Summer 2023 Bulletin: Specialty Focus - Allergy, Asthma and Immunology

SPECIALTY FOCUS: Allergy, Asthma and Immunology

WHAT: Physicians for a Healthy California (PHC) Health Equity Leadership Summit attendees will find community, engage in hands-on trainings and workshops, and hold in-depth conversations about how they are addressing the issue of health equity in California through their care of underserved communities throughout the state.

WHY: You will leave feeling energized and inspired to continue your important work to improve the lives of all Californians.

WHO: Physicians, executives, advocates and allies are encouraged to attend. Featured speakers include:

Lupe Alonzo-Diaz President and CEO, Physicians for a Healthy California

Lisa Gauthier

Mayor, East Palo Alto, and Senior VP, Inclusion and Belonging, Silicon Valley Leadership Group

Deena McRae, M.D. Associate VP of Academic Health Sciences, University of California Health

Pooja Mittal, M.D. Chief Health Equity Officer, HealthNet

We will also be honoring the winners of this year’s health equity leadership awards. (Nominations are due August 4, 2023.)

HOW: Register today at phcdocs.org/equity-summit

In this issue

SCCMA is a professional association representing over 4,500 physicians in all specialties, practice types, and stages of their careers. We support physicians like you through a variety of practice management resources, coding and reimbursement help, training, and up to the minute news that could affect your practice. The Bulletin is our quarterly publication.

Santa Clara County Medical Association

SCCMA OFFICERS

President | Anlin Xu, MD

President-elect | Gloria Wu, MD

Secretary | Randal Pham, MD

Treasurer | Anh T. Nguyen, MD

Immediate Past President | Clifford Wang, MD

VP-Community Health | Ken Yew, MD

VP-External Affairs | Christine Doyle, MD

VP-Member Services | Sam Wald, MD

VP-Professional Conduct | Lewis Osofsky, MD

SCCMA STAFF

Interim Chief Executive Officer | Erin Henke, CAE

Director of Membership & Programs | Angelica Cereno

Governance & Advocacy Associate | Emily Coren

Facilities & IT Manager | Paul Moore

SCCMA COUNCILORS

El Camino Hospital of Los Gatos | Shahram S. Gholami, MD

El Camino Hospital – Mountain View | Fahd Khan, MD

Good Samaritan Hospital | CK Park, MD

Kaiser Foundation Hospital - San Jose | David Hensley, MD

Kaiser Permanente Hospital | Reena Bhargava, MD

O’Connor Hospital | David Cahn, MD

Regional Medical Center | Raj Gupta, MD

Saint Louise Regional Hospital | Kevin Stuart, MD

Santa Clara Valley Medical Center | Patricia Salmon, MD

Stanford Health Care/Children’s Health | Laurice Yang, MD

Managing Editor | Erin Henke

Production Editor | Prime42 – Design | Market | Host

Opinions expressed by authors are their own, and not necessarily those of The Bulletin or SCCMA. 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 of products or services advertised. The Bulletin and SCCMA reserve the right to reject any advertising.

Address all editorial communication, reprint requests, and advertising to:

Erin Henke, Managing Editor

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SPOTLIGHT ON 2023 SCCMA PRESIDENT Anlin Xu, MD

Dr. Anlin Xu, a renowned allergist and immunologist in private practice, has dedicated her career to the field of medicine with the goal of helping others. In a recent interview, Dr. Xu shared her motivations, experiences, and aspirations.

Dr. Xu’s decision to become a physician was influenced by her upbringing and personal experiences. With a biology major in college and a grandfather who was a pioneering radiologist and nuclear physicist in China, she was exposed to the world of medicine from an early age. Tragically, her grandmother passed away from breast cancer, and her grandfather from lung cancer.

These experiences, combined with her skills and interests, led her to pursue a career in medicine as a way to help people in need.

During her medical training, Dr. Xu learned the importance of logical thinking and objective evidence, which she credits to her background in biology and her parents, who were both physics professors. However, she also discovered the human side of medicine, understanding the significance of knowing her patients beyond their medical conditions. She emphasizes the importance of understanding their unique desires, fears, and support systems, as well as the impact of their social and family environments in caring for her patients. Dr. Xu believes

that forming a partnership with her patients and helping them achieve their life goals is the ultimate objective of medical practice.

Dr. Xu found her passion in the field of allergy and immunology. Having suffered from terrible allergies herself, including nasal and eye allergies and eczema, she empathized with her patients and sought to find solutions for their suffering. She finds the specialty of allergy, asthma, and immunology exciting and fast-evolving, with new medications and tools emerging regularly. Dr. Xu highlights the significant impact of the environment on her patients, including the effects of global warming and climate change leading to an explosive increase in allergy and

asthma cases around the world.

Reflecting on her mentors, Dr. Xu acknowledges the influence of two key figures in her career. In medical school, she was mentored by Dr. Carl Snyderman, an otolaryngologist and skullbased surgeon. He inspired her with his gentle and supportive approach, showing her the human side of medicine. His emphasis on understanding patients’ desires and helping them live their lives with dignity had a profound impact on Dr. Xu. Another influential mentor was Dr. Homer Boushey, a renowned pulmonologist and asthma specialist during her Allergy and Asthma and Immunology Fellowship at UCSF. Dr. Boushey’s work in translational medical research, focusing on translating

lab research findings into clinically meaningful applications, greatly influenced the development of asthma treatments and shaped Dr. Xu’s understanding of the field.

When asked about her biggest accomplishment, Dr. Xu humbly expresses her gratitude for being a doctor and allergist. She takes pride in having helped numerous patients improve their lives and experiences. The gratitude and thanks she receives from her patients for positively changing their lives are what she considers her greatest achievement.

Dr. Xu became a member of the Santa Clara County Medical Association (SCCMA) early in her career, seeking support and connections within the medical community. She emphasizes the importance of nurturing and supporting physicians’ well-being, particularly addressing issues of burnout, mental health, and the challenges faced by women physicians and those in private practice. As the current SCCMA President, Dr. Xu aims to make the organization more personable and personal, focusing on member orientation, supporting private practice physicians, and advocating for physicians’ interests.

Regarding the practice of medicine, Dr. Xu highlights concerns about mental health, burnout, and the need for physicians to seek help without feeling ashamed. She also emphasizes the lack of financial education for physicians, despite their high-income status, and hopes for greater support and education in personal finance and business management.

In her personal life, Dr. Xu strives to maintain a sense of balance between work and home. She sets priorities and dedicates time to her children, her own well-being, and her work, recognizing the importance of social support, exercise, and hobbies in maintaining a healthy mind. Dr. Xu has a love for music and enjoys listening to various genres to revive her spirit. Gardening, swimming, and vacationing by the water are some of her other interests, which provide relaxation and rejuvenation.

Dr. Anlin Xu’s dedication to her patients, her commitment to improving physicians’ well-being, and her passion for helping others are sure to leave an indelible mark on SCCMA as she leads us through 2023 and beyond.

Anlin Xu, MD

Wellness Matters Webinar Series Continues

SCCMA continues its popular wellness webinar series, Wellness Matters (formerly, Resilient MD), with quarterly webinars in 2023. In Q1, attendees heard from Dr. Sheryl Recinos “One Patient at a Time.” In Q2, attendees heard from Dr. Alen Voskanian about “Reclaiming the Joy of Medicine: Finding Purpose, Fulfilment, and Happiness in Today’s Medical Industry.” View the recordings at http://www.sccma.org/ programs/physician-wellness.aspx.

$47 Million Grant Program Launched to Support Health Data Exchange in California

With a January 31, 2024, deadline approaching for many entities to begin securely exchanging health information under the Data Exchange Framework (DxF), the California Health and Human Services Agency’s (CalHHS) Center for Data Insights and Innovation (CDII) is accepting applications for Data Sharing Agreement (DSA) Signatory Grants. California entities that have signed the DSA can apply to receive direct support for DxF implementation, with financial assistance ranging from $15,000 to $50,000, or more via enhanced funding to entities serving underserved communities.

The grant program provides health and social services entities with resources to address critical operational, technical

and technological barriers to DxF implementation. Entities that have signed the DSA and can demonstrate that additional support and capabilities are needed to meet their DSA requirements are eligible to apply. There will be at least three rounds of grants in 2023 with the first-round application window closing on June 16, 2023. First awards are anticipated to be announced in August. A second round of grants will be open in late June, with the award announcements anticipated in September. The third round will be open in July, where it is anticipated that applicants will have three months to apply in this round. Additional rounds may be added on as needed and will be announced at a later date, as necessary. Find more information at http://cmadocs.org/dxf.

CMA Legislative Advocacy Day

In April, the Santa Clara County Medical Association (SCCMA) participated in the CMA’s 49th Legislative Advocacy Day with hundreds of physicians, medical students and residents from all over California. Our SCCMA team sent 22 physicians to Sacramento to meet with our legislative offices. We had nine legislative meetings in one day – meeting with the offices for Assemblymember Berman, Assemblymember Kalra, Assemblymember Lee, Assemblymember Low, Assemblymember Pellerin, Assemblymember Rivas, Senator Becker, Senator Cortese and Senator Wahab.

Naloxone Distribution Coming

To come in the Q3 issue of The Bulletin – increased naloxone distribution for community opioid overdose responders. Naloxone OTC may be available for purchase in many other settings besides a pharmacy. Vending machines are

Physicians lobbied legislators in support of CMA’s priority issues, including:

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

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

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

becoming another increasing access source for naloxone in Santa Cara County. More to come in the next issue of The Bulletin.

Walk with a Doc is a walking program for everyone interested in taking steps for a healthier lifestyle. Attendees take a few minutes to learn about a current health topic from a physician leader, then spend the rest of the hour enjoying a healthy walk and fun conversation. It’s a great way to get out, get active, and enjoy all the benefits that come from walking. SCCMA is now a proud chapter of Walk with a Doc, offering monthly walks the second Saturday of each month at 9:30am at various locations throughout the County. Registration is free to all members, their families, patients, and community members. Well behaved dogs are welcome to join us on walks. We hope you will join us for an upcoming walk!

SCCMA Summer Social

SCCMA recently hosted the second annual Summer Social for a fun evening embracing the Aloha Spirit! More than 50 SCCMA members, field representatives from local legislative offices, and special guests gathered to enjoy live Hawaiian music, dancing, food, and shave ice as well as a presentation on Aloha Spirit by native Hawaiian healer, Kahealani Alapa’i. SCCMA President, Anlin Xu, MD provided guests with updates on current initiatives and announced upcoming programs and events for the rest of the year. Two new programs include Saving Private Practice and Walk with a Doc. The Summer Social was a great time for members to gather and celebrate the medical community!

A program designed to support our physician members from solo, small and medium medical practices

Analyzing and Negotiating

Saving Private Practice is a program created to assist physicians from solo, small, and medium medical practices. The webinar series are monthly educational sessions designed to help with office operations, decision making, and practice management. This one-hour session will be led by Prerna Marwah, MBA from Practice & Liability Consultants, LLC. This webinar will be about understanding your expected vs. actual reimbursement rates and how it is critical to your revenue stream. Learn from a successful PPO contracting expert about analyzing present contract rates and strategies for successful re-negotiation.

Prerna Marwah, MBA from Practice & Liability Consultants, LLC is an experienced Administrator that brings a wealth of knowledge in contract management and negotiation, practice management, financial management, and healthcare operations. She has an intense understanding of the managed care systems including Medicare, Managed Care Organizations, IPAs and PHOs and its dealings with primary care physicians and specialists.

A program designed to support our physician members from solo, small and medium medical practices

Top

Tips to Avoid “Practice Management Hypertension”

Saving Private Practice is a program created to assist physicians from solo, small, and medium medical practices. The webinar series are monthly educational sessions designed to help with office operations, decision making, and practice management. This one-hour session will be led by Debra Phairas, President of Practice & Liability Consultants, LLC. This webinar will provide tips to lower anxiety to successfully navigate the business side of the practice. It is just as important to invest in education about the business side of medical practice throughout your career as the clinical aspects.

Debra Phairas is President of Practice & Liability Consultants, LLC a nationally recognized firm specializing in practice management and malpractice prevention. Her background includes medical clinic administration and loss prevention management for NORCAL Mutual, a physician malpractice insurance carrier in Northern California. She has presented seminars and lectures nationwide for state and local medical/dental associations, management organizations and specialty societies. Please view website: www.practiceconsultants.net

By Anlin Xu, MD

Asthma is the most common long-term childhood disease, but it can also affect adults. As many as 1 in 12 children and 1 in 13 adults experience asthma. It affects 26 million Americans and results in a staggering $50 billion each year in healthcare costs. As with all chronic illnesses, the first step in treating asthma is educating patients on their condition, reviewing treatment options including controller verses rescue therapy, age-appropriate proper medication use, and the rules of 2’s – asthma is not well-controlled when using a rescue inhaler more than twice a week outside of exercise, and waking up more than twice a month at night with asthma symptoms.

In recent years, implementing SMART (Single Maintenance and Reliever Therapy) has simplified the medication regimen so a combination of an inhaled steroid (ICS) and an inhaled long-acting beta-agonist (LABA) can be used as needed during flares – for example, using Symbicort 8 puffs per day for 5 to 11 year olds and up to 12 puffs a day for 12 years and older. Recent trials also found SMART is helpful when used as needed in patients with mild asthma. Meta-analyses showed SMART has been associated with lower risk of severe asthma exacerbations in adolescents and adults when compared to ICS-LABA maintenance plus short-acting beta-agonist (SABA). Soon, we will also have an ICS-SABA combination that can be used as needed as well.

As allergists, we can identify potential triggers such as dust mites, pet dander and other inhalant allergies through skin and blood testing to decrease asthma symptoms and improve control. Simple environmental control measures can help to decrease allergen exposure including covering pillows, mattresses, and comforters with dust mite proof encasing, keeping the cat out of the bed and bedroom, running a HEPA air filter, and using Purina LiveClear cat food which decreases cat allergens by 47% in three weeks. In addition, for patients with allergic asthma, allergy immunotherapy can desensitize patients to their allergens, improve lung function, decrease medication dependence, and make a lasting impact.

For patients who are not well-controlled on a standard therapy of asthma medications and allergy shots, Xolair was the only biologic available for many years. Now we have several new biologics that can improve lung function, decrease not only oral steroid use and inhaled steroid dose, but also the number of exacerbations. Many of these biologics can reduce disease burden for other conditions at the same time – for example, using Dupixent for patients with recurrent nasal polyposis, moderate to severe atopic dermatitis, and/or poorly controlled eosinophilic esophagitis. Xolair is not only indicated for patients with asthma, but also those with chronic idiopathic urticaria and/or nasal polyps. Nucala is approved for hypereosinophilic syndrome, eosinophilic granulomatosis with polyangiitis as well as nasal polyps. Most asthma biologics target allergic inflammation. The newest biologic, Tezspire, can be use in patients with or without an allergic component.

The selection of a biologic that is right for each patient is dependent upon other concomitant diseases the patient may have. For example, I have a patient with allergic asthma and frequent exacerbations who is not compliant with medications/ allergy shots. He was started on Fasenra and was subsequently diagnosed with colon cancer. Despite having surgery and treatment for his cancer, having his asthma well-controlled likely improved his recovery and overall outcome.

We have come a long way from using epinephrine and theophylline for asthma to now more precision medicine in caring for our asthma patients. It will be exciting to see what the next 10-20 years will bring to hopefully alter the course of the disease and improve patients’ quality of life.

About the Author:

Anlin Xu, MD, is a board-certified allergist and immunologist and president and CEO of South Bay Allergy and Asthma Group, which offers convenient locations in San Jose, Los Gatos, Mountain View, and Redwood City, California. Certified by both the American Board of Internal Medicine and the American Board of Allergy & Immunology, Dr. Xu’s medical career began as a student at the University of Pittsburgh in Pennsylvania, where she graduated magna cum laude with a Bachelor of Science in molecular biology, and later a medical doctorate,

which she earned with honors. Dr. Xu completed her internal medicine residency at Yale University, during which time, she received a postdoctoral fellowship award by the National Institute of Health (NIH) for her research in Cutaneous T Cell Lymphoma (CTCL). Dr. Xu relocated to the San Francisco Bay Area for her fellowship in Allergy, Asthma and Immunology at a combined program of Stanford University and the University of California, San Francisco (UCSF) Medical Centers. Dr. Xu’s areas of expertise include hay fever, food allergy, asthma, allergic contact dermatitis, hives, and eczema in children and adults. She speaks Mandarin and Shanghainese fluently. In addition to her clinical duties, Dr. Xu is the president of the Santa Clara County Medical Association, and a past and current co-president of the South Bay American Medical Women’s Association. She is a member of American Medical Association and a delegate to the California Medical Association. She is also a Fellow of the American Academy of Allergy, Asthma & Immunology; the American College of Allergy, Asthma & Immunology; and the American Contact Dermatitis Society.

Anlin Xu, MD

There are 32 million people with food allergies in the U.S. and 5.6 million of them are children. Food allergies affect 1 out of every 13 children in schools. By addressing the significant over diagnosis of food allergies, implementing updated prevention guidelines and offering treatment options we can hopefully decrease these numbers over time.

60% of the time there is over diagnosis of food allergies. As

By June Zhang, MD

allergists, we not only are able to accurately diagnose the allergy but also, when possible, introduce more foods back into the patient’s diet. My personal favorite type of visit is a food challenge, where a patient can potentially tolerate a previous allergenic or thought to be allergenic food. Examples include an infant eating a baked egg product for the first time, an older child who outgrew their peanut allergy or an adult who thought they were allergic to shrimp. Food challenges can make a significant impact on a patient’s daily life.

ALLERGY,

In recent years, food allergy prevention has made dramatic changes due to the pivotal trial of Learning Early About Peanut study led by Dr. Gideon Lack, showing that consuming peanuts early and frequently in high-risk infants led to a more than 80% reduction in the development of peanut allergy. Early introduction of allergenic foods is key, especially for children with eczema when families are often avoiding many foods as they feel it improves their infant’s skin symptoms. Meta-analysis shows that avoiding foods that may flare eczema only marginally improves skin symptoms but dramatically increases the child’s risk of developing a food allergy. Instead, eczema can be very well-controlled with a good skin care regimen. It is crucial to treat eczema early and aggressively as we now know many of these infants are being sensitized to foods through their skin due to skin barrier breakdown. I always remind families if they are snacking on nuts to make sure to wash their hands thoroughly before touching the baby’s skin. Along the same lines, it is important to avoid using topical skin care products that contain foods. Lil Mixins Early Introduction Powder is a great way to incorporate allergenic foods into an infant’s diet. Barrier therapy, applying Vaseline around the mouth, before introducing new foods can also decrease topical irritation and misdiagnosis of food allergies especially for infants with facial eczema.

Current treatment options include avoidance, carrying EpiPen, and now oral immunotherapy. In 2020, Palforzia introduced peanut oral immunotherapy, the first FDA-approved treatment for food allergy. After six months of treatment, a patient is able to eat one peanut daily and reduce risk of severe allergic reactions by increasing the threshold that triggers reactions. Off-label treatments for nuts, milk, egg, wheat, sesame, and other foods can use similar dosing protocols. Even though it is a life changing treatment option as patients can now take control of their disease and improve psychosocial aspects of having a severe food allergy, oral immunotherapy is not a cure. Oral immunotherapy can rarely lead to treatment associated eosinophilic esophagitis and patients still need to carry EpiPen. Patients also need to observe a strict two-hour rest period after daily dosing for several years and possibly indefinitely. Current data is exciting as younger patients less than four years old tolerate the desensitization well and have a potentially higher chance of sustained unresponsiveness (“cure”).

The future of food allergy is bright, with numerous novel treatment options in the pipeline such as percutaneous immunotherapy in the near future, adjunct therapy with probiotics and multiple biologics. Soon there will be several options of needle-less epinephrine which will decrease usage hesitancy and improve outcomes. It is an exciting time to be an allergist. Even as a fellow, all we had was “avoid the food and carry an EpiPen.” Now we have the option to treat motivated patients and families to help decrease the burden of their disease and improve their quality of life, with more options in the near future. Hopefully, all these measures can help increase early introduction, decrease the development of food allergies, provide a painless way to administer epinephrine, offer more options to

ASTHMA & IMMUNOLOGY FOCUS

June Zhang, MD treat and maybe one day cure the disease!

About the Author:

June Zhang, MD is a board-certified allergist and immunologist with the South Bay Allergy and Asthma Group. Certified by both the American Board of Pediatrics and the American Board of Allergy & Immunology, Dr. Zhang treats children and adults. She is passionate about treating food allergies, eczema, vocal cord dysfunction, asthma and chronic hives/swelling. Dr. Zhang graduated with honors with a Bachelor of Science in cell and molecular biology from the University of Washington in Seattle before earning her medical doctorate from the Medical College of Wisconsin in Milwaukee in 2003. She later completed her pediatrics residency at Children’s Hospital Oakland in California and then moved to Pennsylvania for an allergy and immunology fellowship at Children’s Hospital of Pittsburgh and University of Pittsburgh Medical Center. She speaks Mandarin fluently and is an active member of the California Medical Association, the San Mateo County Medical Association, South Bay American Medical Women’s Association and the American Academy of Allergy, Asthma & Immunology. She is also a fellow of the American College of Allergy, Asthma & Immunology.

Recognition

Anaphylaxis is an allergic medical emergency that requires prompt recognition and immediate, appropriate intervention. To help with recognition, recent guidelines state that anaphylaxis is highly likely when any of the following three criteria is fulfilled:

Sudden onset of illness with involvement of skin, mucosal tissue or both (e.g. hives, itching, flushing, swelling of lips, tongue or uvula)

AND

1. At least one of the following:

• sudden respiratory symptoms (shortness of breath, hypoxia, cough, wheeze, stridor),

• sudden reduced blood pressure * or end organ dysfunction (hypotonia, collapse, incontinence)

2. Two or more of the following after known exposure to a likely allergen or trigger:

• Sudden skin or mucosal involvement (hives, itching, flushing, swollen lips/tongue/uvula)

By John Kellogg, MD, MS

• Sudden respiratory involvement (wheezing, shortness of breath, cough, stridor, hypoxemia)

• Sudden reduced BP or end-organ dysfunction (hypotonia, collapse, incontinence)

• Sudden gastrointestinal symptoms (nausea, vomiting, diarrhea, abdominal cramping)

3. Reduced BP after exposure to a known allergen for that patient

*Reduced Blood Pressure is defined: Age

1 month to 1 year < 70 mm Hg

1 year to 10 years < 70 + (2 x age) mm Hg

11 years to 17 years < 90 mm Hg

Adult < 90 mm Hg or more than 30% drop in baseline

First Line Intervention:

The first line treatment of anaphylaxis is solely epinephrine and the administration of epinephrine should not be delayed.

Epinephrine is best administered IM in the anterolateral thigh using a 1:1,000 concentration (1 ml = 1 mg). IM poses much less risk for cardiac adverse events than IV and is just as rapid.

Dose:

Age/Weight Epinephrine Dose (1:1,000) IM

Adults

0.3 to 0.5 mg

Children > 25-30 kg 0.3 mg

Children < 25-30 kg 0.15 mg

If response is inadequate may repeat dose every 5 to 15 minutes. If response remains inadequate consider adding 1 mg of epinephrine to 1 liter normal saline and start an IV infusion at 2 ml/min and titrate the dose upward to 10 ml/min according to blood pressure, heart rate and oxygenation.

Second line interventions:

IV Fluids for circulatory symptoms and hypotension

Children <25-30 kg 10 ml/kg bolus, max 500 ml

Adults, children >25-30 kg 500 ml bolus

H1 Antihistamines for Urticaria, Flushing, Pruritus (ineffective for cardiovascular or respiratory symptoms)

Benadryl has no advantage over second generation antihistamines when given PO.

Onset of action is 30 minutes with peak plasma levels in 60120 minutes. Benadryl may be given IM or IV. Cetirizine 10 mg IV is available as an alternative to Benadryl 50 mg IV with less side effects.

H2 Antihistamines for GI symptoms (ineffective for cutaneous symptoms)

Steroids for prevention of biphasic anaphylaxis (no role in acute reactions because onset of action is 4-6 hours)

Epinephrine nebs for laryngeal symptoms or stridor (1 mg epinephrine in 4 ml normal saline via nebulizer)

Albuterol nebs for bronchospasm, wheezing, chest tightness (5 mg albuterol in adults/children, 2.5 mg in preschool children via nebulizer) (alternative albuterol HFA + spacer 6 puffs adult/ Child, 4 puffs preschool child)

Oxygen for respiratory symptoms, hypoxia. (6 L/min will drive a nebulizer set)

Observation:

Until stable, at least one hour after onset, and at least 30 minutes after the last epinephrine. Consider extended observation for at least six hours if there are risk factors for a biphasic anaphylactic reaction such as severe initial reaction and >1 dose of epinephrine needed.

About the Author:

John Kellogg, MD, MS is an Allergy, Asthma, & Immunology Physician with the South Bay Allergy and Asthma Group, Inc. Born in San Francisco, Dr. Kellogg spent some time in the Navy after graduation from the U.S. Naval Academy as a Naval Flight Officer (NFO). He subsequently attended Stanford University to get a Masters in Biological Sciences and Tulane University Medical School to complete his MD. After residency in Internal Medicine at UCSF, he served as a staff physician at the Naval Hospital in Lemoore, CA. During his tour of duty he was appointed President of the Medical Staff of the hospital. He then went on to an allergy fellowship in Texas with the San Antonio Uniformed Services Health Education Center. Finishing 24 years of combined Navy service as the staff allergist at Naval Medical Center Portsmouth VA, he joined the South Bay Allergy and Asthma Group in 2005. Dr. Kellogg’s special interests include chronic sinusitis, immune deficiencies, contact dermatitis as well as asthma and allergic rhinitis.

John Kellogg, MD, MS

Up to 40% of patients report that at some time in their life, they have had an adverse reaction to a medication. Many of these are non-immune mediated reactions, however drug allergies affect a significant portion of the population.

Approximately 10% of patients report a history of reacting to a penicillin class antibiotic; however, when evaluated for penicillin allergy, up to 90% of these individuals are able to tolerate penicillins and therefore are designated as being penicillin-allergic unnecessarily. This emphasizes the importance of correct diagnostic testing for patients with a history of penicillin reactions.

Though penicillin allergy is certainly the most common drug allergy that we see, we are also able to evaluate possible reactions to other antibiotics, anti-hypertensives, local anesthetics, and pain medications. Many of these medications do not have validated allergy testing available, however we are able to discuss and determine whether a drug challenge would be appropriate. At South Bay Allergy & Asthma Group, we have extensive experience in the diagnosis and management of drug allergies. If you have a patient with a history of drug allergy, let us know—we can help!

About the Author:

Katharine Nelson, MD is a board-certified allergist and immunologist with the South Bay Allergy and Asthma Group and specializes in the comprehensive diagnosis and treatment of aller-

By Katharine Nelson, MD

gies and asthma in children and adults. She is certified by both the American Board of Pediatrics and the American Board of Allergy & Immunology. Dr. Nelson graduated with a Bachelor of Science in Medical Microbiology and Immunology, with honors, from the University of Wisconsin in Madison, before completing her Doctor of Medicine at the University of Wisconsin Medical School. She then completed her Pediatrics residency at UPMC Children’s Hospital of Pittsburgh in Pennsylvania, serving as chief resident. Dr. Nelson came to the Bay Area in 2009 to complete her fellowship training in Allergy and Immunology at Stanford University. Her special interests and areas of expertise include food allergy, urticaria (hives), angioedema, allergic rhinitis, asthma, and pediatric and adult immune deficiency. Outside of her clinical work, Dr. Nelson is on the board of South Bay American Medical Women’s Association and was an adjunct clinical faculty member at Stanford University School of Medicine. She is also an active member of the American Academy of Allergy, Asthma & Immunology, the American Academy of Pediatrics, Western Society of Allergy, Asthma and Immunology and the American College of Allergy, Asthma & Immunology.

MD

Katharine Nelson,

Getting Back on Track with Routine Immunizations

Vaccines are an important part of growing up, but some children in Santa Clara County have fallen behind on routine vaccinations. The County of Santa Clara Public Health Department has created materials for healthcare providers and office staff to encourage routine childhood vaccinations with parents and caregivers. Materials include counseling tips and conversation guides, wall posters in multiple languages, rack cards, and a

cgov.org to order some of these for their practice, or visit https:// bit.ly/3CQSuR6.

In addition to sharing the campaign materials, you can join the Vaccines for Children (VFC) Program. VFC is a federal program that provides vaccines at no cost to eligible children. The federal government purchases vaccines, which are then shared with VFC participants. Learn more and enroll in the California VFC at https://eziz.org/vfc/overview/

Las vacunas son parte del desarrollo saludable

Cũng như những cột mốc phát triển khác, tiêm ngừa là một phần quan trọng của thời kỳ thơ ấu. Thuốc tiêm ngừa an toàn và giúp bảo vệ để trẻ em lớn lên khỏe mạnh và hạnh phúc.

Hãy hỏi bác sĩ loại tiêm ngừa nào con quý vị cần trong năm nay.

Al igual que su primer gol de fútbol, las vacunas son una parte importante del desarrollo infantil. Son seguras y protegen a los niños para que crezcan sanos, felices y fuertes.

Hable con el doctor de su hijo sobre las vacunas necesarias este año.

Like ngày ˛˝y tháng, vaccines are another part of growing up

Like many milestones, vaccines are an important part of childhood. Vaccines are safe and protect children, so they can grow up healthy, happy, and strong.

Talk to your child’s doctor about what vaccines they need this year.

PartOfGrowingUp.org

Yes!

Vaccines are another part of growing up

Just like their first soccer goal, vaccines are an important milestone. They are safe and protect children, so they can grow up healthy, happy, and strong. Talk to your child's doctor about what vaccines they need this year.

PartOfGrowingUp.org

C˜ng nh° ngày ˛˝y tháng, tiêm ng˙a là mˆt ph˝n cˇa quá trình tr°˘ng thành

VACCINE HESITANCY REBUTTALS: Strategies to Address Vaccine Hesitancy and Misinformation with Parents and Caregivers

When discussing childhood vaccines with parents, you may encounter hesitancy or resistance. It is important to address vaccine hesitancy and misinformation during these conversations by sharing additional information to encourage caregivers to vaccinate their children. As you communicate with parents, try to use ‘fact-focused’, positive language rather than restating misconceptions or myths as this may reinforce them. We provide several examples of what this can look like.

General Recommendations:

Use clear, easy-to-understand, language during these conversations

• Use non-judgmental language

Use motivational interviewing strategies to engage in conversation

• Practice reflective listening

Be empathetic

Motivational interviewing is a style of communication that sits somewhere between listening and giving information or advice. It is a tool designed to empower people by drawing out their own motivations and capacity for change through a series of questions or prompts.

Myths and misinformation you may hear from vaccine-hesitant parents/caregivers You might reply with…

“Vaccines aren’t safe.”

“Vaccines contain toxins and ingredients that are dangerous.”

“Vaccines can cause autism and Sudden Infant Death Syndrome (SIDS).”

As a parent, I know you want what’s best for your child. Vaccines are an important tool we use to make sure children grow up to be happy, healthy, and strong.

Vaccines protect children from serious diseases, including measles, mumps, rubella, polio, and whooping cough. These diseases can cause serious complications and even death. Vaccines are a safe and effective way to prevent these diseases, and they have been tested to ensure that they are safe and effective for children of all ages. Every vaccine undergoes extensive testing before being licensed, and vaccine safety continues to be monitored as long as a vaccine is in use.

Myths and misinformation you may hear from vaccine-hesitant parents/caregivers You might reply with…

“Vaccines are expensive” or “I can’t afford to get my child vaccinated.”

“Giving more than one vaccine at a time increases the risk of dangerous side effects or can overload a child’s immune system.”

Additional Resources

If you have health insurance, your child’s vaccines are covered by insurance plans. There may be a small co-payment or coinsurance for some doctor’s visits..

If you do not have insurance, all Santa Clara County community clinics offer free or low-cost routine vaccinations for children. Contact the County of Santa Clara Public Health Department for more information.

Giving several vaccines at once has no negative effect on a child’s immune system.

In fact, administering vaccines together can save time and money through fewer visits to your doctor and reduce discomfort for a child through fewer injections.

You can refer caregivers you work with to the following resources depending on their needs:

Healthychildren.org provides information on immunizations for parents, from the American Academy of Pediatrics.

Centers for Disease Control and Prevention (cdc.gov/vaccines) provides lists of recommended vaccines by age.

• VaccineInformation.org provides timely, accurate, and factual information about vaccines and the diseases they prevent.

VaccinateYourFamily.org provides information about vaccines for parents, pregnant women, adults, healthcare providers, and vaccine advocates.

Find a Clinic in Santa Clara County that will offer free or low-cost vaccines.

Myths and misinformation you may hear from vaccine-hesitant parents/caregivers You might reply with…

“It is better if my child catches the disease and builds their immunity that way.”

“Vaccines can infect my child with the disease it’s trying to prevent.”

“Vaccines can cause long term side effects, illness and even death.”

“The side effects from the vaccine are worse than the disease itself.”

• Vaccines are the best way to protect your child from getting seriously sick from diseases.

• Just like wearing a seat belt reduces your chances of being injured in a car accident, vaccines reduce the chance that a virus will cause serious health issues or death even if you are exposed.

If your child is exposed to a virus, they may experience serious or life-threatening health effects, and immunity may not last very long. Getting vaccinated is a much safer way for your child to build immunity against serious diseases.

Like any other medication we take, vaccines can have some potential side effects. However, the side effects are usually mild and will typically go away on their own after a few hours or days. Some common side effects may include:

Pain, redness, and swelling at the injection site

Fever Mild rash

Tiredness and irritability

Your child’s doctor or a pharmacist may keep an eye on your child for 15 minutes after giving a vaccine, just to make sure they do not have a serious reaction (e.g., an allergy).

“If everyone around me is immune, then my child doesn’t need to be vaccinated.”

Getting children vaccinated protects them and the people around them, including older adults, people who might have existing health issues, and others who may be more likely to end up in the hospital if they get sick. Children that are vaccinated are less likely to pass on an illness to someone else.

• However, if enough people choose not to get vaccinated, that means serious diseases—like measles or polio—can spread, even to people that have been vaccinated.

“Children don’t get COVID.”

“My child is healthy and will not get seriously ill if they get COVID.”

“If my child already had COVID, they don’t need to be vaccinated.”

“My child can still catch COVID even if they’re vaccinated, so what’s the point?”

Like adults, children are susceptible to COVID and can experience serious symptoms and long-term health problems, including death. This includes healthy children.

Even if your child catches COVID, the vaccine reduces their risk of serious outcomes, hospitalization, and the risk of developing long-term health problems (which can develop even after a mild illness).

It’s important to stay up to date by getting the most recent booster for COVID, as those protect against the most common strains circulating now.

CONVERSATION STARTERS: Talking to parents about recommended and required childhood vaccines

Throughout the United States, rates of childhood vaccination have declined during the course of the COVID pandemic.

This job aid offers suggestions that staff working in clinical or community settings can use to start a conversation with parents and caregivers about recommended and required vaccinations, using the opportunity afforded when you may be meeting with them for another reason.

Conversation Basics

Set a positive, affirming tone. “It’s great to see you today” or “It’s so good that you’re taking care of your child’s health.”

Use normalizing language, so that the caregiver doesn’t feel singled out or judged. “I talk about this with all of my [patients/families/individuals]” or “A lot of parents/caregivers have questions about...”

• Ask permission to continue the conversation. “May I ask you some questions about vaccines your child has had in the past?” or “Would it be okay if we spend some time talking about this today?”

• Ensure the caregiver knows it is their choice to vaccinate their child. “While I strongly recommend that your child receive the required and recommended vaccines, as their parent/ caregiver, this decision is completely up to you.” or “If you need to take some time to think about this after our conversation, you do not have to decide today. We can always revisit this conversation another time.”

Use presumptive language, if you are a healthcare provider. It is a best practice for healthcare providers to use “presumptive language 1 when talking about vaccinations with families. Using presumptive language assumes that vaccination is the default option and is shown to increase the likelihood that parents will vaccinate. Presumptive language is a strong, confident vaccine recommendation. It might sound like “Your child is due for 3 vaccines today: HPV, Meningococcal, and Tdap. The nurse is going to prepare them and will be back in a few minutes. Do you have any questions I can answer?”

Use inclusive language. For example, say “parent” instead of “father” or “mother.”

Conversation Starters and Follow Up Questions

Here we present several conversation starters as well as follow-up questions you may use to initiate and continue the conversation. You may modify these based on your role. We recommend practicing these with a co-worker or peer to increase comfortability in conversation.

Starting the Conversation

• “Many parents and caregivers I talk to appreciate the chance to talk about the recommended and required vaccines their child needs, so they know what to expect. Can we review which vaccines your child is due for?”

• “Since you’re here, I’d like to review the vaccines your child is currently recommended or required to receive. Over the past few years, some children have fallen behind on their vaccinations, and I’m working with all of my [patients/families/individuals] to get their children back on track. How does this sound?”

• “I know we often have conversations about your child’s health and development. One part of a child’s growth and development is getting their vaccines. Would it be okay if we have a conversation about this?”

• “Is your child planning to or do they currently attend childcare or school? There are several vaccinations that are required by the state of California for children attending childcare or school. Would you like to review them together?”

“We have [child’s name] down for a [reason for visit]. It’s nice to see you two again. We like to let everyone coming into our office know about the recommended and required vaccines children need at this age. Let’s plan to go through this today.”

Continuing the Conversation

• “I know that you prioritize your child’s health. What are your hopes and expectations for their health in the future?”

“Do you have any questions or concerns about getting your child vaccinated? It is possible that they may experience side effects but these are normal and mild.”

“I wanted to revisit the conversation that we had about vaccination a few weeks ago. How are you feeling about that?”

Endnotes

1

When there is vaccine-preventable disease in your community:

• It may not be too late to get protection by getting vaccinated. Ask your child’s doctor.

• If there are cases (or, in some circumstances, a single case) of a vaccine-preventable disease in your community, you may be asked to take your child out of school, childcare, or organized activities (for example, playgroups or sports).

• Your school, childcare facility, or other institution will tell you when it is safe for an unvaccinated child to return. Be prepared to keep your child home for several days up to several weeks.

• Learn about the disease and how it is spread. It may not be possible to avoid exposure. For example, measles is so contagious that hours after an infected person has left the room, an unvaccinated person can get measles just by entering that room. ­

• Each disease is different, and the time between when your child might have been exposed to a disease and when he or she may get sick will vary. Talk with your child’s doctor or the health department to get their guidelines for determining when your child is no longer at risk of coming down with the disease.

Be aware.

4 Any vaccine-preventable disease can strike at any time in the U.S. because all of these diseases still circulate either in the U.S. or elsewhere in the world.

4 Sometimes vaccine-preventable diseases cause outbreaks, that is, clusters of cases in a given area.

4 Some of the vaccine-preventable diseases that still circulate in the U.S. include whooping cough, chickenpox, Hib (a cause of meningitis), and influenza. These diseases, as well as the other vaccine-preventable diseases, can range from mild to severe and life-threatening. In most cases, there is no way to know beforehand if a child will get a mild or serious case.

4 For some diseases, one case is enough to cause concern in a community. An example is measles, which is one of the most contagious diseases known. This disease spreads quickly among people who are not immune.

If you know your child is exposed to a vaccine-preventable disease for which he or she has not been vaccinated:

• Learn the early signs and symptoms of the disease.

• Seek immediate medical help if your child or any family members develop early signs or symptoms of the disease. ­

IMPORTANT: Notify the doctor’s office, urgent care facility, ambulance personnel, or emergency room staff that your child has not been fully vaccinated before medical staff have contact with your child or your family members. They need to know that your child may have a vaccinepreventable disease so that they can treat your child correctly as quickly as possible. Medical staff also can take simple precautions to prevent diseases from spreading to others if they know ahead of time that their patient may have a contagious disease.

• Follow recommendations to isolate your child from others, including family members, and especially infants and people with weakened immune systems. Most vaccine-preventable diseases can be very dangerous to infants who are too young to be fully vaccinated, or children who are not vaccinated due to certain medical conditions.

• Be aware that for some vaccine-preventable diseases, there are medicines to treat infected people and medicines to keep people they come in contact with from getting the disease.

• Ask your health care professional about other ways to protect your family members and anyone else who may come into contact with your child.

• Your family may be contacted by the state or local health department who track infectious disease outbreaks in the community. ­

If you travel with your child:

• Review the CDC travelers’ information website (http://www.cdc.gov/travel) before traveling to learn about possible disease risks and vaccines that will protect your family. Diseases that vaccines prevent remain common throughout the world, including Europe. ­

• Don't spread disease to others. If an unimmunized person develops a vaccine-preventable disease while traveling, to prevent transmission to others, he or she should not travel by a plane, train, or bus until a doctor determines the person is no longer contagious.

For more information on vaccines, ask your child's health care professional, visit www.cdc.gov/vaccines or call 800-CDC-INFO (800-232-4636)

If You Choose Not to Vaccinate Your Child, Understand the Risks and Responsibilities

Reviewed March 2012

If you choose to delay some vaccines or reject some vaccines entirely, there can be risks. Please follow these steps to protect your child, your family, and others.

With the decision to delay or reject vaccines comes an important responsibility that could save your child’s life, or the life of someone else. Any time that your child is ill and you:

• call 911;

• ride in an ambulance;

• visit a hospital emergency room; or

• visit your child’s doctor or any clinic

you must tell the medical staff that your child has not received all the vaccines recommended for his or her age. Keep a vaccination record easily accessible so that you can report exactly which vaccines your child has received, even when you are under stress.

Telling health care professionals your child's vaccination status is essential for two reasons:

• When your child is being evaluated, the doctor will need to consider the possibility that your child has a vaccinepreventable disease. Many of these diseases are now uncommon, but they still occur.

• The people who help your child can take precautions, such as isolating your child, so that the disease does not spread to others. One group at high risk for contracting disease is infants who are too young to be fully vaccinated. For example, the measles vaccine is not usually recommended for babies younger than 12 months. Very young babies who get measles are likely to be seriously ill, often requiring hospitalization. Other people at high risk for contracting disease are those with weaker immune systems, such as some people with cancer and transplant recipients.

Before an outbreak of a vaccinepreventable disease occurs in your community:

• Talk to your child’s doctor or nurse to be sure your child’s medical record is up to date regarding vaccination status. Ask for a copy of the updated record.

• Inform your child’s school, childcare facility, and other caregivers about your child’s vaccination status. ­

• Be aware that your child can catch diseases from people who don’t have any symptoms. For example, Hib meningitis can be spread from people who have the bacteria in their body but are not ill. You can’t tell who is contagious.

Vaccines are another part of growing up

Like your child’s first words, vaccines are an important milestone. They are safe and protect infants and toddlers, so they can grow up happy, healthy, and strong.

Your child needs certain vaccines to go to childcare and kindergarten. Talk to your child’s doctor today about what vaccines they need.

Do you have questions or concerns about vaccines?

It’s normal to have questions about vaccines. Your child’s doctor will be happy to answer any questions you have.

Here are some questions you could ask the doctor:

• What vaccines does my child need to attend childcare or to enter kindergarten?

• Is my child behind on any recommended or required vaccines?

• What should I know about the specific vaccines my child needs right now?

• Can you explain the purpose of the vaccines?

• What possible symptoms could my child have after getting vaccinated?

• Should any other family members get vaccinations from their doctor in order to best protect my child?

Some vaccines are required for children to attend school in California:

Hepatitis B

DTaP (Diphtheria, Tetanus, Pertussis)

Hib (Meningitis)

IPV (Polio)

MMR (Measles, Mumps, Rubella)

Varicella (Chickenpox)

Talk to your child’s doctor today about what vaccines they need to catch up on.

Visit PartOfGrowingUp.org for more information.

Some vaccines are required for children to attend school in California:

Hepatitis B

DTaP (Diphtheria, Tetanus, Pertussis)

Hib (Meningitis)

IPV (Polio)

MMR (Measles, Mumps, Rubella)

Varicella (Chickenpox)

Talk to your child’s doctor today about what vaccines they need to catch up on.

Visit PartOfGrowingUp.org for more information.

Like their first soccer goal, vaccines are another part of growing up

Vaccines are safe and protect kids, so they can grow up happy, healthy, and strong. Your child needs certain vaccines to go to school. Talk to your child’s doctor today about what vaccines they need.

Do you have questions or concerns about vaccines?

It’s normal to have questions about vaccines. Your child’s doctor will be happy to answer any questions you have.

Here are some questions you could ask the doctor:

What vaccines does my child need to attend school?

Is my child behind on any recommended or required vaccines?

What should I know about the specific vaccines my child needs right now?

Can you explain the purpose of the vaccines?

What possible symptoms could my child have after getting vaccinated?

SCCMA Physicians Participate in Water Reuse Symposium with EPA

Dr. Ken Yew and Dr. Santosh Pandipati attended the WateReuse 2023 Symposium this spring in Atlanta where they participated in a panel discussion, “Water and Health: A Physician Looks at Water Reuse (CA)” on the topic of water reuse, health professional’s perspective and its importance to public acceptance.

The WateReuse Association is dedicated to advancing laws, policy, funding, and public acceptance of recycled water. WateReuse represents a coalition of utilities that recycle water, businesses that support the development of recycled water projects, and consumers of recycled water. Their goal is to increase safe and reliable water supplies.

With support from Valley Water, the US Environmental Protection Agency (EPA) and the Centers for Disease Control and Prevention (CDC), SCCMA physicians wrote a series of articles in 2022 about “Water and Health,” focusing on Valley Water’s Purified Water Project.

The reception to the article series and panel presentation led to discussion about where the work on water reuse might go next, including continued EPA-SCCMA partnership, a possible American Medical Association (AMA) resolution, pollution prevention, medical education, and a possible WRAP item.

EPA-SCCMA Partnership

EPA representatives appreciated that this is the first partnership developed between the Agency and a group of practicing

physicians in support of water reuse. The value of this partnership is enhanced by the emergence of regulations regarding the use of recycled water for direct potable reuse which will be emerging, state by state, over the next several years. SCCMA representatives acknowledged that given the role of physicians in responding to environmental health impacts, it is appropriate for EPA and medical associations to work together.

AMA Resolution

The group discussed the value and feasibility of obtaining a resolution from the AMA advocating the use of recycled water as a mitigation for the impacts of climate change for the benefit of public health.

• SCCMA representatives offered to update CMA Resolution 118a-12 adopted in 2012 by the CMA advocating for water reuse, and to propose it for consideration by the CMA at the next meeting of the House of Delegates. The update places the benefits of recycled water in the context of the impacts of climate change and the need to ensure that adequate supplies of clean water are available to the public. Dr. Yew submitted the resolution on the CMA website after getting the endorsement of the SCCMA council and District VII delegation.

• If passed, the resolution could then be forwarded to the AMA Technical Advisory Board (TAB) for consideration as a national resolution. EPA would be willing to provide the TAB with technical background information to

Dr. Ken Yew and Dr. Santosh Pandipati attended the WateReuse 2023 Symposium this spring in Atlanta where they participated in a panel discussion

support the resolution.

• If the resolution is passed, it would be up to the AMA to bring their position to individual legislators. At that point, it might be possible for the AMA and the EPA to issue a joint statement about the importance of water reuse to mitigate the impacts of climate change in support of public health.

Pollution Prevention

• SCCMA representatives pointed out that any resolution that went forward to EPA would likely include an acknowledgement of the importance of pollution prevention in protecting both conventional and recycled water supplies.

• EPA representatives pointed out that pollutants in drinking water are regulated out of the Office of Groundwater and Drinking Water (OGDW) which is out of their direct purview (as leaders of the Water Reuse Action Plan, or WRAP). They also noted that the Toxics Safety Control Act (TSCA), which establishes the rules for the use of potential pollutants, will not be reopened until 2024, at which point the SCCMA could submit comments. In the meantime, their involvement would be limited to discussion of recycled water. In short, if the resolution focused on pollution prevention, it would not likely receive a formal endorsement from EPA. However, if it simply specified that “AMA (or CMA) endorses the use of advanced water purification for the purpose of potable reuse as a means of adapting to climate change” EPA may formally support it. In that case, the resolution may also need to acknowledge that potable reuse is only appropriate when wastewater is properly treated to meet state regulations.

• SCCMA and EPA identified this issue as a topic for further discussion.

Medical Education

The group discussed the importance of providing medical professionals with accurate and relevant information about water and health, including recycled water, during medical training.

• SCCMA representatives acknowledged that “environmental health is just starting to get into the medical schools” and offered to speak with the American College of Graduate Medical Education about possible distribution of the information through their organization.

• EPA representatives offered to produce a webinar on “Water and Environmental Health.” They could collaborate with SCCMA and others to develop other appropriate webinars on recycled water that might be attended by (and later distributed to) interested health professionals, which might focus more on chemical pollutants in water rather than the pathogens which are the focus of much of the current discussion of recycled water. In short, EPA would develop a webinar that could be used in medical schools that have an environmental health curriculum.

• SCCMA representatives offered to contact Dr. Robert Gould who works with UCSF Medical School about their environmental health program and promote the SCCMA Bulletin Special Issue to other county medical associa-

tions.

New WRAP Action Item

EPA and SCCMA representatives agreed to develop and propose an Action Item that would comprehend the recommendations with respect to a webinar on water and health geared towards health professionals and an AMA resolution endorsing water reuse.

• General language for a WRAP Action Item was proposed:

• Engage the medical community to communicate the risks and benefits of water reuse.

Objectives:

1. Develop a webinar on toxic and microbiological risks to drinking water and available treatment methods for use in medical schools.

2. Develop and promote resolutions suitable for adoption by state and national health associations supporting the use of recycled water as an appropriate addition to public water supplies to enhance community resilience.

3. Encourage medical associations and other health institutions to consider the SCCMA “informed consent” model for presenting information about water use to their communities.

Source control regulations continue to be a concern for the physicians. Simply treating water for reuse is like focusing only on treating an acute illness. Prevention is a big part of medicine, and similarly, for clinicians, source control has to be in the discussion. The Environmental Health Committee with continue to discuss, share and support this momentum.

Wealth Management

The 2023–24 health budget trailer bill renews the state’s Managed Care Organization (MCO) Tax and provides the largest Medi-Cal rate increase in California history, ensuring that millions of Californians have greater access to affordable, high-quality, life-saving health care.

Investments in the state’s health care infrastructure will make meaningful strides toward achieving justice and equity by fulfilling Medi-Cal’s promise of access to health care for the more than 14 million Californians – including 6 million children – who rely on the program for their health care.

The California Medical Association (CMA) and other members of the Coalition to Protect Access to Care have been working together over the past few months to ensure that this generational opportunity to make critical and meaningful investments in the Medi-Cal system and shore up our health care delivery system is realized.

The coalition’s goal has been to ensure that Medi-Cal enrollees have the same access to care as those with commercial insurance, and that providers can afford to treat their communities as they present themselves – without worrying about the financial solvency of their practice.

BACKGROUND

+ Medi-Cal provides essential health coverage to one in three Californians and is foundational to the state’s health care delivery system and economy. In fact, 50% of California children are born into Medi-Cal, making it an essential program for preventive and routine care for children.

+ Medi-Cal provider rates have not increased in more than a decade, and for most physicians it’s been more than 25 years – leaving millions of patients insured, but without meaningful access to health care. Patients with Medi-Cal coverage routinely wait weeks or months for appointments, and oftentimes must travel long distances to receive care.

+ Thanks to a series of Medi-Cal expansions, universal health care coverage will soon be a reality in California, a goal CMA has long advocated for. To fulfill California’s commitment to health care access and equity, we must ensure that the remarkable gains we’ve had expanding health care coverage actually translate to improved access to care for Californians.

+ It has been clear for quite some time that the state needs a new, ongoing revenue stream to improve access for Medi-Cal beneficiaries in a sustainable manner.

+ Historically, California has used the MCO Tax to draw down federal funding and help support the state’s General Fund, but the last MCO Tax expired at the end of 2022. While that revenue stream was used to backfill General Fund obligations, the state was not obligated to use it to increase funding for health care programs.

Over the past several months, CMA and the coalition have advocated to reinstate and increase the MCO Tax and use this important financial mechanism to directly increase access to health care by increasing the funding for Medi-Cal providers to provide care to millions of patients in a variety of care settings.

THE NEW MCO TAX

In a win for physicians and patients, the 2023–24 health budget trailer bill incorporates key pieces of the coalition’s proposal, including an increase to Medi-Cal provider rates for the first time in more than two decades.

THE MCO TAX PLAN IN THE BUDGET TRAILER BILL INCLUDES:

Medi-Cal Rate Increases

PRIMARY CARE

+ Starting in 2024, the budget trailer bill increases provider rates to at least 87.5% of Medicare for primary care, maternity care and non-specialty mental health services.

+ Starting in 2025, an additional annual appropriation of $1.38 billion will be directed to primary care providers in the Medi-Cal program to support the comprehensive services that protect and promote beneficiaries’ overall health.

SPECIALTY CARE

+ Starting in 2025, the bill includes $1.15 billion annually to increase Medi-Cal rates for specialists, which will increase access to care and decrease wait times.

Emergency Services

EMERGENCY DEPARTMENT ACCESS

+ Starting in 2025, the bill includes an annual appropriation of $700 million to be used to support inpatient facilities, most notably through hospital emergency departments, including $200 million to go toward rate increases for emergency physicians seeing Medi-Cal patients in emergency departments.

GROUND EMERGENCY TRANSPORT

+ Starting in 2025, $100 million annually will be directed to support 911 emergency ground providers and increase staffing capacity to help address increased workforce challenges.

Health Care Workforce

INCREASE GRADUATE MEDICAL EDUCATION

+ Starting in 2024, an additional $75 million will be allocated annually to increase residency slots for primary and specialty care and expand the number of residency programs in California.

WORKFORCE

+ Starting in 2025, $150 million annually will be allocated to grow the health care workforce.

Hospitals

STABILIZE AND INCREASE INPATIENT PSYCHIATRIC BED CAPACITY

+ Starting in 2025, $600 million annually will go toward increasing the number of inpatient psychiatric beds and funding additional care for the severely mentally ill.

PUBLIC HOSPITALS

+ Starting in 2025, $150 million annually will go to increase access to care at public hospitals.

DISTRESSED HOSPITALS

+ The 2023-24 budget includes a one-time allocation of $150 million to the Distressed Hospital Loan Fund.

+ The 2023-24 budget includes a one-time allocation of $50 million for small and rural hospital relief for seismic assessment and construction.

Reproductive Health Care

PROTECT FAMILY PLANNING AND ABORTION ACCESS

+ At least $500 million will be directed to family-planning related services in both Medi-Cal and FPACT and to abortion services.

NEXT STEPS

CMA will continue to remain engaged as implementation details are worked out over the next months and years, and will continue to advocate on behalf of physicians to ensure the funding flows efficiently to providers.

cmadocs.org/access

By Marcia Daszko

Many organizations struggle because they cannot get enough applicants to interview and hire. Once they hire people, they often don’t engage with, appreciate or retain them. Why not?

The Reality. It is true that baby boomers left the workforce in millions. That was no surprise; leaders could anticipate that (but did they?), and crisis times accelerate it. If possible, people choose not to work full-time or in unfriendly work environments; that’s also driven us to the current unemployment rate. But there are many organizations that are booming, and they can hire and retain their talent.

What’s the difference? Why do some organizations have high turnover and others have virtually none?

There are three major reasons. Assess your organization (or better yet, hire someone who can objectively assess it, and give you a rapid perspective based on systems-knowledge from the outside.) Understand the root causes to your employment challenges; create a plan to address them. What is the status of your three variables: leadership, communication, and culture?

Three key strategies can create the workforce you need. Develop and optimize these three systems: leadership continually transforming; effective two-way communica-

tion, and a learning focused on continual improvement and innovation to serve your customers.

Leadership. Leaders create the workplace where all staff flourish. It’s where they are self-motivated, appreciated, and can contribute to the compelling Aim or Purpose for the organization. Values are defined and taught, both verbally and behaviorally. Leaders invest in developing their employees. If you’re not continually communicating, educating, and coaching your employees, your organization is in decline. The leadership team creates the system that the staff works in. It must be work-able!

Communication. The leader’s significant role is to communicate, especially in a crisis or uncertain times. He/she communicates clearly and often! Again, leaders create and clearly and repeatedly communicate the aim and the values (in behavior.) Use every method possible to share your messages, direction, and vision. Use Zoom, emails, newsletters, the Intranet, town

Marcia Daszko

hall meetings, social events, etc. to repeatedly tell your stories.

Watch for inconsistencies between your values and the vocabulary and actions people use. For example, most companies have a stated value such as teamwork or collaboration. But what practices counter that and are barriers to teamwork? Do you have performance appraisal systems where you rank, rate, judge and criticize people? Then do you tie the appraisal to the compensation system? Nothing erodes teamwork faster than internal competition and team members who can’t trust each other!

Culture. The leader creates the workplace culture. Does your work environment attract new employees? Is your company the place new graduates want to work after graduation, or get excited to go to work, or have an engagement score of over 80 or 90%? What creates a workplace you want to be proud of for the work you do, the peers you support, and the customers you serve? What kind of culture do you want? What do you want to be known for? Quality, fun, speed, dependability, safety? You select it and focus your priorities and activities, so they are consistent with that? Can you imagine if Southwest Airlines hired some of its flight attendants who are shy, introverted, impatient and intolerant? Instead, they are well known for providing a safe, fast, fun experience. They hire and train for the culture they want their customers to also experience.

The foundation for hosting a healthy workforce are these three elements. There are inter-related, inter-dependent, and all connected.

One More Significant Tip for a Stable, Engaged Workplace: People speak, advise, coach, consult, and train to address employment issues in the workplace. Topics include employee engagement; retaining your staff; recruiting and interviewing

tips; onboarding; training; mentoring and coaching. There are numerous speeches and workshops! Companies spend millions of dollars to lower their turnover rate. But often there is little impact. Why don’t organizations achieve the results they want? (Their “parts” approach is ineffective.)

The answer is easy! The implementation is a little more challenging, but easily do-able. The above topics are all parts of the system that must flow together. They are All interconnected. Each one relates to the other processes. If they all don’t flow, the system breaks down, and the result is sub-optimal: high turnover or disengaged employees.

For example, if you recruit and interview great candidates, but the hiring system is slow and tedious, you’ll lose the applicants and start over. Research shows that candidates in the current job market expect an offer with a week, at most two weeks (and you take a chance they’ve accepted another offer.) Or if you hire great candidates, but you don’t onboard, train, or mentor them, they’ll realize you don’t plan to invest or develop them, and they’ll move on.

If you want great results, leaders must create and lead an optimal system. The processes, all working together for one aim, make up your system. People work IN the system and continually work to improve the flow. Are you getting the results you want? If not, look at the system. Look at all the processes that must connect in your system.

About the Author:

Marcia Daszko is a board and executive management consultant, speaker, and bestselling author of PIVOT DISRUPT TRANSFORM: How Leaders Beat the Odds and Survive. She can be contacted at md@mdaszko.com.

…if you recruit and interview great candidates, but the hiring system is slow and tedious, you’ll lose the applicants and start over.

Dr. Santosh Pandipati acknowledges that our American healthcare delivery system is broken, ranking 55th in the world in maternal mortality despite spending $100 billion annually on pregnancy and newborn care. “Relying on an outdated prenatal practice model that is nearly 100 years old has exacerbated significant inequities in maternal, perinatal, and neonatal outcomes as well as having contributed to rampant clinician burnout,” says Dr. Pandipati. Indeed, ACOG estimates a shortage of nearly 10,000 OB/GYNS currently, that will swell to over 20,000 by 2050. He is focusing the second half of his career to seeking, innovating, and implementing new solutions to fundamentally transform maternal care delivery. This has culminated in the birth of his startup, e-L ōvu Health. “At e-L ōvu Health, my co-founders and I are leveraging the best of emerging technologies to wrap a digital care blanket of holistic services around expectant patients. With frequent human interaction augmented by AI-driven insights, we can finally provide personalized pregnancy and postpartum care, restore access and reduce inequities, all the while generating valuable information to expectant mothers as well as to their clinicians that can finally improve our abysmal perinatal outcomes.”

Dr. Pandipati received his medical degree from the University of Michigan, where he was elected to the Alpha Omega Alpha Honor Medical Society. He completed his OB/GYN residency at the University of Washington Medical Center in Seattle. There, he was asked to serve as administrative chief resident. During residency, he was selected as the Best Teaching Resident for medical students. Subsequently, Dr. Pandipati completed his maternal-fetal medicine fellowship at the University of Colorado Health Sciences Center in Denver.

Santosh Pandipati, MD FACOG

FEATURED MEMBER

When he is not working, Dr. Pandipati enjoys spending time with his wife and children, date night, speaking to professional audiences on climate change impacts to human health, writing (he has a number of pieces published in Medium), iPhone photography, hiking, watching Star Trek, working out, mindfulness meditation, reading non-fiction and the occasional novel, trying out new restaurants, and spending time with his pooch.

Maternal-Fetal Medicine is a specialty that allows Dr. Pandipati to practice medicine in different ways. The ability to be a medical doctor, a surgical doctor, and a radiologic doctor all at the same time makes the specialty particularly appealing to him. This field allows him to interact with many physicians and surgical colleagues in a variety of specialties to coordinate care for complex patient problems that results in continuous learning and intellectual stimulation.

Dr. Pandipati has been a member of the Santa Clara County Medical Association for four years and participates in the Environmental Health Committee. Dr. Pandipati also serves as a Delegate to the CMA on behalf of SCCMA. He has previously written articles on climate change and women’s health for The Bulletin, and has been involved

in co-authoring articles with Valley Water highlighting advanced water purification for water reuse — technology that will be essential for adapting to anticipated clean water shortages from droughts and flooding due to climate change. The Special Issue of The Bulletin featuring articles on water and health was published in 2022. He has worked for Obstetrix of San Jose since 2012 and was Director of Maternal-Fetal Medicine at O’Connor Hospital from 2012 to 2022. He is currently on staff with Good Samaritan Hospital (San Jose), El Camino Hospital (Los Gatos and Mountain View), and Doctors Medical Center (Modesto).

In his spare time, Dr. Pandipati seeks better understanding of the anticipated critical impacts of anthropogenic climate change on human health. For the past 20 years he has been educating healthcare professionals on health harms posed by the ongoing climate crisis. He recently spoke on this topic when he was featured on ABC News’ Daily Podcast (12/8/22) and Good Morning America 3. He has also been quoted in The Washington Post and other podcasts on this topic. His published articles can be found in peer-reviewed journals as well as in Medium, a digital publishing platform that supports complexity and vital storytelling without giving incentives of advertising, where he provides a “Doctor’s Perspective” on climate change.

What is the best advice you have been given throughout your career so far?

Remain calm. Be patient. Work through a problem

“I LOVE THAT I HAVE TO KNOW HOW TO BALANCE THE INTERESTS OF TWO HUMAN BEINGS SIMULTANEOUSLY, WHICH CAN RAISE INTERESTING PHILOSOPHICAL CONUNDRUMS. BUT MOST IMPORTANTLY, I LOVE THE PATIENTS I HAVE TO CARE FOR, AND I LOVE THAT WE MOST OFTEN HAVE WONDERFUL OUTCOMES.”

without fear and with diligence. Solutions are often accessible with a clear mind and concentration of effort. I am not sure anyone actually told me any of that, but it is what I have observed amongst the best clinicians I have worked with. It is a pattern of behavior and thought I have endeavored to incorporate into my own practice of medicine. It is not easy to do, as we are all human and subject to varying levels of emotion and ego and fear. But I remind myself that we can be more than these feelings, especially in times of challenging patient care.

If you weren’t a physician, what profession would you like to try?

I always loved space, cosmology, and time. Had I not been a physician I would have become an astrophysicist or cosmologist. Better understanding of the universe means better understanding of humanity, of who we are and how we came to be. Nothing could be more profound of an investigation for me.

What is the most important thing you learned in medical school or residency?

Factual knowledge changes, and while it’s absolutely critical to keep up-to-date, it’s even more important to be open to the human condition - to understand that suffering is universal, that the most important thing we as clinicians can offer to our patients in accompaniment to the medicine or surgery we provide is our compassion and humility.

What do you think will be some of the lasting impacts of the COVID pandemic on the health care system?

COVID fundamentally altered the way clinicians interact with patients. Patients were already significantly ahead of many clinicians in their acceptance of mobile platforms for communication with family and work, but it took a crisis of immense proportions to move the healthcare industry to where patients have been. Telehealth is here to stay, largely because of COVID. We have seen a blossoming of telehealth services and startups as well as internet-based resources, and combined with remote wearable technologies, many of us have realized that much of the care we provide does not have to be in the immediate physical presence of patients. Please don’t misunderstand - a lot of care has to be in physical contact with patients, but we now have the ability to learn deep clinical insights from big data so as to hybridize and personalize care for each patient, and not just use a “one-size-fits-all” approach. This is a turning point in medicine, and one that will be extolled by future historians.

Dr. Pandipati and his wife attended the 2022 SCCMA Annual Awards Gala at the Fairmont Hotel in Downtown San Jose.

Dr. Pandipati with his beloved family pooch.

Walk with a Doc

Second Saturday of the month | 9:30-11:00am

Free registration; visit www.sccma.org/programs/walk-witha-doc.aspx

The Santa Clara County Medical Association is now a proud chapter of Walk with a Doc to bring walk events to a park near you! Walk with a Doc is a walking program for everyone interested in taking steps for a healthier lifestyle. A physician gives a brief presentation on a health topic and then leads participants on a walk at their own pace. It’s a great way to get out, get active, and enjoy all the benefits that come from walking while connecting with others in the community.

SCCMA is looking for physician members to volunteer to lead a walk – please contact Angelica Cereno at angelica@sccma.org if you are interested!

Saving Private Practice Webinar Series

Third Wednesday of the month | 12:15-1:15pm

July 19 – PPO Contracts

Register at https://bit.ly/44iI4VS

August 16 – Avoid Practice Management Hypertension

Register at https://bit.ly/43Wk7E2

The Saving Private Practice (SPP) Webinar Series offers free educational presentations designed for solo, small, and medium private practices. SCCMA physicians members and their office staff are welcome to attend. CME is available.

Wellness Retreat

August 11-13 | 1440 Multiversity in Scotts Valley, CA

Register at https://bit.ly/3Py07De

Join us for an all-inclusive three-day, two-night Wellness Retreat for SCCMA members and their guests. Attendees will be immersed in a beautiful backdrop of nature as they unplug over the course of the weekend and participate in sessions aimed at delivering healing and supportive care. All guests are served fresh, organic, plant-based food. Retreat facilitators include Christophe Gimmler, MD, LMFT, Kristine Burkman, PhD, Alistair Shanks, and John Chuck, MD.

Guests can select a private room with single or double occupancy. As an important pillar of support in life and in the home, physician spouses or someone who is a primary source of support are encouraged to join registered members for this retreat. The SCCMA-subsidized cost is $350 per person in a private single occupancy room or $500 per pair ($250 per person) for private double occupancy room. Space is limited.

SCCMA Book Club: Doctors and Friends by Kimmery Martin, MD

Wednesday, September 6 | 6:30 PM | SCCMA Office – 700 Empey Way, San Jose, CA 95128 Register at https://bit.ly/3XA4X5d

SCCMA is excited to announce our very first book club! Whether you are an avid reader, (re)starting, or simply read in your free time, you are invited to join. An in-person book club meeting will be hosted at the SCCMA office where the author will join us via Zoom to answer questions and talk about the process of writing.

Kimmery Martin, MD is an emergency medicine doctor-turned. Written prior to Covid-19, Doctors and Friends incorporates unexpected wit, razor-edged poignancy, and a deeply relatable cast of characters who provoke both laughter and tears. Martin provides a unique insider’s perspective into the world of medical professionals working to save lives during the most difficult situations of their careers. SCCMA will provide you with a copy of the book, Doctors and Friends upon registration.

Health Equity Leadership Summit

September 14-15 | San Jose Marriott Register at https://bit.ly/3JBuIfw

Hosted by Physicians for a Healthy California (PHC), the Health Equity Leadership Summit provides an opportunity for physicians, executives, advocates and allies to find community, engage in hands-on trainings and workshops, and hold indepth conversations about how they are addressing the issue of health equity in California through their care of underserved communities throughout the state.

CMA House of Delegates Meeting

October 21-22 | LA Live, Los Angeles

Information available at www.cmadocs.org/hod-2023

This year’s California Medical Association (CMA) House of Delegates (HOD) meeting will take place on October 21-22, 2023 at JW Marriott LA Live. Major issues selected for this year’s agenda include Consumer Health Technology/Artificial Intelligence, Office of Health Care Affordability, and Climate Change. We look forward to this year’s lively debate as physicians continue to advocate to improve the practice of medicine.

SCCMA Annual Meeting

Tuesday, November 14 | 6:30-8:00pm

Save the date for the SCCMA Virtual Annual Meeting & Ratification of 2024 Council Slate of Candidates. More details to come!