrictions, or beoff work on what is called in the workers’compensation system total temporary dis-ability (TTD). It is to the benefit of theemployer and the employee that the pa-tient be returned to modified, then regu-lar duty as soon as feasible. This can beaccomplished in the vast majority of cases,ensuring efficient resolution of the case,and avoiding the development of the “dis-ability mentality” and becoming decondi-tioned.

The modalities available for treatmentare not different from treating other pa-tients with private insurance plans, andinclude medication, physical therapy, chi-ropractic, acupuncture, diagnostic stud-ies, injection therapy, surgery, and manyothers.From a physician’s standpoint, one has

to walk the fine line between the needs ofthe patient, the employer, and the insur-ance company. The key to facilitate effi-cient resolution of work-related injuries isprompt treatment and communicationbetween the injured worker, the employerrepresentative, and the insurance adjuster.There are some differences in the work-

ers’ compensation system from the pri-vate arena. These include the concepts ofapportionment, TTD (total temporarydisability) payments, firm guidelines forutilization review, the ACOEM (Ameri-can College of Occupational and Envi-ronmental Medicine) guidelines, qualifiedmedical evaluations (QME), and use ofthe AMA Guides to Impairment, when apatient has reached a period of maximalmedical improvement (MMI), also called

permanent and stationary (P and S).Apportionment is the legal concept that

the causation of an injury may be appor-tioned, percentage-wise, to several differ-ent etiologies. For example, let us take thecase of a 60-year-old male with a historyof significant degenerative arthritis of hislumbar spine, who has had several previ-ous back surgeries from which he hasnever fully recovered, but has been able towork as a mechanic. Suppose he has anacute injury to his lower back when heslips and falls at work, sustaining a lum-bosacral strain. At the point that hereaches a point of MMI, the treatingphysician must make a determinationabout apportionment — that is, whatportion of the back condition was preex-isting to the acute injury, and what por-tion was attributed to the recent fall? This

From a physician’s standpoint, one has to walk the fine line between the needs of the patient, the

employer, and the insurance company.


determination has legal and financial ram-ifications.In the workers’ compensation system,

not only are all medical costs paid for theinjured worker, with no deductible or co-pay, but the injured worker is also entitledto total or partial temporary disabilitypayments if he or she is not able to work,or if there is no appropriate modified dutyavailable from the employer. The worker,while on TTD, receives up to two-thirdsof his income, up to approximately $700per week. This differs from the privatearena, where, if the patient cannot workhe may be entitled to State Disability In-surance (SDI), but this amount is muchless. Parenthetically, the injured workermay apply for SDI in addition to hisworkers’ compensation payments.Several years ago, workers’ compensa-

tion costs were rising at an alarming rateand were costing employers more andmore money, and forcing some out ofbusiness or out of the state. Part of theserunaway costs was due to overutilizationof services, such as physical therapy andchiropractic. In 2004, due to the effortsof Governor Schwarzenegger and the leg-islature, in an effort to stem these risingcosts, and loss of companies to otherstates, a sweeping legislation was passed:SB-899. One of the most important as-pects of this legislation was the institu-tion of stringent utilization reviewrequirements. Each workers’ compensa-tion insurance company was required tohave a utilization review program, withphysicians doing a large portion of the re-views, covering topics such as PT, chiro-practic, MRIs, surgery, epidural steroidinjections, facet injections and the like.A cap was instituted for chiropractic andphysical therapy of 24 per year, at themost.Along with these changes, there was

the adoption of the American College ofEnvironmental and Occupational Medi-cine Guidelines (ACOEM) to be pre-sumed correct, from a legal standpoint.Generally, the ACOEM guidelines stressfunctional restoration as indicative of rea-sons for approving further treatment,such as PT, or chiropractic; there needsto be shown subjective and/or objective

improvement from a treatment modalityif further treatment was to be recom-mended. Physicians all over the state aremaking peer-to-peer telephone calls todetermine and understand their col-league’s rationale for a particular treat-ment plan.When a patient has reached a period of

maximal medical improvement (MMI),physicians or other providers are requiredto do a permanent and stationary report,and determine factors such as apportion-ment (see above), appropriate futuremedical care, and, most recently, impair-

ment rating; this rating must be doneusing the AMA Guides to ImpairmentRating, fifth addition. Depending on thebody part, there are various measure-ments of ROM, presence of spasm, andobjective findings of radiculopathy orneuropathy that translate into, first, alocal impairment rating, for example thehand, and are then converted into awhole-body impairment rating. This rat-ing is used by California’s disability rat-ing system and takes into considerationfactors such as future earning capacity,type of occupation, and age to convert toa disability rating. This disability ratingtranslates into a monetary payment, ifimpairment and therefore disability isfound, for the injured employee.Qualified medical examiners (QMEs)

are certified by the state to give a secondopinion if either the injured worker (or hisattorney, if he is represented) or the em-ployer disputes any aspect of the perma-nent and stationary determination.

How does this look from a physician’sstandpoint? The physician who is willingto treat injured employees can build aclose relationship with both the injuredemployees and groups of employers. Asthe injured worker moves through the sys-tem and observes that you have treatedhim or her efficiently and in a caring man-ner, he or she may choose to refer friendsor relatives to you. As employers havewatched you treat their employees appro-priately, they may choose to send otheremployees to you, both workers’ compen-sation and private patients.How does the system work from an in-

jured worker’s standpoint? The injuredemployee is treated appropriately for hisor her injury and is kept working, albeitwith certain specific restrictions. He or sheis paid for all medical care and does nothave to worry about high deductibles, co-pays, and high hospital bills. In more than95 percent of cases, the injured worker isable to return to his or her livelihood ofgainful employment. If the injured workeris one of the unfortunate employees whomust be off work for a period of time, heor she is reimbursed to some extent fortime off work. If he or she cannot returnto his or her usual and customary duties,employers are given incentives to create apermanent modified duty position for theemployee. If the injured worker is deter-mined unable to return to full duty or amodified duty position, he or she usuallyreceives a lump sum payment, sometimespayment for vocational rehabilitationcosts, and continued payment of his med-ical costs.No, it is not a perfect system, but with

the cooperation of the main players, thedoctors, therapists, insurance companies,nurse case managers, employers, and thepatients, a fair shake is possible for all in-volved.

ABOUT THE AUTHOR: Dr. Pohl re-ceived his medical degree from the Universityof Buffalo and his masters degree in publichealth from the Medical College of Wisconsin.He is board certified in both family and occu-pational medicine.

No, it is not a perfectsystem, but with thecooperation of themain players, a fairshake is possiblefor all involved.


Public Health

s every kid I see today going tobe obese?” a frustrated col-league asks me. “I feel like that’s

all I’m seeing in the office!” Whatever yourspecialty and wherever your practice,whether you see children or their grand-parents, chances are you’re seeing your pa-tients get heavier. In Chula Vista, as inother communities, underserved patientspresent to their doctors not only with highrates of obesity, but also shouldering thehighest burden of preventable diseases suchas diabetes and hypertension.We know that exercise is an important

part of the solution, and our patients knowit too. But for our patients who live andwork below the poverty line, getting out towalk for exercise in their neighborhoodsmay not be easy. Poorly lit streets, no side-walks, and community violence can keepeven the most motivated family indoors.Finding affordable, safe, and structured ex-ercise programs can be a challenge. Howdo we encourage exercise in these high-riskcommunities in a way that brings realityinto the equation?The answer to this question is certainly

not in the office. Part of my colleague’s frus-tration comes from knowing that physi-cians and patients just don’t have enoughtime together. A typical office visit todaytakes 15–20 minutes, and community clin-ics in underserved areas can be even busier.Patients can be frustrated as they try tocommunicate “just one more thing” to theirphysicians, and doctors have the impossibletask of delivering important preventive caremessages in their brief time together.One study at Duke found that it takes an

average of 7.4 hours to deliver preventivemessages to an average patient panel andan additional 10.6 hours for patients withchronic disease. After seeing more andmore underserved patients in my practicewho desperately needed to exercise, I beganto wonder: Even if I deliver a message that

sticks with patients, how do I identify andminimize those barriers to exercise thatmay be specific to my lower SES patients?In Chula Vista, I’ve begun to answer this

question by finding a perfect partner forpublic health: the Chula Vista Parks andRecreation Department. The Chula VistaPhysicians Winning with Recreation (CVPoWeR!) program is the result of a part-nership between the department and areaphysicians that is designed to provide reli-able, safe, and structured physical programsto children, adults, and seniors through apoint of care “recreation prescription” thatallows them to exercise for free. Whetherit’s swimming or after-school programs forthe kids, a walking club for adults, or chairyoga and tai chi for seniors, there is some-thing for everyone.When I presented the idea to Parks and

Recreation Director Buck Martin and As-sistant Director Ed Hall, there was no hes-itation. We sat down and looked over therecreation brochure and put together sev-eral age-group-specific activities thatcould be represented on the “recreationprescription.” While there was some ini-tial concern about costs to the city havingan increased number of nonpaying par-ticipants, it soon became apparent that wecould create this program without raisingthe city’s overhead. For instance, who isusing the other half of the pool when thehigh school water polo team is practicingin the deep end? The city is paying to heatthe pool and provide a lifeguard, so whynot offer self-directed water aerobics inthe shallow end for free to Dr. Smith’sgroup of patients with osteoarthritis whocan’t bear weight without pain?As we went through the recreation

brochure, we all began to realize that bymatching a knowledge of recreation pro-gramming with the insight of a physicianpartner who can talk about the healthneeds of the community in a meaningful

way, something special can happen. TheCV PoWeR! program has opened accesspoints for the underserved in new and ex-citing ways, and, though additional study isneeded, we hope that community mem-bers at the highest risk for preventable dis-ease are getting healthier.Our success in Chula Vista encouraged

me to start www.RecreationRx.org to helppromote partnerships between physiciansand recreation organizations working inareas of unmet need throughout California.The website is designed to be informative,but also to be used as a tool to help newprograms manage themselves. The site hasa “Program Forum” that can serve as the ad-ministrative home to new programs. “Pro-gram Champions” can receive orders fornew prescription pads, get and receive feed-back, place important files (orientationguides for participating doctors, etc.), andmoderate a discussion board specific to theirprogram. By housing this resource for newprograms, my hope is to facilitate new pro-gram development and to make it easy forprograms to share their experiences.In the summer of 2008, the County of

San Diego will pilot a recreation prescrip-tion program modeled after CV PoWeR!that will be the first regional program of itskind. As city, county, and state budgetsshrink, the need to address health dispari-ties among the underserved is increasing.By finding community partners with sim-ilar goals, physicians can maximize their ef-forts in the office and help patients tacklethe barriers they face as they strive to livelonger and healthier lives.

ABOUT THE AUTHOR: Dr. Searles is afamily physician and a psychiatrist who works pri-marily with the underserved and uninsured of SanDiego County. He is on the clinical faculty atUCSD’s Department of Family and Preventive Med-icine and is the co-director of the UCSD CombinedFamily Medicine and Psychiatry Residency Program.

“I

Taking It Out of the OfficeRecreation Prescriptions for the

Underserved in Chula VistaBy Chris Searles, MD


With more than two million articles published each year

and the emergence of thousands of health-related websites,

we are in the midst of an unprecedented information explosion,

which can make it very challenging for the patient

to find reliable information.


NNTTRROODDUUCCTTIIOONN:: TTHHEE RRIISSEE OOFF TTHHEE SSMMAARRTT PPAATTIIEENNTT

How often does this happen in your practice: You enter theroom to meet your patient, who presents you with a stack of

literature she has downloaded off the Internet, self-diagnosing herperceived medical condition. You walk into the next room and apatient states that he wants a prescription for a new drug after read-ing information contained on that drug’s website, which he sawadvertised on TV.Like it or not, patients are searching the Internet to find health-

care information. At latest count, more than 113 million individ-uals in the United States have searched for healthcare informationonline. They are finding answers to almost any health concern, cre-ating personal health records, finding doctors, hospitals, and clin-ical trials, and managing insurance-related concerns. We arewitnessing the rise of the smart patient, driven by the availabilityof 24/7 health information, reduced time for office visits, risingpremiums, and the emergence of high-deductible health plans, allof which press patients to find their own answers to maintain bothphysical and financial health.With more than two million articles published in the literature

each year and the emergence of thousands of health-related web-sites, we are also in the midst of an unprecedented information ex-plosion, which can make it very challenging for the patient to findreliable information. And while being more informed is good, ifthe information is neither relevant nor reliable, then it’s distracting,time consuming, and potentially frustrating to both the physicianand the patient. So the issue is, how can we, as physicians, helpguide our patients at the crossroads of information overload andeconomic concerns to find more reliable information online?For more than 10 years, physicians have been using evidence-based

medicine (EBM) to sort through the overwhelming amount of in-formation. However, due to time constraints, this is often challeng-ing to do in daily practice. On the other hand, many patients have

the time, interest, and willingness to perform research online, butthey don’t have a systematic way of doing this. This article presentsan EBM-aligned strategy to empower physicians to take an activerole in enabling these patients to make wise use of online resourcesto support their quest to become smarter and healthier patients.

HHAARRNNEESSSSIINNGG EEBBMM TTOO SSUUPPPPOORRTT TTHHEE RRIISSEE OOFF TTHHEE SSMMAARRTT PPAATTIIEENNTT

Most clinicians do not have the time to educate patients on the in-tricacies of EBM. But, if we can identify and invest our patientswith the most basic principles of EBM, and offer appropriate evi-denced-based resources, it will likely result in their bringing higherquality information to the visit, open new lines of communication,and strengthen a shared decision-making bond that may even savetime in the patient encounter.The Evidence-Based Medicine Resource Center at

SuperSmartHealth.com provides a free resource that teachespatients the basics of EBM and also provides links to many ofthe resources mentioned below.EBM teaches patients to think about their health decision-mak-

ing as a four-step process that supports them to:1) Frame their questions properly;2) Find the best evidence to answer their questions;3) Evaluate what they find to ensure it’s relevant and reliable; and4) Apply the evidence to the particulars around their care.

SSTTEEPP 11:: FFRRAAMMIINNGG TTHHEE QQUUEESSTTIIOONN

The problem with much of the information patients bring toproviders is that it does not answer the right question to begin with.For example, let’s return to the patient with Internet research sup-porting his request for the drug he saw advertised on TV. While thepatient might initially believe he is the perfect candidate for themedication, reframing the question using the EBM PICO model(Patient, Intervention, Comparison intervention, Outcome) helps

By Daniel Friedland, MD

I

The Rise of the Smart PatientAt the Crossroads of Evidence-based Medicine and Consumer-directed Healthcare

evidence-basedmedicine

to clarify crucial gaps in the information required to make a fullyinformed decision.Introducing and using the PICO format with such a patient in-

vites a discussion about whether the patient population (P) in thestudy is indeed similar to the patient; the intervention (I) is avail-able on his health plan; the benefit of this particular therapy wasfound not only more effective than placebo, but also more effec-tive when compared (C) against the current best available regi-men; and that the outcomes (O) of benefit demonstrated in theresearch are truly meaningful to the patient’s quality and lengthof life, rather then simply a change in some laboratory test value.This format saves everyone time by streamlining the discussion

and increasing the likelihood patients will find the right answersto the right questions when they proceed to search for informationon the Internet.

STEP 2: FINDING THE EVIDENCE

When it comes to guiding our patients to help them find better in-formation on the Internet, it’s important to recognize where theyare searching and to direct them to high-quality resources that maybe underappreciated.According to the Pew Online Health Search Survey (2006), 66

percent of individuals begin their health inquiry at a search en-gine such as Google. This returns an overwhelming amount of in-formation, although Google now enables one to refine the searchby categories such as treatment, test/diagnosis, symptoms,causes/risk factors, and alternative medicine.Another 27 percent start at a health-related website. The top

trafficked websites according to Compete.com are listed in Table1 below. The quality of these health-related websites has improveddramatically over the years. It is worth surfing these top 10 sites toexplore some of the information they provide.

Table 1. Top Trafficked Websites

Of the top commercial websites, WebMD.com and Revolu-tionHealth.com include comprehensive coverage of health condi-tions, drugs, assessment of symptoms, screening, risk assessmenttools, discussion boards with physicians and fellow patients, per-sonal health records, and directories for healthcare providers andhospitals.The top nonprofit health site, NIH.gov, the medical research

agency for the United States, acts as a clearinghouse for the 27 in-stitutes and centers that make up the NIH. It provides access forconsumers to high-quality information on a comprehensive A-Zlist of health topics, as well as newsletters, and a helpful list of toll-free hotlines to health organizations across the country.Beyond the websites ranked most popular are other quality re-

sources too numerous to mention in the space of this article.However, you can find links to many of them through The Con-sumer and Patient Health Information Section (CAPHIS) ofthe Medical Library Association’s “Top 100 List” of “HealthWebsites You Can Trust” at http://caphis.mlanet.org/consumer/generalhealth.html.One resource worth mentioning is the first referenced on the

CAPHIS list: MedlinePlus.gov from the National Library of Med-icine. Drawing approximately 200,000 visitors per month (ac-cording to Compete.com in January 2008), it is relativelyunderappreciated when compared with the most trafficked websiteslisted in Table 1. MedlinePlus is one of the best patient education re-sources you will find, with extensive information on 750 health-re-lated topics, the latest health news, a comprehensive resource ondrugs and complementary alternative medicine supplements, an il-lustrated medical encyclopedia, interactive patient tutorials, a med-ical dictionary, and physician and hospital directories. One of its mostuseful resources is an extensive list of organizations by health topic(www.nlm.nih.gov/medlineplus/organizations/orgbytopic_a.html),which have been pre-screened for quality, authority, and accuracyof health content, thus enabling the patient to efficiently iden-tify the top few websites related to his or her particular healthcondition.A few other resources referenced by CAPHIS also bear mention:

Healthfinder.gov developed by the Department of Health andHuman Services, MayoClinic.com (one of the top 10 most pop-ular sites listed in Table 1 and contributes information to Revolu-tion Health), the ClevelandClinic.org/health (which contributesinformation to WebMD), and FamilyDoctor.org, produced by theAmerican Academy of Family Physicians.The strong point of many of these resources is that they cater

to the health literacy of the average Internet user. For select pa-tients with high health literacy (or for their designated “EBMchampions” who search on their behalf ), the following three-step drill down strategy may also be offered as an efficient andrigorous way to find high-quality, evidence-based information.First, these patients may begin searching the same online med-

ical textbooks healthcare providers search, such as those at Emed-icine.com and UpToDate.com. Many chapters of both resources



RANK WEBSITE VISITORS/MONTH in Millions*

1 WebMD.com 15.1

2 NIH.gov 8.2

3 RevolutionHealth.com 6.1

4 RightHealth.com 5.6

5 everydayHealth.com 5.0

6 MayoClinic.com 5.0

7 MedicineNet.com 4.2

8 RealAge.com 3.0

9 Drugs.com 2.8

10 Healthline.com 2.4

*January 2008


According to the Pew survey,

almost three-quarters of health

seekers do not consistently

check the sources and date

of the health information

they find online.


provide links to free consumer information. The health professionalinformation of UpToDate requires a subscription, but motivatedpatients may pay $20 per week or $45 per month for full access.Next, patients can drill down further looking for high-quality,

evidence-based information on focused clinical questions in theform of systematic reviews or practice guidelines. The CochraneCollaboration (www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOME) publishes some of the highest quality reviewsaround and provides free abstracts with easy-to-read plain languagesummaries for patients. The National Guidelines Clearinghouse(NGC) (www.guidelines.gov) is the single best resource to findpractice guidelines from hundreds of institutions and affiliated or-ganizations. Links are provided to the major recommendations and,where available, to the full text of each guideline and handouts forpatients.Finally, patients who want to drill down even further to search for

the latest studies on their specific questions of interest can searchthe U.S. National Library of Medicine’s MEDLINE database atPubmed.gov. PubMed currently searches more than 17 millionrecords from more than 4,800 journals. A helpful tutorial is avail-able to guide individuals in using its powerful search tools, includ-ing the “Clinical Queries” link that has filters for searching onquestions of therapy, diagnosis, etiology, and prognosis. Abstractscan be downloaded for most articles and some have links to freefull-text articles. For those that don’t, one can try retrieving the fulltext article through freemedicaljournals.com, which provides freeaccess to more than 430 journals.

STEP 3: EVALUATING THE EVIDENCE

According to the Pew survey, almost three-quarters of health seek-ers do not consistently check the sources and date of the health in-formation they find online. In partnering with patients to improvehealthcare, it’s essential to highlight the importance of evaluatingthe reliability of online information.There are two key steps to evaluating information online: First,

evaluate the reliability of the website searched, and second, evalu-ate the quality of the research that the website ideally references.MedlinePlus has a great section on “Evaluating Health Infor-

mation Online” at www.nlm.nih.gov/medlineplus/evaluat-inghealthinformation.html. It leads off with a flash tutorial atwww.nlm.nih.gov/medlineplus/webeval/webeval.html, which goesthrough four key considerations, including who authored andfunded the site, how to determine quality, and issues of privacy.The big issue for patients evaluating the quality of research ref-

erenced on websites involves them recognizing a hierarchy of evi-dence: how randomized controlled trials (and systematic reviewsthey contribute to) provide more reliable information than obser-vational studies, which provides superior information to anecdotalevidence. Healthcare providers and patients can find more infor-mation on this and on how to tell whether evidence is relevant,believable, and meaningful at the EBM Resource Center at Super-SmartHealth.com.

STEP 4: APPLYING THE EVIDENCE

Once patients identify more reliable information, they will be more

The problem with much of the information patients bring to

providers is that it does not answer the right question to begin with.



prepared to engage in the final step: discussing how the evidenceapplies to them and sharing in the decision-making process.This step involves a consideration of the best options, extrapolat-

ing from the evidence the likelihood of the key outcomes for each op-tion, and weighing the patients’ preferences for those outcomes.In deciding whether one approach is a step better than another,

physicians can outline several factors the patient may consider byusing the pneumonic STEPC (Safety, Tolerability, Efficacy, Price,and Convenience). This pneumonic may help the patient remem-ber the key outcomes to be weighed and frame subsequent discus-sions with healthcare providers.In addition, great resources are available to help prepare patients in

advance for decision-making discussions with their providers. TheFoundation for Informed Medical Decision Making (in-formedmedicaldecisions.org) and its partner Health Dialog (health-dialog.com) work with health plans and employers to provide shareddecision programs that help patients clarify their options and therisks, benefits, and preferences associated with each. The OttawaHealth Research Institute (http://decisionaid.ohri.ca/index.html)provides one of the best free resources for patient decision aids. Inaddition to providing generic forms to help patients structure theirdecisions, they provide an extensive A-Z list of disease-specific de-cision aids, all of which have been graded according to the Inter-national Patient Decision Aid Standards to ensure they incorporatevalid information.As patients become more informed about their options and em-

powered to make decisions, we also need to be mindful of the con-

text in which decisions are made. Optimal health is more thantreating disease. Any decision may also be influenced by patients’socioeconomic circumstances, cultural context, spiritual values, andtheir personal vision and goals for optimal health and well-being.

CONCLUSION

By working with our patients, we can play an active role in sup-porting the rise of the smart patient. In teaching patients EBM-aligned strategies, which enable them to frame questions properly,find evidence in more reliable databases, and become more criticalin the way they evaluate information, patients will bring more re-liable evidence to their office visits. If they also have the ability torecognize the factors that contribute to the decision-makingprocess, they will come to the visit prepared to discuss their variousoptions. It’s a vision to the future — a partnership between physi-cian and patient, leveraging the skill set and time of both parties —that may not only save time but result in more fulfilling encountersand smarter, healthier, and more satisfied patients.

ABOUT THE AUTHOR: Dr. Friedland is the author of Evidence-basedMedicine: A Framework for Clinical Practice and founder of SuperSmartHealth.com,which incorporates the principles of EBM into a vision of optimal health andwell-being. For the past 10 years, Dr. Friedland has trained thousands of physi-cians and allied health-related professionals in EBM across the United States.Dr. Friedland now also provides EBM programs for patients to facilitate theirpartnership with healthcare providers to better health.


When clinical reference content is accurately and consistently derived from the

best available research using transparent methodology, then the “evidence-based”

approach allows clinicians to make informed decisions that enable them

to provide the best care to their patients at the point of care.


he term “evidence-based” is as misused and misidentifiedas politicians’ quotes. It has been used to denote system-atic evaluation of research, but has also been used to con-

fuse and “sell” concepts without providing comprehensiveevaluation of the evidence supporting the concepts. When clinicalreference content is accurately and consistently derived from thebest available research using transparent methodology, then the“evidence-based” approach allows clinicians to make informed de-cisions that enable them to provide the best care to their patientsat the point of care.Evidence-based, in any field, means that conclusions are based on

the best available evidence. This doesn’t mean that the evidencewill never change or be altered; to be consistently reliable, evidencemust be continuously and consistently and systematically identi-fied, evaluated, and selected.For evidence-based medicine (EBM) content to correctly, accu-

rately, and reliably be labeled as evidence-based, the following stepsare required:1) Systematically identifying all applicable evidence2) Systematically selecting the best available evidence fromthat identified

3) Systematically evaluating the selected evidence (critical appraisal)

4) Objectively reporting the relevant findings and quality ofthe evidence

5) Synthesizing multiple evidence reports6) Deriving overall conclusions and recommendations fromthe evidence synthesis

7) Changing the conclusions when new evidence alters thebest available evidence

Editors use these seven steps to consider medical literature forinclusion in DynaMed, an online clinical EBM resource for clini-cians at the point of care. But simply stating that seven steps areneeded isn’t enough to be assured that the best available evidenceis being presented. Each step needs definition, clarification, andprocess. Outlining the editors’ process through these steps will helpillustrate what is required behind the scenes for clinicians to prac-tice EBM.

To systematically identify all applicable evidence in Step 1, anextensive set of current literature is monitored daily. Systematic lit-erature surveillance (SLS) is conducted using more than 500 journalsdirectly or indirectly through many journal review services and othersources of systematic evidence evaluation.For each source monitored, each issue is reviewed cover to cover.

All entries are considered because information in letters to the ed-itor, editorials, and “reporting from the literature” pages may con-tain reports of new research that would be otherwise unidentifiedif relying exclusively on abstracts posted with traditional researcharticles.When adding a new topic or critically revising an existing topic,

PubMed Clinical Queries is used to provide systematic searches foridentification of the best available evidence. In addition, numeroussources are searched for evidence-based reviews (such as CochraneDatabase of Systematic Reviews), for guidelines (such as NationalGuideline Clearinghouse), and for traditional reviews.Editors then move to the second step in the process. Each arti-

cle is assessed for clinical relevance and each relevant article is fur-ther assessed for validity relative to existing content. The most validarticles are summarized, the summaries are integrated with con-tent, and overview statements and outline structure are updatedbased on the overall evidence synthesis.Determining clinical relevance is the first consideration in sys-

tematically selecting the best available evidence from that identi-fied. The relevance of medical information is different for everyuser. DynaMed is used in clinical care by practitioners with a widerange of experience and interests, and is also used in medical edu-cation. When adding information, the editors consider severalquestions to determine relevance.

DOES THIS INFORMATION HAVE A DIRECT BEARING ON PATIENT-ORIENTED OUT-COMES? Patient-oriented outcomes are outcomes that affect qualityof life without extrapolation. Examples include mortality, inci-dence of myocardial infarction, and presence and severity of pain.These are also called clinical outcomes. Disease-oriented outcomesare used as surrogate markers for monitoring the effects of inter-ventions ultimately intended to affect patient-oriented outcomes.

T

“Evidence-based”A Term in Search of a DefinitionBy Brian S. Alper, MD, MSPH



Examples include cholesterol concentration, blood pressure, andbone mineral density. Patients are only interested in these out-comes as a means for affecting clinically significant outcomes suchas mortality or fracture incidence. Because DynaMed is primarilya clinical tool for use during patient care, patient-oriented out-comes information is considered relevant and included. Patient-oriented evidence is given priority over disease-oriented evidence,with disease-oriented evidence entered only if it adds substantiallynew information.

IN THE ABSENCE OF PATIENT-ORIENTED EVIDENCE, MIGHT THIS INFORMATION BEUSEFUL IN CLINICAL DECISION-MAKING? Much of medical knowledge isstill lacking in terms of patient-oriented outcomes research. Clini-cal decisions based on extrapolated disease-oriented evidence are notproven to be appropriate. However, clinicians still need to make de-cisions in situations where patient-oriented evidence is not yet avail-able. Disease-oriented evidence is considered relevant for inclusionin situations where patient-oriented evidence is lacking. Individualclinicians will have to determine if this information is considered

relevant within theirpractice. When dis-ease-oriented evi-dence is not presentedas such in the support-ing reference, com-mentary will be addedand may appear as“patient-oriented out-comes not assessed,”“clinical outcomes notassessed,” or specificcommentary pointingout problems with ex-trapolating the infor-mation to clinical care.

IS THIS INFORMATION PART OF A CLINICAL CONTROVERSY? In situationswhere the evidence does not clearly support or refute a clinicalfact, opposing views are presented. DynaMed is not designed toresolve clinical controversies and strives to present informationwith as little “inappropriate” bias as possible. The inherent bias to-wards patient-oriented outcomes is considered appropriate. In-formation that questions “standard” approaches and has apotential bearing on patient-oriented outcomes is considered rel-evant for inclusion.

IS THIS INFORMATION THAT IS OF UNIQUE INTEREST DUE TO POPULARITY? Somemedical information is not clinically relevant but widely publi-cized. Summarization of this type of information (often with com-mentary) is relevant to users if it is likely that clinicians will beasked about it during clinical encounters. It is important for physi-cian and patient education to point out where this type of infor-mation is not clinically applicable.

Clinically relevant articles must be assessed to determine the sci-entific validity of conclusions and facts presented before consid-eration for use. Conducting critical appraisal for all articles wouldbe wasteful if these articles did not make a change to the existingknowledge base.Easily identifiable study features (e.g., study method, sample

size) are compared with existing studies in current content to de-termine if new articles potentially represent the best available ev-idence. Articles that do not provide relevant information withvalidity that meets or exceeds the existing content are excluded atthis stage.In Step 3, editors have found that abstracts in research publica-

tions often do not accurately reflect the methodologic quality andresults found in full-text articles. Article summaries in other pub-lications also often do not accurately reflect the methodologicquality and results found in full-text articles.Full-text evaluation of articles is required for:• Any article rated as Level 1 [likely reliable] evidence or GradeA recommendation [consistent high-quality evidence] (1)

• Any article potentially ratable as Level 1 or Grade A basedon abstract-only information; full-text evaluation is necessary to provide lower levels or grades

• Any article for which definition of absolute magnitude of effect and/or detailed description of interventions or expo-sures are necessary, regardless of level of evidence

• Any article which represents the most important guidancefor a topic, regardless of level of evidence

Reports used for updating content represent the best availableevidence for the specific content under consideration. Evidencemay be labeled in one of three levels: Level 1 (likely reliable) Evi-dence; Level 2 (mid-level) Evidence; Level 3 (lacking direct) Evi-dence (1). Articles that potentially warrant the highest evidenceratings undergo complete critical appraisal using methods estab-lished in the Users’ Guides to Evidence-based Practice from the Evi-dence-Based Medicine Working Group (2). If serious methodologicalshortcomings are discovered (sufficient to affect clinically relevantresults), then the evidence is labeled as mid-level evidence and theshortcomings are described.When reporting the evidence, editors consider all of the follow-

ing as they go through Step 4:• Were all relevant outcomes reported in the original article?• What are the most relevant outcomes to report in the topic?• For relevant outcomes, what is the magnitude of effect? This

may be represented by absolute rates and number needed to treat(NNT) or harm (NNH) abbreviations, or by absolute differencesin continuous variables (e.g., mean decrease in 1.3 points on 0–10visual analog pain scale).• Were the findings clinically significant?• In the case of no statistically significant differences, werethe findings robust enough to rule out clinically significant difference?

• Are there any methodologic limitations sufficient to alter reliability of clinical conclusions?


While it is true that the definition of “evidence-based” can be confusing and is often misused, when the term is

correctly used, and the evidencein an EBM content source is

accurately and consistently derivedfrom the best available evidence,clinicians can use that contentsource to make decisions that enable them to provide the best care to their patients at

the point of care.

In Step 5, evidence-based summarization of articles is neces-sary, but insufficient for a point-of-care reference. Evaluatingindividual evidence reports requires synthesizing multiple evi-dence reports.Addition, deletion, and organization of information within

content is done with consideration of levels of evidence. Whenmultiple articles are present on the same topic, preference forinclusion and organization is based on the quality of method-ology, e.g., preference given to data derived from randomizedcontrolled trials over data from prospective observational stud-ies, which is given preference over retrospective studies, whichis given preference over anecdotal reports. When data of lesserquality does not add any substantially new or different infor-mation, this data is then deleted from content.Moving to Step 6, deriving overall conclusions and recom-

mendations from the evidence synthesis is required for a com-prehensive point-of-care reference. Multiple evidence reportsof similar quality are organized such that the overall conclu-sions quickly provide a synthesis of the best available evidence.In DynaMed, treatment overviews (the ultimate synthesis of

evidence for a clinical topic) are based upon all of the availableevidence in the treatment section, and selection of the most im-portant concepts. As new topics are created and existing topicsare critically revised, treatment overviews are explicitly linkeddirectly to the supporting evidence synthesis.The final step in DynaMed’s evidence-based methodology is

changing conclusions when new evidence alters the best avail-able evidence. This step is crucial because new evidence ispublished every day. Having new evidence summaries han-dled separately from reviewed content in a manner requiringthe clinician to search in two locations to synthesize the en-tire story would make finding the best available evidence moredifficult.As soon as new evidence is evaluated using the six steps gov-

erning systematic processing, it is added to the appropriatetopic(s) in context. This process allows immediate and com-prehensive access to the best available evidence as it occurs.In conclusion, while it is true that the definition of “evidence-

based” can be confusing and is often misused, when the termis correctly used, and the evidence in an EBM content sourceis accurately and consistently derived from the best availableevidence, clinicians can use that content source to make deci-sions that enable them to provide the best care to their patientsat the point-of-care.

ABOUT THE AUTHOR: Dr. Alper is the founder and manager ofDynaMed, a point-of-care reference resource designed to provide doc-tors and medical researchers with the best available evidence to supportclinical decision-making.


RESOURCES:(1) Definitions and sources available at www.ebscohost.com/dynamed/levels.php.(2) Available from the Centre for Health Evidence at www.cche.net/usersguides/main.asp.

Visit DynaMedOnlineDynaMed, a leading point-of-care

clinical reference tool, is available

to all healthcare professionals at

www.ebscohost.com/dynamed. Sub-

scribers to the site are provided with

the most up-to-date, evidence-based

information gathered from more

than 500 medical journals and evi-

dence review databases that will as-

sist them in making the best clinical

decisions when it is needed most.

Updated daily, the data presented on

DynaMed’s website is thoroughly re-

viewed for scientific relevance and

validity, and then integrated with ex-

isting content to produce the best

available evidence on various health-

related topics. Residents, medical

students, practicing physicians, and

medical scholars looking for answers

to complex clinical questions are in-

vited to subscribe to this site.


Safety Net

ince 1977, the Council of Community Clinics (CCC) hasprovided a wide array of support services to community clin-ics and health centers in their efforts to provide quality care to

diverse communities, particularly those with low income and unin-sured populations. In 1980, CCC member health centers served a totalof 103,800 patients, which accounted for 200,000 patient visits. In2006, CCC member health centers served a total of 500,000 patientsin 1,400,000 patient visits representing a 280 percent growth. In 2006,more than half (61 percent) of these patients were Hispanic, 17 per-cent white, 4 percent black, 5 percent Asian, and 1 percent AmericanIndian. Ninety-five percent of the CCC’s clinic population is below200 percent federal poverty level.Through local, state, and national advocacy efforts, the CCC works

to continually keep important issues facing community health centersin front of public and private decision makers. This is extremely im-portant, as more than 600,000 people in San Diego County alonehave no health insurance, and it appears that state healthcare reformproposals, which were a large focus of 2007, will not happen in 2008.Our commitment to the community is unwavering. In the last year

alone, the CCC has secured funding for health centers to expand men-tal health services to the uninsured and manage specialty treatmentpools for breast cancer, HIV/AIDS services, asthma, and dental care.The CCC used its experience in emergency preparedness to supportcommunity health centers during the October 2007 firestorm by mo-bilizing and coordinating the delivery of supplies and equipment. TheCommunity Clinics Health Network (CCHN), a subsidiary of theCCC, supported quality-improvement initiatives, and health centersexceeded national benchmarks in diabetes care. The CCHN providedinformation technology services to health centers, including leading acollaborative process to evaluate electronic health record software, andworking with health centers to select and implement pharmacy man-agement software. Council Connections (CC), a subsidiary of theCCC, is the largest clinic-based national group purchasing organiza-tion in the United States and has expanded to 30 states and 500healthcare organizations with more than 2,500 member sites. It helda successful and well-received annual conference with attendees fromthroughout the nation.The CCC has accomplished a great deal during the past year alone.

We worked in partnership with community health centers statewidethrough the California Primary Care Association, which uses a col-laborative process to identify priorities and move them forward in thelegislative process. Every April, the CCC, along with health centerleadership and physicians, visit the San Diego and Imperial countiescontingent of state legislators to educate them about health center is-sues. In addition, the CCC works with the National Association ofCommunity Health Centers and visits Washington annually in Marchfor the Policy and Issues Forum. Visits to local members of Congress

take place at the same time to educate them on the importance of fed-eral health center funding and other issues.We also work closely with the County of San Diego to assure health

services to our community. Key among these services is a contract forthe Mental Health and Primary Care Services Integration Project thatenables our member clinics to receive reimbursement to care for unin-sured individuals with serious mental illness. In 2007, the project’sfirst year, a total of 638 patients were served. Almost 70 percent ofthese patients had not received county-funded mental health servicespreviously, demonstrating the need for programs to be delivered in thecommunity health center setting and meeting the MHSA mandatethat counties identify underserved and unserved individuals.In addition, the CCC managed contracts with close to 100 special-

ists (e.g., pathologists, periodontists, radiologists, surgical facilities)throughout San Diego County to provide treatment services. TheCCC staff determined patient eligibility and authorized treatment pro-cedures for 2,225 patients in 2007. The CCC managed specialty treat-ment pools covering the following types of services:• Breast cancer screening and diagnostic services• Medical, dental, and home health/home hospice services for patientswith HIV/AIDS

• Asthma treatment for children and youth ages 0–17• Dental Services for children ages five and underOne of our key responsibilities to the San Diego community is to

serve as the safety net for essential health services. Our training and ex-perience in emergency preparedness in support of community healthcenters positioned us as a major health resource during the Octoberfirestorm. The CCC Emergency Preparedness Coordinator, togetherwith other CCC employees, staffed the Clinic Liaison position at theSan Diego County Medical Operations Center during the first 108hours of the wildfires. The clinic liaison served as the hub for cliniccommunication and fielded multiple medical resource requests fromthe clinics. In coordination with the San Diego County Office ofEmergency Services and international relief organizations, critical med-ications, N-95 particulate masks, respiratory inhalers, and evacuationshelter supplies were mobilized to the clinics to serve their patientsand community members. CCC also polled clinic sites daily to iden-tify their operational status and shared this information with severalmedia outlets to help inform patients in need of care.At the end of the day, we remain dedicated to our mission and vi-

sion: to represent and support community clinics and health centersin their efforts to provide access to quality healthcare and related serv-ices for the diverse communities they serve with an emphasis on lowincome and uninsured populations; and serve as the common voicefor these entities by building and strengthening relationships withstrategic public and private partners resulting in sustainable resourcesand healthier communities.

S

The Council of Community Clinics

Stephen R. O’Kane, CEO, Council of Community Clinics


oday’s Family Health Centers of San Diego (FHCSD)evolved from a single, small clinic, the Chicano CommunityHealth Center, established in 1970 and tucked under the

Coronado Bridge in Barrio Logan, to 25 sites where more than 700employees and approximately 100 providers are engaged in the missionof community medicine. In the absence of a national healthcare plan,FHCSD made a commitment more than two decades ago to create acomprehensive healthcare organization where patients could obtainlow- or no-cost medical care, physicians could practice medicine with-out administrative burden, and national quality goals would drive theoperations of its clinics. The early successes prompted the board of di-rectors to expand the mission and scope of FHCSD into all San Diegocommunities that lack affordable, accessible, quality medical care.The physicians who currently work in the Family Health Centers of

San Diego system appreciate the opportunity to practice medicinewithout the responsibilities of practice overhead: workers’ compensa-tion premiums, personnel management, rent payments, billing, andclaims management, to name a few.The FHCSD system also ensures the physicians have the supportive

services needed to promote optimal patient care. For example, a team ofhealth educators are scheduled at each clinical site; case management isprovided in all clinical departments; needed equipment is procuredthrough a team of grant developers; appointments and reminder calls arecapably handled by a centralized call center; and licensed nurses in everyclinical department provide nursing services and education support.Years ago, FHCSD developed its own software — a sophisticated

patient tracking system capable of features such as on-demand re-porting and electronic prompts to remind physicians the date andvalue of their patient’s last lab test. Monthly medical staff forums offerthe opportunity to connect with other physicians who serve at the var-ious FHCSD locations.Quality is the act of continually striving to be the best, and at Fam-

ily Heath Centers of San Diego, the physicians have a voice in the de-velopment of new programs and services. For example, ahigh-complexity lab was established in 2006 to provide faster lab re-sults to physicians, and program grants are written to establish neededservices such as a free immunization program, no-cost cancer screen-ing programs, and sliding-scale medical care. Family Health Centers ofSan Diego is not mandated to have national accreditation, yet FHCSDhas been accredited by The Joint Commission for more than a decade.This is another testament to the quality goals of FHCSD.FHCSD offers the capability for many in-house referral services for

physicians. These include podiatry, speech therapy, health education,nutrition, dental, mental health counseling, and many more. Programsare conceptualized and developed based on input from the FHCSDphysician partners. These physicians represent such disciplines as in-ternists, pediatricians, ob-gyns, family practice physicians, and a host

of specialists, including endocrinology, neurology, ENT, cardiology,and orthopedics.FHCSD is proud of the growth and expansion into needy communi-

ties throughout San Diego County. Each year, FHCSD has experi-enced a significant increase in patient volume. Now the secondlargest-volume community health center in the nation, FHCSD pro-vides more than 450,000 healthcare encounters each year.In addition to freestanding clinics, for more than a decade the organ-

ization has provided needed medical care to homeless shelters, battered-women’s shelters, elementary schools in disadvantaged neighborhoods,and other community settings utilizing three 40-foot mobile medicalunits. The KidCare Express program, as the mobile medical unit proj-ect is known, provides more than 25,000 visits each year.Through years of focused grant writing, the following programs were

created to enhance the services of FHCSD: pediatric speech, occupa-tional, and physical therapies; the most comprehensive HIV servicesin San Diego; a Health and Developmental Services Program forscreening young children; vision care clinic; specific programs forasthma prevention, teen pregnancy prevention, lead screening, and di-abetes management; dedicated walk-in clinics and a dedicated teenhealth center, to name a few. These programs enhance the delivery ofmedical care services throughout the network of FHCSD clinics.Physician practice at Family Health Centers of San Diego has

changed from its early beginnings almost 40 years ago. Volunteers rep-resent the past. Today, all physicians are on-staff at the health center.Wages are competitive and benefits are excellent — certainly a far cryfrom the days when physicians finished a busy day at their privatepractice or at the hospital and then ran down to the Barrio to volun-teer until late in the evening. Today’s physician makes a career com-mitment to community medicine. In addition to the competitivesalary and benefits package, the physicians at FHCSD derive satisfac-tion from knowing that the healing arts are never enjoyed more thanwhen they are provided to those with the highest need.FHCSD chief medical officer Mark Bulgarelli, MD, states, “As an

FHCSD physician, I am honored to be of service and to be a part of therich history of this community. Each day we deal with patients with fewresources and we face those challenges together. We at FHCSD havefound innovative ways to provide high-level services. I am part of a teamof caregivers that is touching lives in a positive way every day.”Where else in San Diego can physicians practice medicine their way,

not worry about the overhead of a group and know deep in their heartsthat they are helping those who need care and help the most? The an-swer is in a community health center.Family Health Centers of San Diego invites physicians to take a tour

and see firsthand the wonderful world of community medicine. Callus at (619) 515-2301. We would enjoy showing you healthcare — ourway!

TFran Butler-Cohen, CEO, Family Health Centers of San Diego

Family Health Centers of San Diego

Safety Net


Public Health

new system of stroke care for patients with acute strokesymptoms is on the verge of starting in San Diego. Thissystem will help assure patients with acute stroke receive

rapid, appropriate care. Physicians are an integral part of this neweffort, and this article outlines changes you may see in hospitals,and enlists your support for the system.In 2005, The Board of Supervisors directed the Health and

Human Services Agency (HHSA) to look at ways to improve strokecare in the county. As a result, a Stroke Task Force was formed to ad-dress this issue. The Task Force divided the approach to the solutioninto an educational component and an examination of care com-ponent.The education component developed a media program to educate

the public about stroke symptoms and encourage individuals withstroke symptoms to seek care rapidly. This has been used in a num-ber of low cost media and is available.The next phase and the second component identified by the task

force to improve stroke outcomes in the county will focus on acutestroke care. This will seek to assure the identification of acute strokepatients in the field by paramedics, and transporting patients tohospitals with procedures in place to rapidly assess and treat acutestroke. The guidelines are modeled on the criteria for hospital cer-tification as a Primary Stroke Center by the Joint Commission.HHSA’s Emergency Medical Services developed the criteria in con-cert with the Stroke Task Force. The criteria will be implemented inthe summer of 2008.Patients with symptoms of an acute stroke starting in the previ-

ous three hours will be transported to hospitals that either are cer-tified as Primary Stroke Centers, or are surveyed by the EmergencyMedical Services and found to meet similar criteria in the countypolicy.Hospitals are required to have staff to coordinate stroke care activi-

ties, with appropriate input from neurologists and other members ofthe medical staff. A team will respond to acute stroke patients, usingprotocols to deliver rapid, evidence-based care. The facility will obtainCT head scans rapidly, to facilitate use of thrombolytic therapy usingTissue plasminogen activator (tPA), if indicated.Just as important, care pathways will encourage use of important

measures, such as swallowing tests before oral intake, cardiacrhythm monitoring, blood pressure monitoring and treatment, andothers. Similar protocols already exist in many or most of local hos-pital facilities.An important component will be performance measures for stroke

care, accompanied by a quality improvement system to improve use of

important care measures. A patient registry will facilitate this. Earlymeasures will mirror those recommended by the American StrokeAssociation. These include deep vein thrombosis prophylaxis foradmitted patients, patients discharged on antithrombotics, thosewith atrial fibrillation receiving anticoagulation therapy, and throm-bolytic therapy considered for administration when the patient ar-rived. Other standardized measures considered important areantithrombotic medication within 48 hours of hospitalization, a lipidprofile obtained during hospitalization and discharge on cholesterolreducing medication, the screen for dysphagia, stroke education,smoking cessation, and consideration of a plan for rehabilitation. Localproviders should check with their respective hospital to understandthe measures in effect.The program’s goal is to help assure that patients with acute stroke

receive rapid, coordinated, and currently accepted care to lowermortality and reduce disability from stroke. Physicians will play thekey role in achieving these goals. Medical staff members are en-couraged to check with their facilities about implementation plansfor this stroke care initiative.Hospital surveys will be disseminated in early summer, with sys-

tem implementation beginning sometime during the summer of2008. Please contact Bruce Haynes, MD, medical director of theHHSA Emergency Medical Services, at (619) 285-6429 if you havequestions or comments.

New Stroke CareSystem

By Bruce E. Haynes, MD

Coming Soon…

A

ABOUT THE AUTHOR: Dr. Haynes, an emergency medicine physician, isthe medical director for the Emergency Medical Services Branch in the Division ofPublic Health Services of the County of San Diego Health and Human ServicesAgency, a position he has held since February 2006.


RESOURCES:1) Community Health Statistics Unit online Com-munity Profiles: Death Statistical Master Files (CADHS), County of San Diego, Health & Human Serv-ices Agency, Community Epidemiology; SANDAG,Current Population Estimates, 9/27/2006.

STEMI Receiving System UpdateYou may be interested in an update on the STEMI receiving system that began in January

2007. In this effort, paramedics obtain a 12-lead EKG in the field on patients who appear tobe experiencing a myocardial infarction. If the EKG shows an acute myocardial infarction, des-ignated on the EKG as ***Acute MI*** or similar interpretation, the patient is transported toa hospital identified as a “STEMI Receiving Center,” a facility that offers emergent cardiaccatheterization and angioplasty/stent placement.In the first year, 330 STEMI patients had a “field activation,” or notification and response

of the cardiologist and catheterization laboratory personnel before the patient arrived in the hos-pital, and underwent an angioplasty or stent placement. The median door-to-balloon time inthese patients was 62 minutes. This is well below the door to balloon times reported before theSTEMI system. The rapid door to balloon time should translate into lower mortality and im-proved outcomes among STEMI patients. The County of San Diego would like to thank allof the physicians who have been so dedicated to providing these low door-to-balloon times.

San Diego County Health Statistics• In 2004, there were 1,423 deaths due to stroke in San Diego County, with almost 90percent among residents ages 65 and older. Of the total deaths, 1,087 were whiteand 863 were female. (1)

• In 2004, among San Diego County residents, the rate of stroke death was 53 percenthigher for females than for males (57.1, 37.3 per 100,000), while the 2005 rates forstroke hospitalizations was only 15 percent higher for females than for males (224.6,196.1 per 100,000). (1)

To request additional health statistics describing health behaviors, diseases, and in-juries for specific populations, health trends, and comparisons to national targets,please call the county’s Community Health Statistics Unit at (619) 285-6479. To accessthe latest data and data links, including the Regional Community Profiles document,go to www.sdhealthstatistics.com.

San Diego County Medical SocietyTake Advantage of These SDCMS-CMA Benefits!

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CONTACT SDCMS TODAY(858) 565-8888 • [email protected]


TO SUBMIT A CLASSIFIED AD, email Ketty La Cruz at SDCMS at [email protected]. SDCMS members place classified ads free of charge (excepting serv-ices-offered ads); all others pay $100 for the first 75 words and $0.50 per word thereafter. Ads will also appear on SDCMS’ website at www.SDCMS.org.

Classifieds�DONATED ITEMS

MEDICAL JOURNALS: Retired neurologist has severalneurological medical journals that range from 1960to present. Some are bound. Please contact Dr.Levine at (619) 588-4929 if interested. [562]

FREE CPAP MACHINE: This is an opportunity to obtain a used CPAP machine in excellent condition for adeserving patient or institution. Call Irv Sherman at (858) 487-6370. [548]

�OFFICE SPACE

ACROSS FROM SHARP AND CHILDREN’S HOSPITAL: Beauti-fully furnished 2,000ft2 office, fully equipped, fiveexam rooms. Share with part-time physician. Pleasecall (619) 823-8111 or (858) 279-8111. [385]

SUBLEASE NEW MEDICAL OFFICE IN SAN MARCOS: Pre-mium, class-A medical office space in San DiegoCounty’s fastest growing city! All or part of an ap-proximately 1,950ft2 newly constructed suite in SanMarcos’ city hall building. Spacious reception area,large procedure room with hardwood floors, fourexam rooms, two restrooms, doctor’s office with largewindow, and reserved parking. Easy access to I-78.Ample patient parking. Contact Kristina at (760)942-9028 or by email at [email protected] more information. [520]

SUBLEASE OPPORTUNITY IN HIGH-END MEDICAL SPA INCARMEL VALLEY: A portion of an upscale, 4,000ft2medical spa available for sublease. Ideal for an oph-thalmologist, plastic surgeon, ENT, and cosmeticdentist. Sublease includes a spacious reception andwaiting area, six exam/procedure rooms, surgerysuite, two dental chairs, three doctor offices, andconsultation room. Easy access to I-5, 805, 56, and I-15. Located inside a medical and dental officebuilding within a retail center. Contact Janice at(858) 481-7701 or [email protected] formore information. [561]

MEDICAL OFFICE AVAILABLE TO SHARE: Beautifully re-modeled, state-of-the-art office in Chula Vista con-veniently located across from Sharp MemorialHospital campus. Terrific opportunity to share of-fice with a respected dermatology/cosmetic sur-geon who has been well established for over 20years in the community. Lots of potential for a newphysician beginning his or her own practice, or awell-established specialist. Included are severalexam rooms with a procedure room, spacious re-ception area, office staff, and a computerized, pa-perless medical records system. Office openMonday thru Friday. Contact Michele, office man-ager, at (619) 421-9332. [560]

MEDICAL OFFICE SPACE (SCRIPPS ENCINITAS CAMPUS):OB/GYN-type consultation room and one to two

exam rooms with staff, receptionist, etc. Equipmentis available at extra cost. Surgical center next door.Free parking. Perfect for low-volume hospital cam-pus consultations one to five half-days per week.Email [email protected] or call (760)753-8413. [557]

3998 VISTA WAY, SUITE 100 IN OCEANSIDE: Two medicaloffice spaces (approximately 2,312ft2 and 3,999ft2contiguous) available for lease. Close proximity toTri-City Hospital with pedestrian walkway con-nected to parking lot, and ground floor access.Lease price: $2.75/ft2+NNN. Tenant improvementallowance. For further information, please contactLucia Shamshoian at (760) 931-1134 [email protected]. [556]

OFFICE SPACE AVAILABLE: Office space at the corner of 8th Avenue and Washington Street in Hillcrest.Surgical center in building. Ample parking and simple freeway access. Close proximity to ScrippsMercy Hospital. Call (619) 297-6100 or [email protected]. [555]

OFFICE TO SHARE: Office available in desirable buildingon Scripps Encinitas lot. Share elegant office thathas just undergone complete interior design reno-vation. Includes doctor’s desk, your own examroom, front desk, common waiting area, staff bath-room (including shower), and kitchen. Contact us atSan Diego Vein Institute at (760) 944-9263. [546]

COSMETIC OFFICE AVAILABLE TO SHARE: East County loca-tion with accredited operating room. Ideal for facialor general plastic surgeon to use as satellite office.Central location with ample parking. For more infor-mation, please contact (619) 701-4786. [542]

OFFICE BUILDING FOR SALE: Kearny Mesa medicalsuites for sale or lease. Address: 8910-12 Claire-mont Mesa Blvd. (off Highway 163). Ground and/orsecond floor: 12,312ft2. X-ray and physical therapyon ground floor. Price: $4,300,000 or $1.80 NNN.6.5/1,000 parking. Call Shauna at CB Richard Ellisat (858) 546-2606. [540]

EASTLAKE: Prime location in new medical officebuilding: 1,000ft2 office (shell condition). Tenantbuild-out credited in reduced rent. Basic office in-frastructure already provided. Ideal for neurologist,psychiatrist, podiatrist, etc. One mile from new SR-125 exit. Call (619) 216-0400 or [email protected]. [538]

OFFICE SPACE FOR SUBLEASE: Office available part timefor Scripps doctor in desirable Scripps/Ximed build-ing in La Jolla. Share elegant office; available fullday Mondays and Friday afternoons. Includes con-sultation office, two exam rooms, front desk, com-mon waiting area, staff bathroom, and kitchen. Useof operating suite or use on other days negotiable.Contact Cindi at (858) 452-6226. [535]

SHARE MEDICAL OFFICE SPACE IN POINT LOMA AREA (OFFMIDWAY): Share fully furnished, six-exam-room/two-office suite with internist. Ample free parking, greatlocation. Contact Elaine Watkins at (858) 945-3813or at [email protected]. [527]

MEDICAL SPACE FOR LEASE: 2,350–11,761ft2 com-pleted shell building on Highway 86 in ImperialCounty for $2.05ft2/month. Please contact Dr.Maghsoudy at (760) 730-3536 or at [email protected]. [525]

PREMIUM HILLCREST OFFICE SPACE: 800ft2 office spaceavailable immediately. Includes 200ft2 waiting

room/balcony; great location next to Mercy Hospital.Competitive pricing. Opportunity to share office staffand resources. [email protected]. [524]

OFFICE SPACE TO SHARE (SOUTH COUNTY): Chula Vista-area family practice office to sublease at 340 4thAve., Suite 10, just north of Scripps Mercy ChulaVista Hospital. Office includes three exam roomsand one treatment room, and is 1,700ft2. Supportstaff available. Contact Dr. Jenkin or Dr. Tetteh at(619) 804-7252. [521]

MEDICAL SPA AVAILABLE TO SHARE: Brand new, upscalemedical spa in Eastlake available to sublet a portionof the facility to a specialist. Ideal for plastic sur-geon or aesthetic physician performing minimallyinvasive procedures. Also open to acupuncturist orwellness/anti-aging physician, which complementsthe spa and noninvasive aesthetic services currentlybeing offered. Call (619) 228-4483 for more infor-mation. [519]

MEDICAL OFFICE AVAILABLE TO SHARE: Primary care office available to share. Store-front building withgreat visibility and recently updated interior. Cur-rent physician has been in practice for 10 years andwants to cut down on hours. Lots of opportunitiesfor a starting physician or specialist. Office staffavailable to share if needed. Call (619) 575-4442 or fax letter of interest to (619) 575-1297. [518]

OFFICE SPACE AVAILABLE: Office space in a desirablelocation directly across the street from ScrippsMercy Hospital. The office is currently occupied by a well-established internal medicine practice. Inquiries: call Connie at (619) 718-9440 or email to [email protected]. [515]

OFFICE SPACE FOR LEASE (ESCONDIDO): Premier fur-nished medical office space for lease in Escondido.Excellent location near Palomar Medical Center.Please call (760) 743-1033. [501]

AVAILABLE OFFICE SPACE: For an updated list of available offices, please visit www.sandiegohealthcareproperties.com. [495]

MEDICAL OFFICE SPACE FOR LEASE (ENCINITAS): Sharesuite with three established physicians. Office situ-ated on second floor with ocean view and conven-ient location. Features include: ample free parking,private entrance, roomy front desk area, privatebathroom, and a spacious waiting room. In a multi-specialty medical building located minutes fromScripps Encinitas. Perfect for outpatient consulta-tion. Affordable lease rate in desirable area. Con-tact Wendy Khentigan, MD, or Deeann Wong, MD, at(760) 753-7341 or at [email protected]. [487]

MEDICAL OFFICE SPACE: Two medical suites (approxi-mately 2,500ft2 and 1,300ft2) available for lease.Building located about one mile from Tri-City Hospi-tal; easy access from Freeway 78. For further de-tails, please contact Aruna Garg, MD, at (760)724-8562, Wendy Shumate, MD, at (760) 940-2268, or call (760) 630-4715. [478]

MEDICAL OFFICE SPACE AVAILABLE: Medical office spacelocated in Hillcrest available. The space is approxi-mately 4,500ft2 with several advantages for agroup of one to four surgical specialists. There isample parking, a full outpatient surgical center onfirst floor of the building, and a therapy area on thesecond floor. Ample medical records storage spaceand phone and computer wiring already installed.For more information, please contact (619) 299-0007. [462]

LLEEAASSIINNGG,, RREENNEEWWAALLSS AANNDD SSAALLEESS:: Call theHealthcare Real Estate Specialists atColliers International for a complete in-ventory of aallll available medical officespace for lease or for sale in San DiegoCounty. Use our knowledge and expertiseto help you negotiate a new lease, re-newal, or purchase agreement to assureyou obtain the best possible terms.There is no charge for our consultingservices. Contact Chris Ross at (858) 677-5329; e-mail cchhrriiss..rroossss@@ccoolllliieerrss..ccoomm.


Classifieds

OFFICE SPACE TO SUBLET: Internal medicine practice in Escondido has office space available for one part-time physician/healthcare professional. Excellent location near Palomar Medical Center. Please contact office manager at (760) 432-6644 or at [email protected]. [459]

SPACE FOR LEASE (CORONADO): Brand new building inCoronado. Last space available: 1,105ft2,$2.75+NNN. Call (619) 742-5555 or email [email protected]. [435]

MEDICAL OFFICE SPACE FOR LEASE: La Jolla medical office in convenient location for solo spine surgeon,psychiatrist, or pain management specialist. Contact Jo Turner at (858) 587-0773, at (619) 733-4068, or at [email protected]. [416]

UTC: Full-time windowed office and part-time inside office in 8th-floor suite with established psycholo-gists and psychiatrist in class-A office building available. Features include private entrance, staffroom/kitchen facilities, professional collegiality andinformal consultation, private restroom, spaciouspenthouse, exercise gym, storage closet with pri-vate lock in each office, soundproofing, commonwaiting room, and abundant parking. Available now!Contact Christine Saroian, MD, at (619) 682-6912,or Jody Saltzman, PhD, Tom Wegman, PhD, orManny Tobias, PhD at (858) 455-5252. [404]

NORTH COUNTY OFFICE SPACE TO SHARE (POWAY): In-house, accredited surgery office available. 3,000ft2includes exam room, dexa scanner, and physicaltherapy. Ideal for a wide range of healthcare practi-tioners. Call John at (619) 549-8870 for more de-tails. [398]

LARGE SUITE (CHULA VISTA): Beautiful suite, 4,550ft2,adjacent to Scripps Hospital, includes large recep-tion and front office, audiology lab, private officespace as well as three large area rooms, many built-in storage cabinets, and staff lounge. Previous ten-ant was Children’s Hospital. Contact Sammye at(619) 342-7207, ext. 8, or [email protected]. [389]

CHULA VISTA: Several suites available now at BayMedical Plaza. We are conveniently located nearScripps Hospital, major freeways, and many restau-rants and retailers. There’s an onsite pharmacy, agood parking ratio, and building is secure. This is agreat opportunity to expand or relocate your med-ical practice in Chula Vista. For more information,contact Sammye at (619) 342-7207, ext. 8, or [email protected]. [387]

BEAUTIFUL, NEWLY RENOVATED OFFICE SPACE TO SHARE:Located in Hillcrest/Uptown San Diego. Physicianwith large suite seeking physician/healthcare pro-fessional or other business professional to share of-fices and/or exam rooms and receptionist. Parkingspaces available for rent (off street, covered). Call(858) 354-9833 for further information. [346]

PART-TIME OFFICE SPACE: Available for sublease in 502S. Euclid medical building, across from Paradise Val-ley Hospital emergency room, in National City. Niceoffice with four exam rooms ideal for sub specialist.Support staff available. Contact Iman Mikhail, MD,at (619) 470-2300. [328]

�PPHHYYSSIICCIIAANN PPOOSSIITTIIOONNSS AAVVAAIILLAABBLLEE

PER DIEM/WEEKEND PHYSICIAN INDEPENDENT CONTRACTOR:Temecula Independent Diagnostic testing facilityseeks physician to monitor patient examinations re-quiring contrast. Position requires availability of atleast two Saturdays a month, typically scheduledfor nine-hour shifts. Candidates must have Califor-nia license. Please contact Lynn at (619) 819-6530for more information, or fax your CV to (619) 241-7790 for immediate consideration. [572]

STAFF PHYSICIAN/STUDENT HEALTH CENTER (JOB #51380):Responsibilities include providing patient care to stu-dents of the University of San Diego at the StudentHealth Center (SHC). Under the direction of the SHCdirector and/or AVP of student affairs for studentwellness, may collaborate to develop and implementwellness area and campus-wide educational andhealth promotion projects and programs. Must beknowledgeable of principles of general preventivemedicine and use those skills for individual and groupcounseling, collection and analysis of health behaviordata, and work with the campus community to im-prove the health and wellness of students. There willbe general guidance and direction from the SHC di-rector and supervising physician. Requirements in-clude board certification/ board eligible in generalpreventive medicine, pediatrics, adolescent medi-cine, family medicine, or other primary care spe-cialty. Candidate must have current, activeCalifornia medical license and DEA. Possession of acurrent, valid CPR certificate is also required. Cur-rent knowledge of drug and treatment protocolscommon to ambulatory care, and one year of outpa-tient primary care experience that demonstrates ev-idence of ability to work independently ismandatory. Prior experience or specialty training incollege health is preferred. Candidate must performall duties in an accurate, thorough, and efficientmanner, and will perform other duties as required.Candidate must be able to organize workflow tomeet the needs of the patient flow, and should beable to adjust the workflow to meet the most criticalneeds first. Candidate must understand and followpolicies as outlined in the office manual, understandand display good, general medical knowledge, hasexcellent interpersonal skills, and is able to commu-nicate effectively at all times. Candidate must workwell with family members, patients, and other non-medical personnel, and adhere to the highestmedico-legal standards of nursing practice. Worksas a team member and demonstrates excellent in-terpersonal and communication skills with the SHCteam. Upholds the mission of University of SanDiego at all times and shall maintain a clean, neat,and professional appearance at all times. Consis-tently meets assigned work schedule, observes ap-propriate conduct standards, is motivated, andshows ambition in performing job duties. Recognizesand completes needed projects, uses informationsystems to solve problems and answer questions.Shows emotional stability, deals with difficult situa-tions in a calm and effective manner, and knowswhen to bring a medical problem to the attention ofthe medical director. Hours are Monday thru Friday,8:30 a.m. – 5:00 p.m. Call human resources at (619)260-4594 or at (619) 260-4626 (24-hour job line),or visit www.sandiego.edu/hr. [568]

PHYSICIAN FOR ADDICTION TREATMENT CLINIC: Opiateaddiction center located in central San Diego islooking for a CA-licensed physician with a non-re-stricted DEA license. Office is on El Cajon Blvd., onemile west of the I-15 exit, which is one mile or so

south of I-8. In need of a physician with at least abasic understanding of substance abuse. Workhours are flexible as our business is open from 5:30a.m. – 1:30 p.m. We currently have a total of 8-12weekly hours available for the position. Please faxresume to (619) 286-0060, or call Justin at (619)286-4600 (office) or (619) 869-2466 (cell). [566]

PARTNERSHIP OPPORTUNITY: ENT position available im-mediately in an existing La Jolla practice. Partner-ship may be quickly achievable. Please call (858)458-1287 for details. [564]

PER DIEM RESEARCH PHYSICIAN: Profil Institute for Clini-cal Research, Inc., a private research institute lo-cated in Chula Vista, CA, is currently seeking apart-time research physician to support recruit-ment, screening, and clinical study activities in bothinpatient and outpatient settings. At Profil, we arefocused on early-phase investigations of potentialnew treatments for diabetes and other metabolicdiseases. This position requires some availability onweekday mornings, but offers flexible hours. Visitour website at www.profil-research.com. Pleasesubmit CV to [email protected]. [554]

RARE INTERNAL MEDICINE OPPORTUNITY: Alvarado Med-ical Group, consisting of five highly respected in-ternists, is seeking a BC/BE general internist totake over the mature, fully scheduled, PPO and fee-for-service, private medical practice of a departingpartner. The practice involves office and hospitalcare, one-in-six easy weekend call schedule, noHMOs/ Medi-Cal, and multiple benefits. The grouphas an in-house, fully certified complex laboratory,cardio and vascular echos, stress echo capability,and a bone densitometer. Partnership expectedwith one year. Please contact Charlynn Case, busi-ness manager, at (619) 229-5055. [549]

FAMILY PRACTICE PHYSICIAN: Immediate opening in com-munity clinic located in the Linda Vista area. 28–32hours per week. Great hours: 8:30 a.m. – 5:30 p.m. No call. Email [email protected]. [544]

OB/GYN NEEDED: Full-time OB/GYN is needed in abusy private practice. Every four- to five-night call.Beautiful San Diego lifestyle. State-of-the-art officepractice and excellent hospital with Level III nurs-ery. Please fax CV to (858) 277-9370, attn: KatyScheneberg, office manager; call (858) 277-9378; or email [email protected] for more in-formation. [541]

PRIMARY CARE PHYSICIAN WANTED: Caring and com-passionate part-time/full-time physician for a traditional internal medicine office in La Mesa/ElCajon. Basic computer skills are necessary. One ortwo weekend calls per month is expected. Call Dr.Prabaker at (619) 698-0606 or [email protected]. [536]

NAVAL HOSPITAL CIVILIAN POSITION: Naval HospitalCamp Pendleton has an immediate opening for onefull-time civilian faculty for its 12-12-12 family prac-tice residency program. This opportunity includesprecepting residents, inpatient/outpatient care (in-cluding ICU and maternity care), and educational re-sponsibilities. Must be residency trained and boardcertified. Previous teaching experience preferred. Acompetitive compensation package is available as aGS-15 with bonuses. If you are interested, check ourwebsite at www.cpen.med.navy.mil. Send your CV to or contact Jim La Joie, business manager, Department of Family Medicine, Naval Hospital Camp Pendleton, CA 92055, by email [email protected], by fax to (760)-725-1101, or call (760) 725-1398. [530]

FAMILY MEDICINE OPPORTUNITY: Seeking a BC physicianin family medicine, full-time position, call responsibil-ities include telephone triage, minimal inpatient care,

MMEEDDIICCAALL OOFFFFIICCEESS FFOORR SSAALLEE FFRROOMM 11,,550000 SSFF:: OWNFOR LESS THAN LEASING! 10—buildingmedical campus. Suites from 1,500 -6,300sq. ft. Strategically located between Tri-City Medical Center & Scripps Encinitas.Purchase your office. Prices startingabout $650,000. Outstanding signageavailable on Melrose Dr. and SycamoreAve. For information call: Jon Walters,Colliers International at (760) 438-8950;John Hoffmann, Cushman Wakefield at(760) 929-2000. www.premiercrossing.com


Classifiedsreplace one or possibly two retiring partners. Qual-ity group; well recognized for excellence throughoutthe South Bay and San Diego. Partnership status orinitial employee relationship is available. Call (619)421-4000 or (619) 787-6948. [483]

PRIMARY CARE JOB OPPORTUNITY: Home Physicians is afast growing group of doctors who make housecalls. Great pay ($60–$100+/hour), flexible hours,choose your own days (full or part time). No week-ends, no call, transportation and personal assistantprovided. Contact Chris Hunt, MD, at (858) 279-1212. [458]

TRADITIONAL INTERNAL MEDICINE OPPORTUNITY: Seekingfull-time, CA-licensed, BC/BE internist to join ourthree-clinician private practice group in Escondido.Inpatient and outpatient care. Competitive salary,malpractice, benefits, and partnership potentialavailable. Please send CV [email protected]. [456]

FAMILY PRACTICE (CHULA VISTA): Seeking a family prac-tice physician to cover solo physician practice oneweek every two months. Contact Ann at (619) 422-1324 or at [email protected]. [451]

FAMILY PRACTICE DOCTORS NEEDED: Full time and parttime; days, nights, and weekends available. Fax CVto La Costa Urgent Care at (760) 603-7719. [449]

�NNOONN--PPHHYYSSIICCIIAANN PPOOSSIITTIIOONNSS AAVVAAIILLAABBLLEE

MEDICAL RECEPTIONIST: Full-time, front office positionwith solo family practice in La Mesa. Experience inscheduling appointments, referrals, insurance, ac-counts payable, accounts receivable, billing, andcollections required. Knowledge of Medical Managerand Quick Books needed. Fax resume to (619) 667-2688. [567]

PHYSICAL THERAPIST: Part-time or full-time PT neededfor group orthopedic practice. Great opportunity,benefits. Please fax CV to (619) 229-3933. [565]

MEDICAL RECEPTIONIST/FRONT OFFICE:We are lookingfor a front office receptionist for a busy OB/GYNpractice. Bilingual in Spanish and OB/GYN experi-ence is a must! Resumes can be faxed to (858) 565-0033. [563]

NURSE PRACTITIONER: Immediate opening in commu-nity clinic located in the Linda Vista area. 28–32hours per week. Great hours: 8:30 a.m. – 5:30 p.m.No call. Email [email protected]. [545]

MEDICAL RECEPTIONIST: New practice opening inSolano Beach looking for an experienced, bright,and well-organized person with knowledge in insur-ance billing (or at least willing to learn). We offer excellent salary and room for career advancement.Please fax your resume to (858) 653-0105, attn:Van Cheng, MD, or email us at [email protected].[537]

PT ECHO TECH NEEDED: Flexible hours, ideal for parentwith child responsibilities. Minimum two years expe-rience, required RDMS, and experience in stressecho. Contact Marybeth at (760) 940-1982. [528]

PHYSICIAN ASSISTANT OR NURSE PRACTITIONER WANTED:Part-time/full-time physician assistant or nursepractitioner wanted for internal medicine practicelocated adjacent to Scripps Mercy Hospital in a wellestablished office. Experience required. Competitivepay and benefits available. Fax resume to Connie at(619) 718-9440 or email to [email protected]. [514]

PRACTICE MANAGER: Retiring practice manager seeksindividual with five years of full-charge experiencemanaging a medical office of 15–25 employees.

Competencies: financial oversight, HR manage-ment, monitoring general practice systems, and reporting within a computerized medical environ-ment. Well-respected, growth-oriented clinical andsurgical practice. Good benefits package. Fax re-sume with salary experience to (858) 552-2182.[512]

MEDICAL OFFICE MANAGER: Busy six-physician internalmedicine group looking for experienced office man-ager. We are located in the College area, adjacent to Alvarado Hospital. Communication and organiza-tional skills are essential and experience with ac-counts payable, accounts receivable, electronicbilling, collections, and payroll are needed. A work-ing knowledge of Medical Manager, QuickBooks, andgeneral computer experience is preferred. Excellentcompensation package. Fax resume to (619) 287-0833. [509]

PHYSICIAN ASSISTANT WANTED: To assist busy cardiol-ogist in Chula Vista. Must be fluent in Spanish andEnglish; experienced; dedicated; and honest indi-vidual. Full-time or part-time positions available.Office hours are from 9:00 a.m. to 6:00 p.m., Mon-day thru Friday. Please fax resume to (619) 656-5250. [504]

MEDICAL RECEPTIONIST WITH MANAGEMENT SKILLS: Posi-tion available, full or part time, in a family practiceoffice located in Scripps Ranch. Fax resume to(858) 271-5327, attn: Dr. Wasserman. [494]

NURSE PRACTITIONER: Four-physician internal medi-cine practice in Chula Vista seeks part-time/full-time nurse practitioner. Work with a quality group;reasonable hours. Previous experience is prefer-able; salary negotiable depending on experience.Call (619) 421-4470 or (619) 421-4000. [488]

NURSE PRACTITIONER WANTED: Part-time/full-timenurse practitioner wanted for internal medicinepractice in Escondido. Previous experience is desir-able. Call (760) 432-6644. [455]

�PPHHYYSSIICCIIAANN PPOOSSIITTIIOONNSS WWAANNTTEEDD

MEDICAL OPHTHALMOLOGIST (PER DIEM): Board-certifiedmedical ophthalmologist available two days perweek for per diem or locums work in the San Diegoor nearby areas. Highest ethical standards. Experi-enced and skilled in therapeutic and cosmetic Botoxand dermal fillers. Also experienced in clinical trials. Email [email protected]. [569]

CARDIOLOGIST SEEKING EMPLOYMENT: Noninvasive cardi-ologist wants to join IM or cardiology practice (of-fice based). Board eligible. Experienced in echo,stress test, nuclear, and CT. Call (858) 922-8354(cell), (760) 633-3044, or email [email protected].[558]

�PPRRAACCTTIICCEE FFOORR SSAALLEE

UROLOGY PRACTICE FOR SALE (SAN DIEGO): Practice op-portunity in San Diego. Busy solo practitioner to re-tire in October 2008. Thriving practice; multiplecontracts; turnkey operation with Spanish languageand laparoscopy skills. Can’t miss. Interested appli-cants email [email protected]. [571]

SUCCESSFUL MEDICAL SKIN CARE CLINIC FOR SALE: Smallinvestment for 51 percent ownership. Looking for anew medical director. Contact Leonard Schulkind at(619) 807-5485. [539]

DEL MAR-AREA GENERAL PRACTICE: Prime location,huge potential for practice expansion in fast grow-ing Carmel Valley community. Established in 1990;terms available. Inquiries call (858) 755-0510.[185]

no OB, competitive salary and excellent benefitspackage. Please submit CV to: Vivian Hudson, Physi-cian Resource Manager, Sharp Mission Park Medical Group, 2201 Mission Ave., Oceanside, CA 92054, call (760) 901-5259, fax (760) 901-5242, or email [email protected]. [529]

FAMILY PRACTICE POSITION: Join a growing family prac-tice office in the Carmel Valley area of San Diego. The practice is professional, caring, delivers out-standing primary care, and is PPO and fee-for-ser-vice ONLY with NO HMO care! Generous startingsalary with production bonus, malpractice, pensionplan, health benefits, and vacation. Easy call everythree to four weeks, with no OB, and hospital care is optional but not required. Send resume to [email protected], or fax to (858)793-2650. Call Dr. Schlitt at (858) 793-2727. [526]

BC/BE NEUROLOGIST, PULMONOLOGIST, OCCUPATIONAL THERAPIST: Harmony Multi-Specialty Group has thefollowing immediately available positions: part-timeBC/BE neurologist, pulmonologist, and occupationaltherapist. Flexible hours, excellent pay with possibleprofit sharing. Please send your resume either by fax at (619) 393-0830 or email at [email protected]. No phone calls.[523]

VOLUNTEER FP/IM PHYSICIANS NEEDED: Camp Pendletonfamily practice residency is looking for a few enthu-siastic volunteer family practice or internal medi-cine physicians interested in teaching to helppreceptor residents and medical students in ouroutpatient family practice clinic. Please contactCAPT John Holman at (760) 725-1398. [511]

PHYSICIAN NEEDED: Board-certified/board-eligible,full-time family practice physician needed for abusy North Inland County physician-owned-and-di-rected group. One hundred percent outpatientbased, guaranteed first-year salary, excellent bene-fit package. Email CV to [email protected] or fax to (760) 745-0451, attn: Judy. [510]

POSITION AVAILABLE: Per diem openings for urgentcare center at Cassidy Medical Group located inVista. Hours are 5:00 p.m. to 9:00 p.m., M thru F,9:00 a.m. to 5:00 p.m. Sat., and 10:00 a.m. to 4:00p.m. Sun. Competitive salary. Malpractice insuranceprovided. Please send CV to [email protected] orfax to (760) 477-7881. For additional information onour group, please visit www.cassidymg.com. [508]

FAMILY PRACTITIONER: Cassidy Medical Group in Vista is searching for a family practitioner for their de-partment. The group is comprised of 16 primarycare physicians, including family practice, internalmedicine, pediatrics, and obstetrics/gynecology.Outpatient hours only as the group uses hospital-ists for all inpatient care. Competitive salary andbenefits. For more information on the group, visit www.cassidymg.com. If interested, please send CV [email protected] or fax to (760) 477-7881. [507]

NORTH COUNTY MEDICAL GROUP: Graybill MedicalGroup, a 35-physician medical group with offices inEscondido, San Marcos, and Fallbrook, is actively re-cruiting physicians in family medicine, internal med-icine, and several specialties including ENT and OB,as well as other surgical specialties. The practiceopenings involve both office practice and inpatienthospital care. Hospitalist-only positions are alsoavailable. Our group is well established with an inte-grated EMR. Physicians interested in discussing posi-tions available should contact Floyd Farley, CEO, [email protected] or via fax at (760) 737-7324.[498]

POSITION AVAILABLE: Four-partner internal medicinepractice in Chula Vista seeking BS/BE internist to


Classifieds�MMEEDDIICCAALL EEQQUUIIPPMMEENNTT

EXAM TABLE FOR SALE: Full-functioning, electric examtable. Includes drawers, storage area, and elevationand tilting capabilities. $100 OBO. Call Pam at (858)456-2114. [559]

MEDICAL EQUIPMENT FOR SALE: From Advanced Derma-tology and Cosmetic Surgery: 1) Surgical chair/table.Ritter electric procedure table with controls on thetable and also as foot pedals; in excellent condition.Has elevation, tilt, back, and foot controls. Patientcan be put in supine and Trendelenberg positions.Price normally $2,000, will sell for $900. 2) Flatexam table. Back can be raised and there is a footrest. Table has drawers and an electric outlet: $200.Call Mike at (760) 436-8700 or at (619) 261-8063.[553]

ULTRASOUND, STRESS, ECG: HP 2000 ultrasound — cardiac, vascular, abdominal, small parts, five trans-ducers: $6,000. Quinton 4000 monitor with Q55treadmill, recording paper, electrodes, crash cart, defibrillator: $2,500. HP ECG Pagewriter XLE, lots of recording paper and electrodes: $700. Call (619)460-0083 or (619) 518-9542. [513]

RETIRED SURGICAL PRACTICE OPERATING ROOM/SURGICALEQUIPMENT: Perfect for plastic surgery/oral surgery.Endoscopy, cameras, loupes, tools. Waiting roomfurniture inventory list is available upon request.Email [email protected]. [506]

�SSEERRVVIICCEESS OOFFFFEERREEDD

PRACTICE FINANCING FOR PHYSICIANS: Up to 100 percentfinancing available for physicians! Includes purchaseof a practice, equipment, partner buyout, workingcapital, and real estate. Contact Monica Coburn atCBN Financial: (702) 310-7111 [email protected]. [522]

BILLING, CONSULTING, OUTSOURCING: We are committedto maximizing your bottom line! Our billing serviceuses state-of-the-art technology to ensure chargecapture, code validation, electronic submission andremittance, payment postings, patient statements,structured follow-up and appeals, electronic docu-ment storage and meaningful reporting. Supplemen-tal services include online appointment scheduling,automated call reminders, scan systems, and othertechnological advances. Consulting services includeaccounts payable, auditing, business development,electronic medical record selection and implementa-tion, credentialing, contracting (payor, physician,and staff), executive assistant, financial manage-ment, information systems, operational manage-ment, practice assessment, practice management,relocation management, and other technological ad-vances. Contact us today for your free consult! Con-tact Kena Galvan (619) 326-0700 [email protected]. [452]

RMC VINYL REPAIR PLUS: Medical equipment upholsterer.Expert in repair and replacement of medical fixture

upholstery, including exam room equipment andwaiting room furniture. Free estimates and mobileservice! Call (619) 443-4060. [400]

�MMIISSCCEELLLLAANNEEOOUUSS

2005 SEA RAY SUNDANCER 30-FOOT LOADED POWERBOAT:Excellent condition; 2K in recent/routine mainte-nance, new front eisenglass, 3.5 years remaining onfull-warranty ($6,000 value), only a paltry100 hoursfor two pristine 220-hp engines, GPS, generator,TV/DVD/stereo/air/heat and much more. Exact boatwith less features costs $150K; $98,000 (firm) tofirst buyer. (858) 254-0202. [454]

2003 BMW M3 CONVERTIBLE (RED, MANUAL): Very goodcondition, low miles, and new tires: $33,750. (858)254-0202. [453]

�CCMMEE//CCEERRTTIIFFIICCAATTIIOONN CCOOUURRSSEESS

ADVANCED WILDERNESS LIFE SUPPORT CME/CERTIFICATIONCOURSE: Offered through UCSD and AWLS, this four-day CME and certification course is designed formedical professionals who are interested in outbackadventure. Course includes didactics, workshops, andsurfing/hiking/kayaking/climbing adventures. Datesare November 12 to 15, 2008. Please visit family-medresidency.ucsd.edu/awlsconference.shtml for further information. [570]

DARI PEBDANISAN DIEGO [email protected]

CALL TODAY TO RESERVE YOUR ADVERTISEMENT

SAN DIEGO COUNTY MEDICAL SOCIETY

2008-2009MEMBERSHIP

DIRECTORY

Discover Your Website!www.SDCMS.org

Renew Your 2008 SDCMS-CMAMembership

Search for a Physician

Access SDCMS Members-only Resources, Including Webcasts, NPI lists, a Bulletin Board, and Much More…Member physicians can access the “Member Physicians” section usingtheir name and birthdate. For assistance, email [email protected].

Join SDCMS-CMA Online

Read Current and Past Issues of San Diego Physician, Including “Web Exclusives”

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If you have any questions or suggestions, contact SDCMS at (858) 565-8888 or at [email protected].


Public Health

ver wonder if your Alzheimer’spatient and her husband followthe treatment plan you suggested

after they leave your office? Ever ask yourstaff to make a referral for your elderly fe-male patient who is losing weight to ameal program for seniors, knowing it maybe a difficult task for a very busy staff per-son? Ever wish there were more supportsin the community to help provide servicesand monitor the health status of your fraildiabetic once he/she leaves the office?Based on national prevalence rates, one

in two San Diegans has one or morechronic conditions and accounts for 83percent of our local healthcare dollars (1).With the “age wave,” it is predicted thatpersons 60 years plus with chronic condi-tions will increase 69 percent between2005 and 2020 (2).A physician survey by Mathematica

shows that they are dissatisfied with cur-rent health policies, including public re-imbursement (3). And while 54 percentreported being “very satisfied” with carefor general patients, only 38 percent re-

ported this for patients with chronic con-ditions. The physicians in the study citedlack of training in several important areas,such as coordination of in-home and com-munity services, patient education onchronic illness, managing psychologicaland social aspects of chronic care, provid-ing effective nutritional guidance, andmanaging chronic pain.The County of San Diego Health and

Human Services Agency, in conjunctionwith its many community partners, is tak-ing action on many fronts to make a dif-ference in chronic care delivery bysupporting physicians and patients withprevention, education, and communica-tion initiatives. Funding for these variousprojects comes from a variety of federal,state, local, and foundation resources. Thesuccess depends on all of us, but most im-portantly, support from the physician iscrucial.Team San Diego is a joint project be-

tween the County’s Long Term Care In-tegration Project, University of Californiaat San Diego (UCSD) Extended Studies,and Mark Meiners, PhD, at GeorgeMason University. This initiative ispreparing to launch its online training forcommunity health and social serviceproviders in July 2008 through UCSDExtension Summer courses. The eightone-hour, online modules are designed toprepare providers of mutual patients withchronic care needs to create a “virtualteam” around each patient, in support ofthe primary care physician.After completing the eight modules, a

six-hour, in-class training will put the newskills into action as providers come face toface, by neighborhood, for team buildingand development of a communicationprotocol. The goal is to improve care co-ordination across settings and providersand increase patient engagement to be-come active members of that team. An in-troductory module is designed forphysicians to present the business case on

the advantages to your practice and howto support your office staff in participat-ing in this training.The full training will provide health and

social service providers with basic infor-mation on working successfully with eld-erly and disabled persons, how to create a“team” when no one has time to be in thesame room for each patient, how to see di-versity as opportunity for developing pro-fessional relationships, legal and ethicalissues with sharing information amongteam members, and tools and techniquesfor empowering patients to manage theirown care better through taking increasedresponsibility.Some of these tools will include sample

personal health records, medication lists,transition checklists, and training on useof the county’s rich resource databank onwww.sandiego.networkofcare.org/aging,where you can find aging and disabledcommunity resources, a large bank ofhealthcare literature, a “virtual” long-termcare options counselor, fall preventionsafety tools, and more. To receive infor-mation or sign up for the introductorymodule (1 CME), call Jackie Kuhn at(858) 964-1059.Other county initiatives will be de-

scribed in more detail in future articles andinclude preventing diabetes in Hispanicelderly, falls prevention, childhood andelderly obesity programs, smoking cessa-tion, feeling fit clubs for the elderly,chronic care self-management (StanfordModel) training, oral health, and Medicaresenior risk reduction.

ABOUT THE AUTHORS: Dr. Wootenis San Diego County’s public health officer.Ms. Greb is a retired licensed clinical socialworker.

Chronic Care Made EasierTaking Action on Many Fronts to Make a DifferenceBy WILMA WOOTEN, MD AND EVALYN GREB

RESOURCES:1) Medical Expenditure Panel Survey, 20012) Department of Rehabilitation, Laurie Dickinson, December 20073) National Public Engagement Campaign on Chronic Illness — Physi-cian Survey, Mathematica Policy Research, Inc. 2001

E

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Endorsed by

Richard E. Anderson, MD, FACPChairman and CEO, The Doctors Company

We proudly announce our 2008 member dividend. We set a higher standard. We ensure that members benefit from our strength. We embrace opportunities to recognize and reward physicians. We exceed expectations. We offer tangible benefits to those who join us. We stand behind the promises we make. We are The Doctors Company.

We are on a mission to relentlessly defend, protect, and reward doctors who advance the practice of good medicine.

We act with single-minded determination to reward our members and to ensure that they share in the company’s

financial strength. In 2007, our members received a dividend of between 5 and 7.5 percent. For 2008, our members

will receive a dividend distribution at the same level. That’s $44 million returned to members in two years. To learn

more about our medical professional liability program for SDCMS members, call (858) 452-2986.

Doctors Co_SDP_0408:Layout 1 3/13/08 11:10 AM Page 1

SAN DIEGO COUNTY MEDICAL SOCIETY5575 RUFFIN ROAD, SUITE 250SAN DIEGO, CA 92123

[ RETURN SERVICE REQUESTED ]

$5.95 | www.SANDIEGOPHYSICIAN.org

PRSRT STDU.S. POSTAGE

PAIDDENVER, CO

PERMIT NO. 5377

May 2008

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