March/April 2019 Bulletin: Health Care and Homelessness

MARCH / APRIL 2019

Volume 25 | Number 2

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The Bulletin  March / April 2019

MEMBER BENEFITS Collections CME Tracking Discounted Insurance

Multidisciplinary Care is Primary Care

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Financial Services Health Information Technology Resources

In This Issue

House of Delegates Representation Human Resources Services Legal Services/ Health Law Library Legislative Advocacy/MICRA Membership Directory APP for the iPhone Physicians’ Confidential Line Practice Management Resources and Education

Feature Articles 8 Homelessness – Causes and Interventions 11 Excerpt From Client of Valley Homeless Healthcare Program 12 Caring For People Who are Homeless 15 Useful Resources for Homelessness 18 Multidisciplinary Care is Primary Care 21 Our Efforts: A Drop in the Bucket

Professional Development

22 A Psychiatrist’s Perspective on Homelessness

Publications

24 Health Homes Program

Referral Services With Membership Directory/Website Reimbursement Advocacy/ Coding Services

Departments 5 Annual Meeting & Physician Wellness Presentation 6 Message From the SCCMA President 7 Save the Date – SCCMA Awards Banquet 28 Medical Times From the Past 29 Classified Ads 30 In Memoriam 30 Save the Date – MCMS Physician of the Year

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The Santa Clara County Medical Association OFFICERS

CHIEF EXECUTIVE OFFICER

COUNCILORS

President

April Becerra, CAE

El Camino Hospital of Los Gatos:

President-Elect

CMA TRUSTEES - SCCMA

El Camino Hospital:

Past President

Thomas M. Dailey, MD (District VII)

Good Samaritan Hospital:

VP-Community Health

Kenneth Blumenfeld, MD (District VII)

Kaiser Foundation Hospital - San Jose:

Kenneth Blumenfeld, MD Seema Sidhu, MD Seham El-Diwany, MD Cindy Russell, MD

Lewis Osofsky, MD Gloria Wu, MD

Vinit Madhvani, MD

Hemali Sudhalkar, MD

VP-External Affairs

Kaiser Permanente Hospital:

VP-Member Services

O’Connor Hospital:

VP-Professional Conduct

Regional Medical Center:

Secretary

Saint Louise Regional Hospital:

Treasurer

Stanford Health Care / Children's Health:

Erica McEnery, MD

Open

Randal T. Pham, MD Faith Protsman, MD Martin Wong, MD Anh Nguyen, MD

Cathy Angell, MD

Heather Taher, MD

Scott Benninghoven, MD John Brock-Utne, MD

Santa Clara Valley Medical Center:

Clifford Wang, MD

The Monterey County Medical Society Printed in U.S.A.

OFFICERS

Managing Editor

Maximiliano Cuevas, MD

Pam Jensen

Opinions expressed by authors are their own, and not necessarily those of The Bulletin, SCCMA, or MCMS. The Bulletin reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted in whole or in part. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by SCCMA/MCMS of products or services advertised. The Bulletin and SCCMA/MCMS reserve the right to reject any advertising.

Address all editorial communication, reprint requests, and advertising to: Pam Jensen, Managing Editor 700 Empey Way San Jose, CA 95128 408/998-8850, ext. 3012 Fax: 408/289-1064 pjensen@sccma.org © Copyright 2019 by the Santa Clara County Medical Association.

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The Bulletin March / April 2019

President

President-Elect

Christopher Burke, MD Past-President

Craig Walls, MD PhD Secretary

Alfred Sadler, MD Treasurer

Steven Harrison, MD

CHIEF EXECUTIVE OFFICER April Becerra, CAE

DIRECTORS E. Valerie Barnes, MD David Holley, MD Jeffrey Keating, MD William Khieu, MD

Walter Mills, MD James Ramseur, MD Stephen Saglio, MD

About our presenters

Annual Member Meeting & Physician Wellness Presentation May 7, 2019 | 6:30 pm - 8:30 pm 700 Empey Way, San Jose, CA As the delivery of health care undergoes fundamental shifts and the rate of burnout among physicians continues to rise, physician wellness and professional fulfillment have become hot topics throughout the health care community – and for good reason.

Our annual meeting will focus on real life examples of programs tackling the burnout of our physician community and also provide strategies you can implement into your own practice.

Earn 2 AMA PRA Category 1 credit(s)TM

Rachel Roberts, MD, Internal Medicine Driven by both her personal experience with burnout and her passion for wellness, Dr. Roberts became the Medical Director for Provider Wellness at the University HealthCare Alliance in 2015. She developed and chairs the program as well as the Professional Fulfillment program. During her time as Medical Director, burnout has decreased by 13% among providers, in contrast with nationally increasing rates of burnout.

Barbette Weimer-Elder PhD, RN, Physician Coach, Service Excellence Currently the Advancing Communication Excellence at Stanford Facilitator and the Director of Physician Partnership Program at Stanford Health Care. Barbette will be addressing the importance and impact of ACES and research indications on how health care outcomes and physician wellness are influenced by the quality of communication in the patient care environment.

The evidence-based ACES curriculum focuses on mastering effective, empathic communication skills, with the twofold goal of improving the patient experience and enhancing professional satisfaction. Since its launch at Stanford in September 2017, the program has received positive feedback from its 450 participants.

For any further questions, please email April Becerra at april@sccma.org or call us at (408) 998-8850

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President, Santa Clara County Medical Association

KENNETH S. BLUMENFELD, MD, FAANS

MESSAGE FROM THE

SCCMA PRESIDENT

Springtime in California

Kenneth S. Blumenfeld, MD, FAANS is the 20182019 president of the Santa Clara County Medical Association.

He is a board-certified Neurological Surgeon with Sutter Health/Palo Alto Medical Foundation and is currently practicing with South Bay Brain and Spine. He also is adjunct clinical professor in Neurological Surgery at UCSF.

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alifornia physicians can’t help being overwhelmed by an ongoing healthcare crisis and never-ending socioeconomic concerns. The volume of non-patient care issues and responsibilities doctors are asked to contend with is escalating exponentially. That is why organized medicine is being increasingly tasked to solve complex socioeconomic issues while protecting the interests of doctors and the patients they serve. Not that being tasked is a bad thing. Organized medicine has always had a voice. The difference is that politicians and the public are once again turning to us for input and answers. We are not a third party blurting out opinion, we are a respected and important stakeholder.

With stakeholder status comes responsibility. It begins locally with grass roots and the SCCMA. It then runs up the flagpole with CMA and AMA. The California legislative cycle is getting started. The bills have been introduced. Our Council on Legislation convenes in March and our Legislative Advocacy Day in Sacramento is in April. Take a moment to review, or better yet subscribe, to CMA’s Legislative Hotlist. Dig a little deeper into SCCMA’s and CMA’s website and you’ll find a plethora of information addressing socioeconomic concerns and related resources. I suspect few members fully explore all the staff driven services and offerings available to them. Consider the Center for Economic Services, practice resources, educational opportunities, and legal help to name a few. If that’s not enough CMA’s House of Delegates, councils, committees, and board of trustees have worked long and hard to provide substantive input, rational recommendations, implementable policy, and much needed advocacy.

As doctors we are faced with a paradox.

We enter our profession as a calling and are trained to put patients first. Unfortunately, few of us are adequately prepared to care for

The Bulletin March / April 2019

ourselves or address the broader issues necessary to carry out our mission. To do so requires a medical community.

As your SCCMA President and a CMA trustee I am often confronted with the question of “what has my county and state society done for me lately?” In truth the list of things that SCCMA and CMA has done and is doing to better the practice of medicine is impressive and tangible, which is why there is such a high membership retention rate. The plan is always to do more and welcome suggestions and participation. But I have to ask why some doctors, predominantly non-members, are unaware or choose not to recognize the work being done on their behalf. Working as an island in an “every person for themselves” mode is neither practical or effective. It is also a failure from the perspective of medical citizenship.

I would suggest that with increasing weight being given to the recommendations of organized medicine now is the time to reengage. Not to poach from JFK but “ask not what your medical society has done for you but what you can do for your medical society?” If nothing else our medical community should coalesce and work together. The socalled return on investment is better when the investment is hands-on, and the benefits utilized by a knowledgeable investor.

Spring is upon us. It is a time of growth and renewal. I invite current and prospective members to look deeper into SCCMA and CMA. We are a medical community with much to offer. SCCMA is an inclusive, diverse, innovative, and influential organization with an exciting and important future. Your input and perspectives are needed. Every doctor in Santa Clara County and California should have a voice. Help us represent you and make your membership invaluable.

SCCMA

Gt!J4tth banquet

Honoring physicians who improve healthcarefar all

Please contact Sameera Manucher at (408) 998-8850 for sponsorship details.

ANNUAL AWARDS BANQUET & INSTALLATION TUESDAY, JUNE 4, 2019 THE WESTIN SAN JOSE 302 South Market Street, San Jose, CA 95113

$600

FOR A TABLE OF 8

OR

$75 FOR A SINGLE TICKET Advance Prepaid Reservations

DUE BY MAV28, 2019 Register at bit.ly/sccmabanquet DINNER ENTREES Breast of Chicken with Artichoke Hearts & Sundried Tomatoes; Chardonnay Cream Sauce Fresh Grilled Salmon with Lemon & Extra Virgin Olive Oil Sauce Penne Melanzane (All Entrees include Salad & Cheesecake for Dessert)

6:00 PM SOCIAL/ MAGNOLIA JAZZ TRIO/ PHOTO�P 7:15 PM DINNER 7:45 PM AWARDS PRESENTATION

Installation Seema Sidhu, MD, SCCMA President 2019-20 Honoring Kenneth Blumenfeld, MD, SCCMA President 2018-19 Award Honorees Joanna Ready, MD-Outstanding Achievement in Medicine Francis N. Chu, MD-Contribution in Medical Education William S. Lewis, MD-Contribution to the Medical Association Faith R. Protsman, MD-Contribution to the Community Jeffrey V. Smith, MD, JD-Citizen's Award

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By Libby Echeverria Licensed Clinical Social Worker Valley Homeless Healthcare Program

H

omelessness is an issue that has garnered national attention in recent years and seems to be getting worse across America. It is commonly believed that homelessness is the result of individual people’s bad decisions, and that people can get out of homelessness if they work hard, stay sober and stay out of trouble. However, this view does not take into consideration the societal complexities that led to modern day homelessness, nor does it acknowledge the internal and external obstacles to recovery that exist for homeless individuals.

Societal Causes Up until the 1970s, widespread homelessness did not exist. There were some urban areas with “derelicts” and some “hobos” who jumped on trains to travel the country. Between 1978-1983, the budget for the Department of Housing and Urban Development (HUD) was cut by 80%. Tens of thousands of people with subsidized housing lost their benefits and ended up on the streets. At the same time, the deinstitutionalization movement occurred.

At that time, there was a large population of mentally ill and developmentally delayed people living in institutions, many of whom did not belong there. The idea behind deinstitutionalization was to move these people into community housing in apartments or with family, with clinical treatment being provided by community agencies. This worked well for many people, however those with the most severe functional impairment could not maintain community placement and there were no longer institutions to

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care for them. These two policies resulted in the widespread sleep on. If the same thing happens to someone but their famhomelessness we see today in America. ily is toxic, or using substances, or already have 12 people sleepAdditionally, other societal factors came into play. Institu- ing on the floor in a studio apartment, they end up on the street. tional racism resulted in mass incarceration, refusal of mortgag- No matter what other events have happened to cause the peres to people of color, lower pay and less access to higher edu- son’s homelessness, lack of social support is a constant. cation. The income gap between The Role of Trauma, rich and poor grew exponentially. In ACE Score = # of categories of traumatic Traumatic Brain Injury and 1980, the CEO out-earned the averevents <18 yo (max 10) age worker by 42:1. By 2000, it was Cognition 541:1. Rental costs have risen steeply A history of trauma is the oth1. Sexual abuse before age 18 over the last decade while there has er strong theme that unifies the 2. Emotional abuse by parent or loved one been no growth in wages. Deeply 3. Physical abuse by parent or loved one homeless population. In 1997, there entrenched stigma against people 4. Emotional neglect by parent or loved one was a landmark study done at Kaiser 5. Physical neglect by parent or loved one with mental illness and substance

by Felitti et al that looked at the oc6. Loss /abandonment of or by parent use resulted in a lack of funds for currence rate of Adverse Childhood 7. Witnessed abuse of a loved one treatment and the further marginExperiences (ACE) in the general 8. Drug/alcohol abuse in the household alization and deterioration of people population, and the effect of trauma 9. Mental illness in the household with serious disabilities. on adult health outcomes. They de10. Loved one incarcerated The “take home” message is fined 10 categories of abuse or trauthat policy changes created modern ma, and participants were assigned day homelessness, and policy changes can fix it. one point for every category they had experienced. The higher the ACE score, the higher the adult rates of suicide, mood disIndividual Causes orders, hallucinations, substance use, cancer, diabetes and hyWhile societal factors play a significant role, there are many pertension. We did our own study of the ACE occurrence rates factors that affect people at an individual level and lead to in the Santa Clara County homeless population and found that homelessness. There are two distinct kinds of homelessness. homeless people had 3-10 times the rate of each ACE category 65% of the people on the streets in Santa Clara County are “situthan the general population. They also had a much higher ocationally homeless.” Some severe event occurred – a stroke, a currence of having experienced multiple categories of trauma divorce, a natural disaster – and they briefly became homeless (high ACE score). as a result. These folks tend to get income and housing in less Research has shown that childhood trauma affects the than a year. The other 35% are the chronically homeless folks, structure of the developing brain and disrupts normal neurowho are homeless for more than a year or become homeless development. This leads to permanent social, emotional and over and over again. They have very complex problems that are cognitive impairment. These impairments often lead to the not easily solved. adoption of health-risk behaviors, which lead to higher rates of What are these complex problems that lead to homelessdisability and social problems, which then often leads to early ness? It’s not simply education. death.

76% of SCC’s homeless popula- ACE event Homeless General We also did a study of the rate tion has a high school diploma or Prevalence % population % of Traumatic Brain Injury (TBI) in higher, and only 1% are illiterate. the Santa Clara County homeless Psychological Abuse 64.6 11.1 People usually become homepopulation and found that there 53.5 10.8 less because of a combination Physical Abuse was a 600% higher prevalence of of medical illness, mental illness, Sexual Abuse TBI than in general population.

43.3 22.0 substance abuse, incarceration, TBI is important because it af78.7 25.6 domestic violence and the lack Substance Use fects insight, judgement, learning 62.2 18.8 of affordable housing, but there Mental illness and cognition. People with a hisare two underlying issues that are Domestic Violence tory of TBI struggle with stressors, 54.3 12.5 universal to all homeless people – have difficulty adapting to new 33.9 3.4 a lack of social support and a his- Criminal bx in home situations, have impaired executory of trauma. tive function, and have mood and Social support networks are # ACE (score) personality issues.

VHHP General Pop one of the most powerful reTrauma, disrupted neuro3.1 26.0 sources that protect people from 1 development, traumatic brain 77.2 12.5 homelessness. If you lost your job 4 or more injury, substance use and menand had a heart attack, and subtal illness all impact cognitive sequently lost your home, you would have a large number of function, including memory, concentration and planning skills. people that you could stay with while you figured out your next Many homeless people have several of these issues simultanestep. Family, friends, colleagues, college friends, cousins – the ously. These cognitive problems obviously lead to employment list is long, and you would be unlikely to run out of couches to barriers. Even unskilled jobs like stocking shelves in a grocery

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store demand certain skills and abilities – the ability to show up Survival mode impacts the doctor/patient relationship and on time, accept instructions from a boss, remember assigned the patient’s adherence to treatment. When a person doesn’t tasks, learn new things, and deal with changes to routine. Indiknow where they will sleep without getting assaulted that night, viduals with cognitive issues also tend to have problems such as they don’t feel that taking their HCTZ is a high priority. Likewise, low frustration tolerance, difficulty persevering and completing they may have a CT scan scheduled, but that morning they distasks, and poor conflict resolution skills. cover their food stamps have been discontinued, so they skip For some homeless people, these impairments are mild, the appointment to go to resolve their food issues. They will foand they can gain employment and stabilize their housing. cus on whatever pressing need presents that day. This can lead For many others, these impairments are disabling. However, to frustration on the part of medical providers, who see down it is difficult for a homeless person to get Social Security disthe road to where the lack of medical care will lead. The best ability income, as they need extensive medical documentation way to bridge this gap is to acknowledge and validate the cliof their illness, injury and functional level in order to win their ent’s priorities, then get their buy-in for the medical piece. “I case. Homeless people have a difficult time attending mediknow you don’t have a place to stay tonight, and that’s overcal appointments regularly, trusting the medical system, folwhelming. But I’d hate for you to put this much time and effort lowing through with tests, and building their case. Additionally, into getting things on track, just to have a stroke in a year. Do medical providers rarely document functional impairment in you think you could take a few seconds to swallow that pill every the record, with few descripmorning so that you can feel tions of behavior in the clinic, free to keep all your focus on SCC HOMELESS POPULATION RATES OF TBI cognitive barriers to completyour housing?” ing medical treatment plans, Another consequence of attendance at appointments cognitive and psychological and the like. Neuropsychoproblems is that many homelogical testing is the best way less people are non-linear in to capture these deficits, but it their thought process. They do is very expensive and difficult not come into an exam room, to obtain. In medical settings, give a succinct summary of behaviors that are due to cogthe course of a medical probnitive impairments are often lem, and ask questions. They labeled as “non-compliant” or tend to have a difficult time “poor health literacy,” or it is asarticulating exactly what the sumed that the patient does problem is, or they tell a long not want the care. story about the illness that gives us fragments of inforBuilding Relationships mation but not a clear picture. with Patients Experiencing Homelessness This can be another frustrating experience for providers, who There is another important factor to understand when have productivity pressures and need the patient to be in and working with people experiencing homelessness. This comes out in 15 minutes. When a provider pushes the client to sumback to Maslow’s hierarchy of need. A human’s most fundamarize or speed things up, this tends to invalidate and alienate mental needs to be able to function are physical safety and bathe patient. The best way to address this in the exam room is for sic physiological needs such as sleep, food and warmth. These the provider to allow the patient to tell the story in their own way. basic needs have to be met before any human can build relaUsually this only takes a few extra minutes, even if it feels like tionships with others, strategize and execute plans, or be crelonger. This gives the patient a chance to feel heard. If needed, ative. If you are at the mall and a gun goes off, your world shrinks the provider can focus on addressing one issue that day, instead to survival only. Where can I go to escape? Where can I hide? of the five the patient described, which leaves enough time for How can I get between the sound and my child? You are not both parties to meet their needs and also build a relationship. thinking about the dinner you will cook tonight, or how to tweak As homeless people show up in our practices more and your resume, or how you want to start online dating. This is a more, it is easy to feel overwhelmed or wonder what can possibasic biologic survival reaction of all human beings. Now multibly be done. The most important thing is to build a relationship ply that by hours, days, weeks and sometimes years. Homelesswith them, gain their trust, and keep in mind the compelling ness is incredibly dangerous. This “survival mode” maximizes a needs they have for survival that make their priorities different homeless person’s safety, but guarantees that they stay firmly than most of our clients. When a patient makes a decision that rooted in the present moment, without the bandwidth to plan seems illogical, remember the circumstances of their life and and strategize their way out of homelessness. All they can think ask questions about it. Validate them. Don’t wait for them to about is where they will sleep that night, what are they going to change before you treat them. And remember that homeless eat, and how they can protect themselves and their belongings. people get better all the time – they stabilize medically and psyWhen survival mode is added to the cognitive deficits innate chiatrically, they get clean and sober, they reconcile with family to their other conditions, it is no wonder that they are unable to and reenter society – but they can only do that with our comwork, attend appointments, or otherwise stabilize themselves. passionate and persistent help.

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Mr. Donald Lee (left) is a long-time client of VHHP and stands alongside Libby Echeverria (right), a VHHP medical social worker and program manager. Mr. Lee is an active member of the VHHP Patient Family and Advisory Team, providing input that informs our services.

By Donald Lee Client of Valley Homeless Healthcare Program I had problems with the educational system when I was young – I had dyslexia and saw things backwards. I got a sixth grade education and then pulled myself away and dropped out. My mom was very sick in the psychiatric hospital and she had cancer and was never around. She passed away when I was 10. My father lost his job and said, “You’re on your own, I can’t help you anymore.” I was a vagabond… I was institutionalized in the foster system, and was “property of the state.” Just when I thought I was going to get out of the system, I had a job and wanted to get married, I got drafted into the Army. I was writing my fiancée and she was not writing me back, but then I got a letter from her mom that said she had been murdered. I was devastated, thinking what am I doing here in the Army protecting my country, when the authorities at home can’t protect my loved ones?

I launched myself on a career of drug abuse and using, trying to overcome all this ill feelings that I had. You know, it wasn’t good, but it was just a way of coping. Eventually I decided that I would stop using, stop all this, and I was sober for ten years.

But then due to a relationship, domestic problems, I went back to things that I was familiar with – you return to the things you used to do because they’re easier for coping. So I continued down that road, then I said drugs weren’t doing me any good, they aren’t helping me anymore.

I would have loved to have a family to grow up with, fall back on in times of need… I’m not perfect, I have my inequities, but even when I make a mistake there is no one ever there to fall back on, no support network whatsoever, I didn’t have any.

And I understand that everybody makes mistakes, I see people make mistakes, but they have help, they have guidance, they are able to get through it. When you don’t have any help or guidance you lose everything.

I started being homeless around age 12, I was homeless maybe 40 years. At times I did manage to get a house and get established, but then something would happen and I would lose it all. I remember I had a job once for Portia-Pack, they made products for the airlines. I was a maintenance mechanic.

I got arrested – I lost my job, I lost my house, my car, my clothes, I lost everything. And I was found not guilty. I didn’t do anything.

I was in the wrong place at the wrong time. And I wouldn’t have lost everything if I had a support network, they could have picked up my car, moved my stuff out of my house…

There comes a time you just give up, you don’t see the light at the end of the tunnel, you just think that this is how society sees me, this is what’s going to have to happen. Then, I don’t know, I wandered into the clinic one day, and maybe there was a glimmer of light at the end of the tunnel, maybe there are people here who are concerned and willing to help. And I guess the transition takes place gradually. The road to recovery is plagued by relapses, you get up, you fall down and get back up and keep going, but you get stronger every time, and it gets easier.

Give a person dignity, give them confidence in themselves, show them a better way, and you will have a successful person. And I’m not talking about myself, I’m talking about everyone. Give them the opportunities, give them the blessings in life that they were deprived of – if everyone lived to help others, we wouldn’t worry about going to paradise, we would already be in paradise.

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By Mudit Gilotra, MD Medical Director Valley Homeless Healthcare Program

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The Bulletinâ&#x20AC;&#x192; March / April 2019

Arminda Perez, a former VHHP nurse, walks arm-in-arm with one of her long-time patients. In homeless healthcare, the essence of our role is a therapeutic connection with our patients.Â

I

am sitting in our mobile medical unit on a Thursday morning, gearing up for a busy day. As we power up the computers and start registering patients, I hear a loud voice coming from the street corner. I peek outside and see a middle-aged disheveled man, Alex, speaking to the air, gesturing aggressively, but staying over in the corner, in his own space, in his own world.

Unexpectedly, he is cradling a little dog in one hand, a dog he loves dearly by the way he holds on to her.

I am a family physician and the medical director of The Valley Homeless Healthcare Program (VHHP). We are a part of the Santa Clara Valley Health and Hospital System (SCVHHS) and operate 14 clinical access points throughout Santa Clara County, including three mobile medical units. Our mission is to promote human dignity, relieve suffering, and provide hope so that people can achieve their full potential and improve their quality of life. We bring our three mobile medical units to all parts of the county as an attempt to better meet people where they are. These are not mere recreational vehicles though. They are sophisticated clinics on wheels staffed with medical and psychiatric providers, social

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For people who cannot get to VHHP’s brick-and-mortar clinics, VHHP has three Mobile Medical Units that bring health care services directly to people all over the County. These are fully-equipped clinics on wheels. workers, nurses, psychologists and outreach workers, in an attempt to create a robust, whole-patient, team approach to each client we see. We recognize that our clients are incredibly vulnerable from a medical, mental, and social perspective and we need to better support them in each of these domains.

Back to Alex. I pop out of the bus and cautiously approach him. After introducing myself and explaining who we are, I offer to take him into the bus, but he is wary to go with me. I decide in the moment to walk around outside with him, in his safe space. As we stroll around the block, I do my best to perform a “medical visit.” Through his tangentiality, I gather that he has suffered with mental illness and methamphetamine and alcohol addiction for several years. His parents used to take care of him, but when they passed away, his siblings sold the house, got him a vehicle, and sent him away. With his level of disorganization, he had no chance of holding on to that vehicle, which long ago was impounded by the state.

He sleeps outside and has his beloved dog which keeps him going. Slowly, over the next 30 minutes, I validate his struggles as best I can and introduce him to our team members, our psychiatrist, our psychologist, and most importantly our social worker and outreach worker. By the end of that visit, we have not started a single medication, nor have I gathered much of his medical history, but I hope that we have sparked a connection that will bring him back.

Next Thursday came and the Thursday after that, and Alex was waiting, dog in hand, every week. We start Naltrexone to curb his alcohol use, start monthly Paliperidone injections to clear his mind, and eventually get him into a rehabilitation program to treat his methamphetamine addiction. As he comes out of rehab, we line up a long term housing option to keep him and his dog off the street. We met him 9 months

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ago, and he has been clean for 7 months and housed for 4 months and just started working part-time. Our visits, which were once much more complex, now revolve around cancer screening and working to quit smoking cigarettes.

Every time I meet a new patient like Alex, I get a chance to travel back to the beginning of medical school and remind myself that the essence of the physician’s role is a therapeutic connection with the patient directly in front of them. This connection, in this day and age, is often lost behind metrics, endless clicks, alerts, and duplicative documentation in health records, volume expectations, patient satisfaction scores, and other demands beyond direct patient care. At VHHP, we consciously put all of that noise on pause and attempt to bring our most present and best selves to each visit, knowing that if we can make that therapeutic connection, we have a chance to partner with our patient and provide profound treatment.

Alex’s story is far from unique. We exclusively care for homeless clients, the vast majority of which suffer from severe mental illness, substance dependence, or both. For many clients in throes of delusion and drug addiction, their path is not as straight and narrow as Alex’s. We may improve their life incrementally but then they relapse or slide back, and it feels like we are starting from the beginning again. However, we are there for them at every relapse, every false start and new beginning because we know we must build a trusting and stable relationship in their otherwise chaotic world if there is any chance they will succeed. For those who are reading this and struggle with taking care of patients who are homeless, know that we struggle as well, but by taking the focus from improving a metric to focusing on partnering with the patient in front of you, we are energized by our work and the therapeutic relationships we build.

USEFUL RESOURCES FOR HOMELESSNESS Valley Homeless Healthcare Program (VHHP) - https://www.scvmc.org/clinics-and-locations/Valley-Homeless-HealthProgram/Pages/health-care-services.aspx VHHP provides comprehensive, multidisciplinary healthcare services for individuals experiencing homelessness, including primary care, psychiatry, psychotherapy, neuropsychiatric testing, substance use treatment, outreach, case management, and more. VHHP is a program of Santa Clara Valley Medical Center and operates 14 different clinical access points that all operate on a walk-in basis and provide services regardless of the ability to pay.

Life on the Streets: Voices of the Homeless - http://lifeonthestreets.buzzsprout.com/175126 This podcast was created by VHHP in partnership with StoryCorps. You can listen to people experiencing homelessness tell their own life stories.

National Healthcare for the Homeless Council (NHCHC) – www.nhchc.org NHCHC is a multidisciplinary professional organization that sets national standards for homeless healthcare. Their website contains extensive resources and supports for clinics and providers serving people experiencing homelessness. Among many other services, they organize a network of providers of all disciplines, collect research and best practices, and host annual conferences.

Homeless Helpline (City of San Jose) – 408-510-7600. This is a resource for people experiencing homelessness. If patients call, they can get connected with the homeless system of care.

Homeless Resource Booklet - http://ca-sanjose.civicplus.com/DocumentCenter/View/11171 An up-to-date listing of the shelters and support services for people experiencing homelessness in Santa Clara County.

Gateway – 1-800-488-9919. The phone number for patients to access substance use treatment services of all acuity levels, including connections to services like detox and medication-assisted treatment.

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March / April 2019 The Bulletin

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The Bulletin March / April 2019

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By Sara Jeevanjee, MD

M

Medical Director, Medical Respite Program, Valley Homeless Healthcare Program

s. F was followed by our backpack medicine team for her poorly controlled heart failure, frequently resisting hospitalization until she would become too sick to refuse. After one such admission, she came to our medical respite program, a twenty-bed facility housed within a homeless shelter and designed for individuals experiencing homelessness to recuperate after hospital discharge. There, she expressed interest in trying to get sober from methamphetamine and alcohol, the root causes of her severe heart failure. She met with our psychologist to work on her feelings of guilt and sadness around using, feelings that threatened her sobriety because they triggered her to use. Our psychiatrist initiated treatment for her previously undiagnosed bipolar depression, and she worked with our social worker to transition to a mental health and substance use program, where she continued to thrive. Almost two years later, Ms. F is now housed, employed, and regularly following up in our primary care clinic!

Individuals experiencing homelessness, such as Ms. F, suffer from disproportionately high rates of trauma (both physical and psychological), mental illness, substance use disorders, food insecurity, lack of social support, physical frailty, and cognitive impairment.1 They have

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The Bulletinâ&#x20AC;&#x192; March / April 2019

complex needs and struggle to navigate referrals and appointments. At the Valley Homeless Healthcare Program, our model of integrated care with walk-in appointments seeks to address that.

Integrated, multidisciplinary team care is the core foundation of how we operate. Often defined as integrated medical and behavioral health services, our integrated care teams include behavioral health providers (social workers, marriage and family therapists, psychologists, psychiatrists, and substance use treatment counselors) and medical providers, as well as non-clinical support staff, such as outreach workers and front desk staff, who are at the front line, triaging and ensuring our patients’ needs are met. By providing all of these services together, not only do we ensure easy access to behavioral health providers, but we are also better able to coordinate and collaborate in our patients’ care.

What does true integrated care look like in practice? For Ms. F, it was psychology, psychiatry, and social work each working to support her recovery through psychotherapy, treatment of her underlying mental illness, and referrals to substance use treatment programs, while I managed her heart failure and atrial fibrillation. Throughout her stay at the medical respite program, each of us coordinated with one another and reinforced the work of our colleagues, encouraging Ms. F to pursue a treatment program referral, reinforcing relapse prevention skills, and reflecting on how well she was doing medically.

For patients with severe mental illness but apprehensive to see behavioral health, integrated care is warm handoffs or joint visits between medical providers like myself and our psychiatrists or psychologists. This not only helps reduce the barrier to accessing mental health care, but also helps reduce stigma among our patients who are resistant to receiving mental health care. If patients are still resistant to seeing behavioral health, the joint visit allows our behavioral health providers to provide medication recommendations for me to implement.

Integrated care is a patient who is new to Santa Clara County who comes into clinic expecting to get refills on medications, and then walks out of the visit with not only the refills, but also a referral to a transitional housing program, a General Assistance application completed, and local Santa Clara Medi-Cal pending.

For patients needing to make it to an important subspecialty appointment, integrated care means connecting with our outreach workers who will come out to wherever our patients are staying, whether it is down a creek far off any road, in an encampment in a deserted field by the airport, or requires jumping a fence to a closed off walkway. Our outreach workers will transport our patients to their appointments, often accompanying them and then helping them navigate the subsequent maze of tests and follow-up appointments, even delivering medications to them. In fact, our outreach workers often find our future patients, engaging them and building trust so they are eventually willing to receive care from our team.

For patients taking buprenorphine for opioid use disorder, integrated care is when our psychologist, who just met with them before their appointment with me, lets me know that they relapsed. The two of us think through what the next steps should be, so I can walk into the appointment prepared with ideas of how to work with them.

Integrated care allows us to address our patients’ multifaceted needs, promote their health to the best of our ability, collaborate in management plans to balance safety and harm reduction, and support one another along the way. It also allows us all to learn from one another, strengthening each of our skills to better understand and meet our patients’ needs. Working at the Valley Homeless Healthcare Program gave me a crash course in understanding cash benefits, learning the criteria for various transitional housing programs, and gaining confidence in initiating many psychotropic medications. I also appreciate that many of our other providers know details of our patients’ lives that provide insight into the immense trauma and loss many of our patients have suffered, and remind me that those patients that I find most challenging are often those who have suffered the most.

I cannot imagine providing primary care any other way. The benefits of integrated care are not limited to homeless healthcare programs. Though we in homeless healthcare see a disproportionately high burden of mental illness and substance use disorders among our patients, 19% of adults in the general population suffer from mental illness and, in 2017, 7.2% of adults and adolescents met criteria for substance use disorder.2 Food insecurity. Housing instability. Lack of transportation. The more you look the more you will find that conditions like hypertension and problems like medication adherence, are a small part of a bigger picture. Integrated behavioral health services in primary care improves clinical outcomes, patient and provider satisfaction, treatment adherence, and access to care, and is cost effective. 3 Saddling primary care physicians with the expectation that they must address many of the social determinants of health during a 15-minute clinic visit is a losing battle. Who is surprised that burnout is so high among primary care physicians?4 Primary care physicians are not consistently trained in diagnosing and treating mental illness, conducting motivational interviewing around substance use disorders, or providing patients with information about available community resources. There are other professionals who can provide these services much more effectively. Though we all work best when we are flexible in addressing what’s within “our domain,” our patients are best served when their needs are addressed by those professionally trained to do so, and when, we as primary care physicians, have access to their expertise and perspective.

Sources 1. Fazel, S., Geddes, J. R., & Kushel, M. (2014). The health of homeless people in high‐income countries: Descriptive epidemiology, health consequences, and clinical and policy recommendations. The Lancet, 384, 1529–1540.

2. Substance Abuse and Mental Health Services Administration. (2018). Key substance use and mental health indicators in the United States: Results from the 2017 National Survey on Drug Use and Health (HHS Publication No. SMA 18-5068, NSDUH Series H-53).

Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www. samhsa.gov/data/ 3. Blount, A. (2003). Integrated primary care: Organizing

March / April 2019 The Bulletin

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Sergio Salazar, a public health community specialist, walks through a homeless encampment, bringing healthcare to people who live in hard-to-find places. VHHP has brick-and-mortar clinics, mobile medical units, and a Street Medicine team, all ready to provide services wherever people are located.

Senior health services representative Julie Gonzales (far left) and physicians Dr. Jackie Newton and Dr. Sara Jeevanjee give flu shots, blankets, socks, and beanies on nighttime street outreach during the cold winter months.

VHHP nurses Maria Serrano and Mark Block find a woman experiencing homelessness during street outreach, and tend to her wounds right then and there.

Integrated, multidisciplinary team care is the core foundation of how VHHP operates. VHHP consists of primary care providers, psychiatrists, psychologists, medical social workers, nurses, health service representatives, pharmacists, community health workers, public health community specialists, outreach drivers, and financial counselors.

the evidence. Families, Systems and Health, 21, 121–134.

4. Shanafelt TD, Boone S, Tan L, et al. Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. Arch Intern Med. 2012;172(18):1377–1385.

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Resources: https://www.nhchc.org/resources/clinical/tools-and-support/interdisciplinary-models-care/

Our Efforts: A Drop in the Bucket

By Cheryl J. Ho, MD Co-Founder of the Valley Homeless Healthcare Program With all of the different propositions and measures that face us every Election Day, it’s easy to become jaded and wonder where all of our hard-earned taxes go. At least that’s how it is for me – with the exception of very local funding, such as at our neighborhood schools, I find it hard to know what makes a difference and what doesn’t.

I joined the Valley Homeless Healthcare Program in 2004 as one if its co-founding physicians and my impetus at that time was to provide healthcare to some of the most marginalized in the wealthy Silicon Valley. Soon after I joined, the County established a Blue Ribbon Commission to End Homelessness led by then District 1 County Supervisor Don Gage and then San Jose Mayor Chuck Reed. I have to admit, with my unseasoned eyes, I thought this was all bureaucratic poppycock, meant for show to the public, but I as a doctor who was in the trenches, was doing the real work among the actual faces of persons experiencing homelessness.

Yet slowly, my patients began to get housed. I used to pride myself when I walked into the County’s largest homeless shelters (the Boccardo Reception Center on Little Orchard Street in San Jose) that I was like Norm at the Cheers Bar. Or when I was stopped at a stoplight next to a panhandler – I would often conduct my clinic visit right then and there before the light turned green. However, after the Housing 1000 initiative in the earlier part of this decade, nearly 1000 homeless individuals were housed in nearly three years. Truth be told, today I very rarely see my old patients anymore on the streets; nearly every single one of them have been housed.

In my most recent rendezvous with the County, I am leading the Permanent Supportive Housing Team which has the gutsy aim to provide wraparound primary care and mental health services to thousands of people experiencing homelessness who will receive permanent housing that is accompanied with personalized, flexible support services. The National Health

Care for the Homeless Council defines permanent supportive housing, or PSH, as an intervention that combines low-barrier affordable housing, health care, and supportive services such as case management and mental health support, in order to assist homeless persons in transitioning from homelessness. PSH typically targets people who are homeless or otherwise unstably housed, experience multiple barriers to housing, and are unable to maintain housing stability without supportive services.

This model has been shown to not only impact housing status, but also result in cost savings to various public service systems, including health care.

In my role with the PSH team, I am seeing scores of my current patients about to be placed in one of many new housing developments that are currently breaking ground. In your spare time, check out 2nd Street Studios in downtown San Jose (about to open) or Villas on the Park next to St. James Park also in downtown. They are beautiful, new residences that will provide a stable, healing place to call home with built-in support services located on the ground floor. Much of this funding came from 2016’s Measure A (yes, there are multiple Measure A’s that have come up for vote), a $950 million Affordable Housing Bond that was passed by Santa Clara County’s voters that year. As of this writing, upwards of $234 million in multi-family housing developments have been approved, in 6 cities, with 19 housing developments coming online in the next few years.

No, the County did not pay me to say this, nor am I a member of any political action committee. I am simply a physician working among those individuals experiencing homelessness, and I am witnessing the power of what can happen when government works together and people help to fund these gigantic initiatives. It’s a phenomenal experience to witness when housing is the single largest, most enduring medical intervention for promoting health and well-being that supersedes any evidence-based medication or procedure that I can provide. It’s a lot for my doctor brain to behold, but it’s enough to make me want to get out and keep voting. Keep it up, my colleagues.

March / April 2019 The Bulletin

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OPINION

A Psychiatrist’s Perspective on Homelessness

By Jea-Hyoun Kim, MD Psychiatrist for Valley Homeless Healthcare Program

S

amuel (a pseudonym), a late middle-aged man with graying hair and a stern expression, had seen psychiatrists for years, but still felt like no one understood him.

Each week, the nurses would encourage him to see me at our mobile medical unit, since he was visibly psychotic. He was constantly talking to himself, and concerned that the FBI had implanted devices inside him. A previous doctor discounted his paranoia, so he was initially reluctant to come in. Worryingly, he was not taking any antipsychotics. At the same time, he was disorganized, and was using an excessive amount of benzodiazepines and sleep aids. In doing so, he became altered, forcing shelter staff to call 911. When we finally started meeting, he had already been to the emergency department twice in recent months.

I am a psychiatrist for the Valley Homeless Healthcare Program. Each time I see a new patient like Samuel, I spend the better part of an hour just listening. This entails bearing witness to unimaginable suffering. Frequently, patients have not seen a psychiatrist in years, or their care has been fragmented due to insurance issues. We hope that our clinic is a place for them to be vulnerable, to share the fear, disappointment, and hopelessness they’ve been burdened with for far too long. Of course, struggling with mental illness can make navigating homelessness, itself already a harsh condition to tolerate, even more difficult.

Patients seek psychiatric care for many reasons. Some are paranoid, and have trouble identifying a safe place to sleep – they’re concerned about being followed and spied upon. Depressed patients find it hard to apply for resources when they’re unmotivated and fatigued. Others have significant anxiety related to stressors they have endured, including domestic violence, rape, assault, and traumatic losses, like losing loved ones to suicide or homicide. A common thread is early childhood trauma, such as living in foster care or facing homelessness at a young age.

Substance use disorder is also prevalent in our patients.

Some patients’ only method of coping is misusing methamphetamines, alcohol, or opioids. Many start using in adolescence to avoid the pain they experience from stressors like parental substance abuse or divorced parents. In a vicious cycle, the substance use exacerbates their mood symptoms, anxiety, or psychosis.

Over time, I realized that Samuel not only had schizophrenia, but had also been abusing methamphetamines and alcohol.

Prior records showed that he was doing well until he stopped his

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psychiatric medications. Afterwards, he started using drugs, and subsequently lost his housing. Likely due to his history of substance abuse, he would frequently overdose on his prescribed medications, so that he could feel their effects immediately. This led to his emergency room visits. Eventually, I convinced him to taper off of the sedating medications, and placed him on a monthly injectable antipsychotic, with only one other oral medication for anxiety.

The challenges of homelessness influence the way I practice. Because patients often do not have a place to safely store their belongings, I avoid medications that have intolerable sideeffects when abruptly discontinued. If patients are staying in public places, I don’t prescribe medications that are too sedating, out of concern that they could be assaulted while asleep.

Consistent follow-up can also be hard, so I have a preference for long-acting injectable antipsychotics over daily oral medications.

I am fortunate to work as part of a larger team. For patients who are reluctant to seek psychiatric care, because of the stigma of being labeled with a mental illness, we implement joint visits with the primary care doctor and myself, until they are ready to talk with me, individually, for a complete evaluation. Outreach workers go out to encampments to build rapport with people, in the hopes that they’ll come to the clinic. Nurses organize the clinic flow, and triage which patients need to be seen first. The pharmacist obtains prior authorizations and ensures that medications are available. Psychologists provide trauma-informed therapy and teach patients coping skills through group therapy.

And, social workers help patients find temporary shelter and apply for disability benefits.

As a team, we cared for Samuel. Our nurses contacted him to return for frequent follow-up visits. The pharmacist helped get coverage for a newer injectable medication that is dosed once every three months. Gradually, his paranoia and anxiety improved. Nowadays, he is well-groomed and more pleasant, sometimes even cracking a smile. Moreover, he’s been sober for over a year, and completely off benzodiazepines. And best of all: he has been organized enough to obtain permanent housing.

He’s staying at our shelter for just a few more weeks.

Prescribing medications is only part of what I do. The relationships I develop with patients is what, over time, ultimately brings about healing. Many patients carry with them a constant sense of demoralization. They may live in vehicles or sleep on park benches and consequently feel marginalized. I see and hear my patients, and in the process, validate their suffering. Whether it is reframing cognitive distortions for a depressed person, encouraging someone to stay sober for one more day, or celebrating when someone finally gets housed, I see my role as walking alongside patients on their journey of recovery.

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March / April 2019 The Bulletin

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Health Homes Program

Overview

The Medi-Cal Health Homes Program (HHP) helps manage and coordinate care for Medi-Cal managed care members with certain chronic health and/or mental health conditions who have high health care needs or experience chronic homelessness.

What is the Health Homes Program?

• The HHP gives qualified members extra services, including their own care team that works together to connect their health care services and doctors and links them to community and social services • Members get these extra services at no cost as part of their Medi-Cal benefits • Members can keep their doctors, but now they can access an added layer of support • The HHP will not take away or change any of the member’s current Medi-Cal benefits The HHP is for Health Plan Members Only health plan members can access HHP services. Medi-Cal beneficiaries who receive care through the fee-forservice delivery system must enroll in a health plan to see if they qualify.

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The Bulletin March / April 2019

Who Can Access HHP Services?

Medi-Cal members with certain chronic conditions and high health care needs can access HHP services.

Members must meet all 3 of the following requirements:

1

Be enrolled in a Medi-Cal managed care health plan; and

2

Have certain chronic health and/or mental health conditions; and

3

Meet at least one acuity or complexity criteria.

Members can choose to access HHP services if they qualify.

See the “Eligibility and Enrollment” section for more information.

Overview

Health Homes Program

What Services Does the HHP Offer?

The HHP offers 6 types of services to help members manage and improve their health:

1

Care Management. Develop and implement a Health Action Plan to manage and guide their care

4

Care Transitions. Help them move safely and easily in and out of the hospital or other treatment facilities and where they live

2

Care Coordination.

Coordinate care and information across all their providers

5

Member and Family Supports. Educate them and their personal support system about their health issues to improve treatment adherence

3

Health Promotion. Teach them about how to monitor and manage their health

6

Referrals to Community/ Social Services. Connect them to community and social services, including housing as needed

March / April 2019â&#x20AC;&#x192; The Bulletin

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Overview

Who Provides HHP Services?

Each member is given a care team, including a care coordinator. The care coordinator works with all of their providers— such as doctors, specialists, pharmacists, social service providers and others—to make sure everyone is on the same page about their needs and care.

Their care team is led by someone from their CommunityBased Care Management Entity (CB-CME) or health plan.

Health Homes Program

How Do Qualified Medi-Cal Members Access HHP Services?

There are 3 ways to access HHP services:

1

Many members who may qualify will be contacted

2

A provider submits a referral form for a member

3

A member contacts their health plan for information and to see if they qualify

What Are CB-CMEs? CB-CMEs are health care providers and community organizations that contract with health plans to provide HHP care management, care coordination, and other services.

CB-CMEs can be primary care providers, Federally Qualified Health Centers, community health centers, local health departments, and other providers. Many members will be able to receive HHP services where they already receive care.

26

Can Members Access HHP Services and Other State Programs?

It depends on what the other program is. For details, see the “Eligibility and Enrollment” section.

The Health Homes Program

The Bulletin March / April 2019bit.ly/HealthHomes

California Health Homes Program Educational Workshop May 8, 2019 | SCCMA conference room Please join us on May 8, 2019 in the SCCMA conference room located at 700 Empey Way, San Jose, CA 95218 for an educational workshop on a new Medi-Cal program called the California Health Homes Program (HHP). The program offers eligible Medi-Cal members extra services as part of their Medi-Cal Managed Care Plan, including a care team that connects their doctors and links them to community and social services. Read below for more details about the HHP. Chris Flannery, an Outreach Specialist with Harbage Consulting, will present on the HHP. Chris works on behalf of the California Department of Health Care Services to implement the HHP and to engage and educate stakeholders about the program. If you cannot attend in-person, you can participate via webinar. To register for this free event, please contact Sameera Manucher (sameera@ sccma.org) or register at www.sccma-mcms.org.

March / April 2019â&#x20AC;&#x192; The Bulletin

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Medical Times From the Past

The History of the Stethoscope

By Michael Shea, MD

Leon P. Fox Medical History Committee

I

n the pre-stethoscope era, examination of the heart was done by percussion and palpation of the chest. This was discovered by Leopold Auen Brugger of Vienna. Only occasionally did a physician see fit to place his ear directly on the chest and practically never elsewhere on the body.

In 1816, when Rene Laennec, a French physician, was asked to consult on a patient with heart disease and obesity, he questioned how he might examine her heart. He said, “I was led to recall a well-known acoustic phenomenon, namely, if the ear can be applied to one extremity of a beam, a person can very distinctly hear the scratching of a pin at the other end. I took a quire of paper which I rolled together as tightly as possible, and applied one end to the precordial region. By placing my ear at the other end, I was agreeably surprised at hearing pulsations of the heart tones more clearly and distinctly than I had ever been able to do by the immediate application of the ear to the chest.”

He struggled to find a name for his invention, discarding such names as “sonometer,” “medical cornet, and petrolique.” He particularly disliked his uncle’s selection of “thoraciscope.” Finally, he chose stethoscope from the Greek meaning, a look into the chest.

He continued his experiments and discovered that a hollowed-out piece of pinewood was the best choice to detect heart and lung sounds. This stethoscope design was approximately 20 inches long, two inches in diameter, and cylindrical. He made it in three parts with a slight funnel shape at the bell end. Wood turners in England quickly picked up his model, and by the 1820’s examples were available for physicians in London.

Rene Laennec, in addition to creating the stethoscope, was able to identify the sounds in the chest and apply them to diseases of the heart and lung.

Over the years, many modifications were made of the monaural stethoscope to improve its efficiency, such as making Rene Laennec's wooden-tube, one end the shape of a bell monaural stethoscope of 1816 to transmit low pitched

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The Bulletin March / April 2019

sounds and the chest piece flatter and covering the end with a diaphragm of parchment or ivory. Later materials used included wood of every variety, glass, ivory, silver, pewter, and brass. An extralong stethoscope of 35 cm was used in pauper practices when physicians wanted to distance themRene Laennec, inventor of the selves from unstethoscope clean, flea ridden patients.

Attempts were made to produce binaural stethoscopes as early as 1829, but it was only when rubber was introduced in the 1850’s that a reasonable improved model of the binaural stethoscope was produced. The invention of the binaural stethoscope is attributed to George Phillip Camman who, in 1853, published specifications for his model using ivory earpieces, a wooden chest piece, and woven tubing held together by a broad rubber band.

Other improvements to the stethoscope came in 1926 when Dr. Howard Sprague of Harvard Medical School and M. B. Rappaport, an electrical engineer, developed a double-headed chest piece. One side of the chest piece, a flat plastic diaphragm, rendered higherfrequency sounds when pressed to the patient’s skin, while the other side, a cup-like bell, allowed sounds of a lower frequency to be discerned.

The next major improvement came in the early 1960’s, when David Littmann, a Harvard Medical School professor, created a new stethoscope that was lighter than previous models and had improved acoustics.

Presently we have technically superior diagnostic tools, such as ultrasound, mri, cat scans, angiograms, and others. Even so, most physicians today still use the age- old reliable stethoscope when seeing patients.

Classifieds OFFICE SPACE FOR RENT/LEASE MEDICAL OFFICE SPACE FOR LEASE • SANTA CLARA Medical space available in medical building. Most rooms have water and waste.

Reception, exam rooms, office, and lab.

X-ray available in building. Billing available.

2,500–4,000 sq. ft. Call Rick at 408/2280454.

1100 SQ. FT. • MTN VIEW-CUESTA PARK Recently remodeled modern - 3 Exams - 4 Work Stations - Parking - Partnership, LLC - Cat 5 Wiring - Kitchenette - Workroom/ Lab. Light - High Ceilings - Storage. Contact greatoffice2017@gmail.com.

BEAUTIFUL MENLO PARK OFFICE TO SHARE New office, upscale and modern – to share with existing pain management practice.

Ideal for psychologist or psychiatrist. Contact Dr. Maia Chakerian at 408/832-3930.

OFFICE SPACE FOR LEASE AND OR SALE Medical office space 1,969 sq. ft. on Jackson Avenue opposite to Regional Medical Center for sale or lease, with option to buy. Very well maintained office building.

Please call 408/926-2182 or 408/315-4680.

EMPLOYMENT OPPORTUNITY OCCUPATIONAL MEDICINE PHYSICIANS • PRIMARY CARE, ORTHOPEDICS, & PHYSIATRY Our occupational medical facilities offer

• • • • • •

METRO MEDICAL BILLING, INC.

Full Service Billing 25 years in business Bookkeeping ClinixMIS web based software Training and Consulting Client References

Contact Lynn (408) 448-9210 lynn@metromedicalbilling.com Visit our Website: metromedicalbilling.com

a challenging environment with minimal stress, without weekend, evening, or “on call” coverage. We are currently looking for several knowledgeable and progressive primary care and specialty physicians (orthopedist and physiatrist) interested in joining our team of professionals in providing high quality occupational medical services to Silicon Valley firms and their injured employees. We can provide either an employment relationship including full benefits or an independent contractor relationship. Please contact Rick Flovin, CEO at 408/228-0454 or e-mail riflovin@allianceoccmed.com for additional information.

WANTED FAMILY PHYSICIAN Family medicine physician needed to share a growing outpatient practice. Start at 16 hours/week and share patient load.

Practice caters to 75% PPO, rest Medicare and HMO. Contact ntnbhat@yahoo.com / 408/839-6564.

FOR SALE OFFICE SPACE FOR LEASE AND OR SALE Medical office space 1,969 sq. ft. on Jackson Avenue opposite to Regional Medical Center for sale or lease, with option to buy. Very well maintained office building.

Please call 408/926-2182 or 408/315-4680.

PRIVATE PRACTICE AND BUILDING FOR SALE Family Practice for sale, including inventory, equipment and Real Estate (can also be leased). Great downtown San Jose location. Financing may be available. Minor Laser Surgery performed as well. Call 415/308-3064.

GREAT BUSINESS OPPORTUNITY • PART-TIME OR ADD-ON TO YOUR EXISTING PRACTICE Medically-supervised weight loss program with 30-year track record. Cash, no insurance. Practice obesity medicine and help patients overcome their weight problems and improve their health. Seeking an associate to train with eventual sale. Contact me at southbayweightloss@gmail.com.

SJSU IS HIRING Job Title: Psychiatrist Job ID: 24928 Full/Part Time: Full-Time Regular/Temporary: Regular Job Code: 7750/ Range 1 Department: Student Health Center ABOUT THE POSITION The SHC Psychiatrist works independently in performing assigned student services and consultations with SHC medical staff and CAPS counseling staff. Consultation could involve advice regarding psychiatric diagnostic treatment and psychotherapeutic activities and are in accordance with the overall operation of the SHC and within the scope of the program established by the Board of Trustees.

The incumbent may provide highly specialized advice regarding planning, coordinating, and evaluating ongoing psychiatric care of students. All staff are expected to conform to CSU, State, and Federal regulations and laws. Although unlikely, there may be an occasion of brief evening or weekend work.

Working collegially and collaboratively to support student success is the bottom line purpose of this and all SHC positions.

To apply, please visit: http://www. sjsu.edu/hr/careers/jobs and search for Job ID: 24928.

EQUAL EMPLOYMENT STATEMENT: SJSU is an Equal Opportunity Affirmative Action employer. We consider qualified applicants for employment without regard to race, color, religion, national origin, age, gender, gender identity/expression, sexual orientation, genetic information, medical condition, marital status, veteran status, or disability.

It is the policy of SJSU to provide reasonable accommodations for applicants with disabilities who self disclose.

March / April 2019 The Bulletin

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June 6, 2019 | 6:30-9:30pm 2019 MCMS Physician of the Year Banquet Please join the MCMS at the Bayonet Blackhorse, Seaside for an evening filled with food, drinks and entertainment. CMA President-Elect Peter Bretan, Jr., M.D. will be the guest speaker for the evening.

The prestigious Physician of the Year award is given to a strong motivator and educator, has a good rapport with patients, has demonstrated extraordinary professional competence and is a strong role model for young physicians.

In Memoriam Arthur M. Brown, MD

John D. Condie, MD

Herbert K. Kain, MD

Richard A. Cirone, MD

Thomas G. English, MD

David W. McCullough, MD

*Obstetrics & Gynecology 7/2/1927 – 2/15/2019 SCCMA member since 1959

*Pediatrics 7/3/1938 – 10/19/2018 SCCMA member since 1969

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*General Surgery 4/19/1927 – 11/28/2017 SCCMA member since 1965 Internal Medicine 10/31/1922 – 10/8/2017 SCCMA member since 1962

The Bulletin March / April 2019

Internal Medicine 1/1/1927 – 11/19/2018 SCCMA member since 1964 *Family Medicine 11/15/1934 – 3/9/2019 SCCMA member since 1965

NOT ALL HEROES WEAR CAPESâ&#x20AC;Ś SOME WEAR DOCTORSâ&#x20AC;&#x2122; COATS Your priority is protecting your patients.

Our priority is protecting you.

For more than 40 years, the Cooperative of American Physicians, Inc. (CAP) has provided our physician members with superior medical malpractice coverage.

Our mission is to help independent California physicians deliver the best care possible, while realizing personal and professional success.

Sarah E. Pacini, JD Chief Executive Officer

CAP members also receive proactive risk management services, in-house legal and claims support, practice management resources, and so much more. Find out what makes CAP different.

CAPphysicians.com 800-252-7706

Medical professional liability coverage is provided to CAP members by the Mutual Protection Trust (MPT), an unincorporated interindemnity arrangement organized under Section 1280.7 of the California Insurance Code.

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