California Family Physician magazine (Summer 2011)

California

WORK-LIFE BALANCE

FAMILY PHYSICIAN VOL. 62 NO. 3

Summer 2011

WHAT PART OF “BALANCE” DON’T 21 I UNDERSTAND? WORK-LIFE BALANCE AND HIRING 22 FOR BALANCE, THINGS TAKE TIME 23 IT'S SINK OR SWIM TO FIND BALANCE 24 FIND WHAT WORKS BEST FOR YOU 25

Family Medicine Summi 1 1 0 2 and California Residency Fair t

October 15-16 • Los Angeles See page 18 for details

2011 AWARD WINNERS

26

From left: Peter Broderick, MD, Family Physician of the Year; Jimmy Hara, MD, Philanthropist of the Year; Ashby Wolfe, MD, MPH, Resident of the Year; and David E.J. Bazzo, MD, Barbara Harris Award for Educational Excellence

T H E C A L I F O R N I A A C A D E M Y O F F A M I LY P H Y S I C I A N S • S T R O N G M E D I C I N E F O R C A L I F O R N I A

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©2011 CALIFORNIA DEPARTMENT OF PUBLIC HEALTH

2 California Family Physician Summer 2011

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“Without concerted action, thousands more Americans will die each year from liver cancer or liver failure…”

‐Hepatitis and Liver Cancer: A National Strategy for Prevention and Control of Hepatitis B and C 2010 Institute of Medicine Report

Check the boxes for

HBsAg test Anti-HBs test

Hepatitis B: A Vital Sign for Asian Americans 1 in 12

Asians and Pacific Islanders is living with chronic hepatitis B. Most became infected at birth or early childhood.

2 of 3

are unaware of their infection because they have not yet been tested.

Most have no symptoms and even their liver enzymes could be normal.

1 in 4

will die from liver cancer or liver disease without long term medical care.

Websites for further information: http://www.cdc.gov/hepatitis/HBV/TestingChronic.htm http://liver.stanford.edu A public service announcement from

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President Carol Havens, MD

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Leah Newkirk Director, Health Policy lnewkirk@familydocs.org

President-Elect Steven Green, MD Immediate Past President Jack Chou, MD Speaker Mark Dressner, MD Vice-Speaker Delbert Morris, MD Secretary/Treasurer Jay Lee, MD, MPH Executive Vice President Susan Hogeland, CAE Foundation President Robert Bourne, MD AAFP Delegates Jack Chou, MD Carla Kakutani, MD AAFP Alternates Jeffrey Luther, MD Eric Ramos, MD CMA Delegation Taejoon Ahn, MD Sam Applebaum, MD Steve Green, MD Carla Kakutani, MD Jeffrey Luther, MD Patricia Samuelson, MD

cafp@familydocs.org Jane Cho

shogeland@familydocs.org

ktop@familydocs.org

Manager, Medical Practice Affairs

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Assistant Director, Government Relations

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Tom Riley Director, Government Relations triley@familydocs.org Shelly Rodrigues, CAE, CCMEP Deputy Executive Vice President CAFP Foundation Executive Director

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California FAMILY PHYSICIAN Quarterly publication of the California Academy of Family Physicians

Michelle Quiogue, MD Editor Chris Navalta Managing Editor

Communications Committee — Michelle Quiogue, MD, Chair • Julia Blank, MD • Lindsay Larson, DO • Jay Mongiardo, MD, MBA • Nathan Hitzeman, MD • Jeffrey Luther, MD • Albert Ray, MD The California Family Physician (CFP) is published quarterly by the California Academy of Family Physicians (CAFP). Opinions are those of the authors and not necessarily those of the members and staff of the CAFP. Non-member subscriptions are $35 per year. Call 415-345-8667 to subscribe.

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WORK-LIFE BALANCE 21 What Part of “Balance” Don’t I Understand?

Carla Kakutani, MD

22 Promoting Work-Life Balance Could Help You Get Ahead in the Hiring Game

Callie Langton, MPA

23 When It Comes to Balance, Things Take Time

Catherine Sonquist Forest, MD, MPH

24 It’s Sink or Swim When It Comes to Finding Balance 25 To Find Balance, Find What Best Works for You

Steve Green, MD

Richard Gibbs, MD and Tricia Gibbs, MD

26 2011 Family Physician of the Year: Peter Broderick, MD 27 Barbara Harris Award for Educational Excellence: David E.J. Bazzo, MD 29 2011 Philanthropist of the Year: Jimmy Hara, MD 29 2011 Resident of the Year: Ashby Wolfe, MD, MPH

6 Editorial

Make the Most Out of Your Glass Jar

7 President’s Message Maybe We Should Call It “Work-Pleasure Balance” 8 Political Pulse

Mr. Smith Goes to Washington

9 Student News

Sometimes, Humanity Is All You Need

10 Resident News

It Takes a Village . . . Something That Had to Be Built

11 News in Brief

12 In the Spotlight

CAFP’s Enoch Choi Provides Relief Efforts in Japan

13 In the Spotlight

Leadership is Alive and Well at NCSC

14 Practice Management News

Twenty-Five Things Family Physicians Should Know about ACOs

Michelle Quiogue, MD Carol Havens, MD Tom Riley Edwin Kwon Sharon Lin, DO Enoch Choi, MD Ashby Wolfe, MD, MPH Leah Newkirk

16 CAFP Foundation Randy Sokol, MD; Alisha Dyer, DO and Charlene Hauser, MD The Future Faces of Family Medicine (FFFM) Program: Inspiring a Future Primary Care Workforce 17 QI Corner

Continuous Flow: What Is It and Why Is It Important?

19 CME Calendar

20 Membership From One Family Physician to Another: How Do You Achieve “Work-Life Balance”?

Jane Cho

Alicia Bachus, MD

29 Classifieds 30 Executive Vice President's Forum How to Take the Right Steps Toward Balance

Susan Hogeland, CAE

Michelle Quiogue, MD

EDITORIAL

Make the Most Out of Your Glass Jar

In an interview with National Public Radio earlier this year, Abraham Verghese, MD, the keynote speaker for the 2011 Annual Scientific Assembly, reflected on his work-life balance in this way: “Perfection of the work won’t get you perfection of the life. You have to think of these as two parallel trains; there’s life and there’s work, and they run on parallel tracks and there’s times when one gets a little ahead of the other, but you can’t let them get too far away ... Human beings need to work to feel fulfilled; human beings need to love and feel loved ... Maybe that is the name for the two trains ­— instead of calling it life and work, you could call it love and work. And they can’t get too far apart before you get into trouble.”1 I have often felt this tug between professional and personal fulfillment. Because I felt that six weeks’ maternity leave was too brief after my first child was born, I took four months off after my second child was born, then returned to work parttime. These last two years have been among the happiest for our family so far. This year, I went back to work full-time, which has led to rewarding leadership opportunities in diversity and culturally responsive care that truly resonate with my sense of purpose. As part of the CAFP delegation, I spent this past Mother’s Day away from my two daughters and my husband for the first time while attending the AAFP National Conference of Special Constituencies and the Family Medicine Congressional Conference. For me, a visit to our Capitol to advocate for family medicine was a culmination of my professional ambition. In an attempt to keep the “love train” in pace with the “work train,” I also scheduled two weeks of vacation after this week-long CAFP trip. I can only hope that kind of math will add up to a balanced life, but I suspect there is more value to being a balanced and fulfilled doctor than just keeping these trains on track.

1 2

According to a recent New York Times article2, we are amidst a “sweeping cultural overhaul of medicine’s traditional ethos that along with wrenching changes in its economics is transforming the profession … young doctors are taking salaried jobs, working fewer hours, often going part-time and even choosing specialties based on family reasons. The beepers and cellphones that once leashed doctors to their patients and practices on nights, weekends and holidays are being abandoned. Metaphorically, medicine has gone from being an individual to a team sport.”

CAFP leaders believe the team model of health care makes possible the delivery of high quality, efficient, patient centered care. Perhaps, by empowering the entire office to fulfill their potential within their scope of practice, doctors free themselves to tend to the other priorities in their lives.

Perhaps when doctors tend equally to their lives outside of medicine, there can be less burnout and more emotional reserve to be empathetic. Patients could benefit as well when doctors can be whole people and not just medical robots cranking out visits. To find balance of purpose and personal fulfillment may not be completely selfish after all.

When I think about balance in my life, I often recall the first day of my freshman physics course. I sat in one of the biggest lecture halls I had ever been in and watched an experiment about volume at the front of the room. The professor challenged the student volunteer to fit the large pile of rocks, pebbles and sand into a glass jar resting on the lab table. The take-home message was this: put the largest rocks in first, then the next largest and so on until you have just the sand left to pour in over the rocks. If you try to put sand in first, the volume displaced does not leave any room for the larger rocks. This, said our professor, was the secret to balance in life. Time is finite, like the glass jar. Decide which are your largest rocks, your biggest priorities, and make time for them first. Space will always remain for the finer grains of sand.

Copyright National Public Radio Audio Chat With Author Abraham Verghese by Rachel Syme April 7, 2011 Harris, Gardiner, “More Physicians Say No to Endless Workdays” New York Times April 2,2011

6 California Family Physician Summer 2011

PRESIDENT'S MESSAGE

Carol Havens, MD

Maybe We Should Call It “Work-Pleasure Balance” I’m always amused when people ask me about work-life balance, as if I have some special insights. Heck, I don’t even understand the concept. Work-life balance sounds like “work” is not part of “life.” For most of us, work is not only a big part of our lives, it is a big part of our identity. So clearly, work is part of life.

Maybe it should be “work-pleasure” balance. Except that work also gives me a great deal of pleasure — I suspect it does you, too. In fact, I think if you don’t find some pleasure in your work, you should find different work. And certainly, there is a lot of work outside of “work.”

So given all that, this is how I view the issue.

We need to have multiple dimensions of our lives — work and non-work. We need to have passion and time in our lives for more than one thing — it can be family, sports, music, literature, travel (or many other things) or all of them. All of those areas should provide both work and pleasure. Balance is making sure our work doesn’t become the only important thing in our lives, or our only source of pleasure.

Perhaps one of the red flags we should pay attention to is when one part of our life becomes more work than pleasure. Perhaps that should make us stop and think: Is this a temporary issue that will resolve soon or is it a function of a more fundamental imbalance? What can/should I do about it? Among my recurring issues — and maybe some of you have the same issue — is that I have a passion for a lot of things. My work (all parts of it), my family, being outdoors, good friends, music, travel all bring me great joy. Sometimes, however, I need to prioritize them because I really can’t do them all even though they all are important to me. Saying no to something I don’t want to do anyway is easy. Saying no to something I would love to do, but the price of doing it is too high because of the toll it takes on other parts of my life, is harder.

I hope I can find pleasure and work in all parts of my life. Is it appropriately balanced? Frankly, probably not in short periods — a day or even a week. My life is not that well organized and events outside my control have a big impact on how I spend my time. But over the course of a month, year or lifetime, I hope it balances out.

So take some time to reflect periodically on how you are finding that pleasure in various parts of your life. If it’s not “balanced,” think about what you can change. Find (and feed) your passion, both at work and outside work.

Or grab a ukulele and come join us!

California Family Physician Summer 2011 7

Tom Riley

POLITICAL PULSE

Mr. Smith Goes to Washington In the 1939 Frank Capra movie, “Mr. Smith Goes to Washington,” a young Mr. Smith (Jimmy Stewart) is selected by Governor Happy Hopper to replace the deceased Senator of an unnamed state. Newly in office, Mr. Smith introduces a bill to authorize a federal loan for a boys’ camp in his home state. The loan would be paid off by donations from youngsters throughout America.

But before the audience can say “awww shucks,” the political boss (Edward Arnold), who has his own nefarious plans for the boys’ camp property, contrives a scheme to discredit Mr. Smith.

But such action takes time and effort.

Patient appointments were cancelled, children abandoned (on Mothers’ Day, no less), red-eye flights taken, sleep lost and expenses accrued.

Was it worth it?

Absolutely. Without this kind of investment in your future Not much has changed in 72 years. Age-old and the future of political machinations still unfold. Battles your patients, the CAFP’s ‘Mr. and Ms. Smiths’ in Washington: (back from left to right) Jon between personal gain and public good con- rhetoric and ideology Malachowski, MD and Tom Riley. (Front from left to right) Leah Newkirk, Ron tinue to be fought.

Labuguen, MD and Robert Bourne, MD. of politicians may The first day of the conference began What’s more, every citizen still has the right eclipse the realities with presentations from members of Conto go the nation’s capital to stick up for of health care in your world. gress, Hill staffers, journalists and political his right to life, liberty and the pursuit of Perhaps the most important thing you can insiders. The tone was somber: The group happiness, and to participate in advocating do as a caring physician, second only to heard from Republicans who spoke against for what he or she believes. That is exactly being a great clinician, is to provide this “Obamacare” and against Democrats for what happened in May of this year: 10 valuable reality check to the policy-making being soft on necessary cuts. Republicans California family physician champions spent process.

Hats off to Drs. Carla Kakutani, want to cut government spending, even if it two days at the AAFP Family Medicine Conmeans debilitating cuts to programs such as Michelle Quiogue, Ron Labuguen, Jay Lee, gressional Conference in Washington, DC Medicare and Medicaid.

Charlene Hauser, Jon Malachowski, Robert with 80 other family physicians from more Bourne and CAFP Policy Director Leah than 20 states, trying to make the health Democrats speaking to the group demonNewkirk for doing just that. care system a bit saner for their patients. ized Republicans for making blind cuts to vital programs. The group also heard from AAFP’s top-notch government relations team about three key legislative issues they would be speaking with lawmakers about the following day. These included: Family Physician Appointed New Director of the California

CAFP Wins

Department of Public Health CAFP member Ronald W. Chapman, MD, MPH was appointed Director of the California Department of Public Health. A graduate of CAFP’s Physician Leadership Program, Dr. Chapman is a former member of CAFP's Board of Directors, Legislative Affairs Committee and the Family Physicians Political Action Committee (FP-PAC) Board.

Family Physicians Propel FP-PAC to New Fundraising Heights Family physicians are showing their support for the Family Physicians Political Action Committee (FP-PAC) in record numbers this year. The amount of money raised in the past six months for family physician-friendly candidates far surpasses total contributions from any previous year in the PAC’s existence. It is important that we keep this momentum as we enter into a very important election year. If you have yet to contribute, please go to www.familydocs.org/fppac to give today!

8 California Family Physician Summer 2011

• The Sustainable Growth Rate Formula (SGR): A formula put in place many years ago that ties Medicare payments to inflation in the US economy. Each year, Congress suspends the formula, which would cut physician payment and votes in a one- to two-percent payment increase. That means that every subsequent year, the cost of suspending the SGR gets higher. Medicare payments to physicians could be cut by 29.5 percent later this year if action is not taken.

• Graduate Medical Education (GME): A congressional advisory board charged with examining the effectiveness of taxpayer-

STUDENT NEWS Edwin Kwon

supported graduate medical education recently recommended cutting GME funding by 30 percent.

Because this funding is channeled through hospitals rather than community-based teaching facilities such as clinics, vital dollars to growing an adequate primary health care workforce are often depleted before they make it to community-based teaching facilities. If California is to meet the primary care needs of five million newly-insured patients in 2014, ensuring a more robust primary care education infrastructure will be vital.

• Title VII, Section 747: In his Fiscal 2012 Budget, President Obama proposed $140 million be spent on strengthening departments of family medicine and the training of primary care physicians to meet the needs of patients. Like GME, Title VII is vital not only to the future of academic family medicine, but to all family physicians: Strong departments of family medicine and stable funding for tomorrow’s family physician workforce are, in large part, what defines the specialty and its value to society.

Weeks in advance of Washington, DC lobby day, participants set up nearly a dozen meetings with key members of California’s Congressional delegation. Many of the participants attended CAFP’s legislative training workshops at our Congress of Delegates meeting last March in Sacramento. Dr. Labuguen said these workshops, and his meetings with state legislators during CAFP’s annual Family Physicians Legislative Day, prepared him for his many meetings on Capitol Hill with elected officials as well as their staffs.

Lessons of the Day: Mr. Smith ultimately got his national boys’ camp because his values were aligned with the public good, because he talked in a simple way about something that most people believed in, and because the bad guy in the movie confessed that he made up the whole incriminating story about the good guy. It is unlikely that the bad guys in health care (yes, you know who you are) will fess up anytime soon.

But family physicians are aligned with the public good and are effective communicators, perhaps more so than many other specialties. The good guys (you) can and must speak loudly at times of critical importance. And now is a time of critical importance: many members of Congress have made cutting health care programs and undermining federal health care reform their top priorities and, perhaps as never before, family physicians are seen by state and federal lawmakers as a key part of solving the health care crisis.

For more information on how you can get involved in the democratic process, as an advocate for your patients and for your practice, please contact me at triley@familydocs.org. Take some inspiration from Mr. Smith: “I’ve got a piece to speak, and blow hot or cold, I’m going to speak it.”

Sometimes, Humanity Is All You Need When I told my friend, an SICU nurse who regularly interacts with medical students, that I was writing a column about work-life balance she scoffed and asked, “What do they expect you to know about that?”

She knows that I regularly wake up at 3:45 am to pre-round on my patients; she knows the countless hours I put into studying; she knows it is often hard for me to just relax; and she knows that this is still just the beginning of my journey. Medical school draws relentlessly hard-working and achievement-oriented people who strive to be fabulous at all things while saving the world. We chronicle our successes in polished curriculum vitae and incorporate academic, athletic, artistic, and humanitarian honors into our identities. We are conditioned to respond to praise, so we do whatever it takes to be praiseworthy. Working hard, sleeping little, missing social events, and spending less time with friends and family have made us praiseworthy; balance has not. So when I was asked to write this article, I found myself reluctant, as I feared it would betray laziness or … even worse … weakness.

My humanity makes me uncomfortable, and much more so since I entered medical school. I am surrounded by incredibly gifted colleagues and mentors who are fabulous and currently saving the world. They are gods, or at least it seems they are, but I am a mortal. I need sleep. I need exercise. I need meaningful friendships outside of medical school. I need a day off. I need healthy food.

I need to surf now and then. I need to remember that I can’t conquer life on my own. I need God. When I forget this, I become overly anxious and overwhelmed or intolerably inflated; I grow unpleasant, and the quality of my work suffers. Worse still, in denying my humanity, I deny others theirs. It is my humanity that requires me to peer into the life of each patient with reverence, reminding me that my work is a privilege. It is my humanity that mandates grace and compassion, reminding me that I could make just as much a mess of my life as Mr. Jones has made of his. It is my humanity that sees Mrs. Smith as mother, wife, daugther, and friend, and not as the 48-year-old patient with diabetes. It is my humanity that leads to my patients’ trust, though I am only a third year medical student. It is also my humanity that keeps me studying and working hard for my patients, while admitting I need to stop at times.

I am only a mortal among gods, but I’m a fabulous mortal on my way to doing all I can for my patients in between scheduled breaks, and I’m thankful for that.

Edwin Kwon is a third-year student at the UC Irvine School of Medicine.

Tom Riley is CAFP’s Director of Government Relations.

California Family Physician Summer 2011 9

Sharon Lin, DO

RESIDENT NEWS

It Takes a Village . . .

Something That Had to Be Built Let me start by saying that I do not have a perfect balance. If work and personal life were two opposite ends of a seesaw and I was standing in the middle, I would clearly be losing my balance. My seesaw is heavily tilted to the side of work. This is because I’ve committed myself to becoming a family physician, which means residency responsibilities, constant learning and the task of taking care of other people — often the sickest of the sick and the poorest of the poor. But where I see myself in the near future is changing the imbalance by shifting the fulcrum of the seesaw from the middle to the side that is heavier (work), so I can reach a state of balance. My fulcrum, in this case, is time.

Balance, in residency, is a constant juggling act. By providing details on how I personally try to achieve balance in residency, my goal is to raise awareness on the subject of wellbeing and how to get closer to well-being as a medical student, physician, supporter of a physician, resident or a working-parent.

Every resident has to consider how to balance personal life with the demands of residency training. My husband and I decided to start a family during my second year of residency. We knew it would be hard to juggle, but we were ready. I was pregnant most of my second year of residency. I worked until the day I gave birth. One of the unfortunate problems with residency is that it is only flexible to a point, and where my residency was able to be flexible was moving my schedule around so I could use my vacation time (six weeks) postpartum. Going back to working those long 60-90 hours per week was extremely difficult. There were a lot of tears, a lot of sweat, and a whole lot of stress. But we survived.

With the help of an au-pair and my husband, who works full-time, I just barely manage to provide for my baby after coming home from work and on my weekends off. We do not have extended family to rely on, so among the three of us, we are stretched pretty thin. Balance is what we strive for, but without a village, times get rough.

Well-Being Often Takes a Village When I think about my own well-being, I have to take into consideration my expectations and my priorities. With most of my time dedicated to residency responsibilities, I have to prioritize very carefully where I put the rest of my time and energy. Number one is time with my family; number two is chores; number three studying; number four self-reflection; number five socializing; and number six health care transformation. There are some months in which none of these priorities gets much attention and there are weeks during which I can do all six in a balanced way. Though I often feel guilty for not meeting my own expectations, I have been focusing more on building greater support so I can better share my responsibilities with others, guilt-free. It really does take a village to help any resident feel well.

The truth is that maintaining wellness during residency has been a harder task than I predicted, but I still manage to have some wellness within me. Luckily, my physical stamina has been excellent during these years, which has enabled me to sustain a busy life throughout my pregnancy and parenthood. The hardest struggle for me is mental well-being, which includes mindfulness and spiritual growth. I yearn for a simple, joyful life in which I can enjoy the art of being, as well as the art of healing.

Multi-tasking may be a norm in residency, but it is not necessarily healthy. My coworkers and I work in a system in which we eat while working, type while listening and, sometimes, think without feeling. What we are finding throughout our training is that skills in boundary setting and prioritizing are just as important as listening and cognitive skills. How do we best take care of others while taking care of ourselves?

Because of all the responsibilities I carry, my mental well-being has dropped from a nine out of 10 as a fourth year medical student to an eight out of 10 as an intern … and now, it’s a three or four out of 10 as a resident and new mom. I am moving from survival mode to building a strong village.

10 California Family Physician Summer 2011

The following are a few survival skills I have acquired during the past three years of residency: • Plan on taking your paid time off (PTO) strategically in tough months of the year.

• Bring your infant with you to lecture and see if it works.

• Connect with others going through the same situation so you don’t feel isolated (online communities are a great resource).

• Communicate your struggles, as well as your successes.

• Proactively ask people if they have time to help, especially when call duty is heavy.

• Stagger easier work loads with hard ones so you don’t burn out.

• Enjoy the outdoors whenever possible.

• Build a safety net of support; when things go awry you know to whom to turn.

• Plan your monthly calendar with your partners ahead of time to anticipate times of greater need for help.

• Consider a live-in nanny, au-pair and/or cleaning/food services.

• Ask for hand-me-down clothes, toys, crib, car seat and other supplies and pass them along as well.

• Invest in a rice cooker, slow cooker and/ or George Foreman grill so healthy meals can be quick and easy without standing over the stove.

• Make sure you have scheduled breast milk pumping time — it’s your right, so don’t feel bad about it, and don’t put it to the side.

• Keep photos of your family handy to share and to keep you sane.

With residency coming to an end, I am looking forward to moving the fulcrum closer to my personal life. I am proud of what I have accomplished during these residency years, but I can’t wait for greater balance and well-being. Hopefully, future residents will have an opportunity to live a more balanced life as work-hour changes occur this coming year.

Sharon Lin, DO is a new family physician; she just graduated from Santa Rosa Family Medicine Residency Program.

Residency Programs Receive AAFP Foundation Awards

Scripps Family Medicine Residency Program and the USC Family Medicine Residency at California Hospital Medical Center are recipients of the 2011 AAFP Foundation Pfizer Immunization Awards.

Both programs earned awards in the category of System Implementation. Scripps was recognized for its work in Adult Immunization Rates while USC received praise for its work in Child Immunization Rates.

The AAFP Foundation Pfizer Immunization Awards recognizes Family Medicine Residency programs that have achieved high or improved immunization rates in children or adults, or are implementing a system to increase immunization rates, especially in medically underserved populations.

CAFP Board Acts on Important New Policies The Academy’s Board of Directors moved through its big agenda under the stewardship of outgoing president Jack Chou, adopting a number of important new policy positions. Among them was a new policy on Accountable Care Organizations (ACOs), following the lead of the AAFP’s newly released Joint Principles for ACOs endorsed by AAFP, the American Academy of Pediatrics and the American Osteopathic Association.

The Board also adopted a new scope of practice policy developed by the Legislative Affairs Committee and the Task Force on Scope of Practice and agreed to participate in the Regional Action Coalition charged with implementing some of the recommendations from the Institute of Medicine Report on the Future of Nursing.

CAFP Associate Director of Health Workforce Policy, Callie Langton, will represent CAFP on this body.

The Board discussed and voted to set up a bylaws task force to develop potential new bylaws that could make the Congress of Delegates even more relevant to the business and policy of the Academy. Finally, the Board voted to oppose the third (and most onerous for physicians) Parental Notification Initiative anticipated on the 2012 primary ballot in California.

The Board honored and presented a gift to Karen Y. Brent, CAFP Director of Information and Technology and an employee of nearly 12 years, for her service.

CAFP Wraps Up Another Great ASA CAFP completed its 63 Annual Scientific Assembly (ASA) on May 14-15 and saw great attendance from its members, perhaps a testimony to the excellent array of topics and speakers compiled by the Committee on Continuing Professional Development (COCPD) with the assistance of Deputy Executive Vice President Shelly Rodrigues and Senior Vice President Cynthia Kear. COCPD chair Geoff Leung emceed the event with skill and charm. rd

A huge highlight was Abraham Verghese, MD, an Infectious Disease faculty member at Stanford University, author of the New York Times Bestseller, Cutting for Stone and the ASA’s keynote speaker. Dr. Verghese addressed the importance of the physical exam, recalling that early in his career he suffered from the “conceit of cure” — the misbelief that “we could cure anything, until the AIDS epidemic,” which he describes as a “humbling” experience.

As if two straight days of CME weren’t enough, CAFP’s new program — the CME Leaders Institute — designed to train new faculty for family medicine continuing professional development, Sunday evening, May 15 and didn’t conclude until 3 pm on May 16.

CAFP thanks new President Carol Havens, MD; Immediate Past President Jack Chou, MD; Tom Bent, MD; Geoff Leung, MD, everyone on the ASA faculty, the attendees (Great crowd! New people! Young people! Old Friends!), CAFP staff and the staff at the Grand Hyatt Hotel.

See you all at next year’s ASA — in Indian Wells!

Student and Residents: Build Your Network at the California Reception Every year, CAFP hosts a California Reception at the annual AAFP National Conference for Medical Students and Family Medicine Residents. The reception is an informal opportunity to network with family medicine leaders and mingle with your peers and California residency directors

NEWS IN BRIEF from family medicine residency programs.

During the event, CAFP also awards scholarships to the medical students who show interest in family medicine and the National Conference.

This year’s conference is on July 28-30, 2011 in Kansas City, MO. The reception will be at the Hotel Phillips on Friday, July 29 from 4:30-7 pm. The hotel is at 106 W 12th St., just a block or two away from the convention center. See you all there!

Lower Your Vaccine Costs with Atlantic Health Partners!

Now is the time to join Atlantic Health Partners, the nation’s leading vaccine buying group, to get the lowest prices before the back to school peak vaccine season! CAFP has a partnership with AHP to work with Sanofi Pasteur and Merck and provide members with the lowest vaccine prices and most favorable payment terms for all size practices.

Additional benefits offered by AHP include reimbursement support, medical supply discount program, office and business supply discounts and more. For more information please contact Jeff Winokur and Cindy Berenson at 800-741-2044 or info@atlantichealthpartners.com.

Dates Set for 2012 Congress of Delegates and Legislative Visit to the Capitol CAFP’s 2012 Congress of Delegates will take place March 3-5, 2012 at The Citizen Hotel in Sacramento, CA. Mark your calendar now and plan to participate in the excellent media and legislative training offered on Sunday afternoon and the legislative visits the following Monday.

The deadline for reporting on delegations and for submitting resolutions is DECEMBER 9, 2011. If you plan to submit a resolution that addresses a problem you are having in your practice now, discuss the issue with Jane Cho, CAFP Medical Practice Affairs Manager, and see if we can help you resolve the problem. If you have a policy issue you would like addressed by the Academy, consider raising the issue with the Board of Directors in advance of the Congress and, please, consider taking a look at current CAFP policy to see if it has already been addressed.

California Family Physician Summer 2011 11

Enoch Choi, MD

IN THE SPOTLIGHT

CAFP’s Enoch Choi Provides Relief Efforts in Japan The peak of the Sakura season of cherry blossoms blooming in May provides hope that “this, too, will pass.”

The Japanese people suffered a triple threat four months ago, the worst within recent history: the strongest earthquake, the tallest tsunami, the worst nuclear disaster — a perfect storm. The country most prepared for natural disaster initially fell flat in responding to each of the three crises, but the people’s resilience and civility have shined a light through the rubble on the hope reflected by the yearly return of these softly falling cherry blossom petals. We can learn much from their charitable character, but also learn how their culture has limited the help offered to them.

It reminds me of Haiti, where last year 300,000 perished in a moment, and two million remain displaced. I’m the medical director of Jordan International Aid, a 501(c)(3) that sent nine teams of more than 200 physicians, nurses and supporters to help this past year. We found Haitians who had never seen a physician in their lives, and had the privilege of caring for them. Although the Japanese disaster led to fewer casualties, the destruction is even morevast.

The Japanese have devoted 100,000 troops to helping in the recovery, but they found that number to be but a drop in the face of the needs. Two million were stripped of water, electricity and utilities, twice as many as in Katrina, and just as many as in Haiti. The supply chain disintegrated, leaving those with (and without) shelter to depend on the sparse resources deployed by the military. Many are homeless due to the six-story wall of water that washed away their homes — a 150 mph tsunami.

Complicating aid efforts are the fears about radiation released from Fukushima nuclear reactors and the lack of fuel, since the refineries along the coast were damaged. Sadly, due to the radiation fears, most medical relief groups, even the US Government’s Disaster Medical Assistance 12 California Family Physician Summer 2011

Team, have not deployed to help. I say fears, since the dosimeters my team wore showed no significant radiation exposure.

My hopes are that those interested in helping out may be encouraged by our experience.

We arrived one week after the disaster, with the flight to Japan nearly empty, but Narita jammed with expatriates fleeing the country, worried about the reactors melting down. The roads were limited to emergency transport vehicles, and our bus cost $1,200 per person to get to Ishinomaki. Although a lot of aid had reached Sendai, we brought the first physician and the first hot food, baby formula and energy bars to Ishinomaki. It was still very cold, and many illnesses we saw were due to crowding in the shelters as folks tried to sleep close together, conserving heat, since kerosene was in short supply. The famously civil Japanese kept the peace in shelters, but survivors privately shared their frustration that blankets were inequitably distributed, leaving many shivering.

Due to the crowding, we were not surprised to see that pneumonia and gastroenteritis also predominated in Ishinomaki, as was common in Haiti.

There was no cholera in Japan, but many symptoms reminded us of Haiti and Katrina, such as conjunctivitis, pharyngitis and bronchitis due to irritation from the dust and rubble and silt left by receding floodwaters. The close quarters in shelters provided the opportunity for respiratory particles to get past face masks as they became soaked with moisture from breathing. Only dry masks filter out infective organisms; when they’re wet, air seeps in around the edge of the mask.

The fastidious cleanliness of the Japanese was limited by the lack of running water, and fecal-oral transmission of viral and bacterial causes of diarrhea spread. Our teams were surprised by the odor of urine in shelters, then realized that the elderly, toddlers and infants hadn’t bathed in a

week and hadn’t had a change of clothes — some of them were incontinent of urine, which fortunately is sterile, but also stool. Alcohol hand rub was in high demand, but no water was available to rinse the residue that accumulates after 20 applications.

Helping out in Japan is much easier in some ways than in past disasters and more difficult than in others. Japanese are rightfully very proud of their excellent preparations for disasters, and the relatively low death rate speaks to the success of executing those plans. It was heartening to hear from many survivors who shared how they followed their disaster plan and made it to higher ground.

It compelled me to make a plan with my own family. It was heartbreaking to hear how many who followed the plan still died, since the inundation was of such a great height that many who evacuated to elevated tsunami shelters also drowned.

Another difficulty was trying to get resources shipped to the disaster. Since the disaster, we’ve been working to get two shipping containers full of medical supplies, new Gymboree children’s clothes and EO Products hand sanitizer to Ishinomaki. Recently, we mobilized the shipment that will take three weeks to get there. The shelter manager just called and they recently received a big shipment and don’t have room for more. Now I’m scrambling to find another shelter to accept the shipment. This is the reality of relief work halfway around the world.

With the rapid changes from day to day in the disaster, it was helpful to review websites that listed the latest news — in disaster parlance it’s called “Situational Awareness.”

It helped us coordinate with those at the shelters by email about what they needed, where we could help. In Japan, XCom Global donated MiFi devices that gave up to five users the ability to share a WiFi connection, so we could stay connected. It was a way

Relief Efforts in Japan > 29

IN THE SPOTLIGHT

Ashby Wolfe, MD, MPH

Leadership is Alive and Well at NCSC In May, I had the opportunity to join a group of fellow California family physicians for the annual National Conference of Special Constituencies (NCSC) in Kansas City, MO. Every year, Academy members representing five specific groups from each state meet to propose and draft policy resolutions for the AAFP’s Congress of Delegates. The meeting is designed as an opportunity for AAFP members from underrepresented constituencies to meet, network and integrate their perspectives into the policies of our organization. First held in 1990, the meeting started out as the National Conference of Women, Minority, and New Physicians. Since then, two additional groups have been added to the NCSC so that International Medical Graduates and LGBT (Lesbian, Gay, Bisexual and Transgender physicians and allies) are now represented. Over time, NCSC has become one of the best opportunities for leadership training and policy development the Academy offers.

While the primary purpose of the forum is to develop policy resolutions, delegates receive training in advocacy and leadership and spend time connecting with family medicine colleagues from all around the country. I wasn’t quite sure what to expect as a resident, but was delighted when asked to join the California delegation. I was certain the conference would be both interesting and educational, but I was not nearly prepared for the amount of energy and work that we managed to pack into the three-day event.

We began our official first day with a keynote speech from David Satcher, MD, PhD, the 16th US Surgeon General, and now head of the Satcher Health Leadership Institute at the Morehouse School of Medicine in Atlanta. Dr. Satcher focused on the theme of leadership, saying he thinks of himself not as an expert, but rather a perpetual student of leadership technique.

He talked about his opportunities to serve, and the experiences he encountered, as both Surgeon General and in his current position. “How do we work toward our goals? How do we begin to address health disparities?” he said. “We need comprehensive health systems, policy development and leadership.” He added,

2012 NCSC Convener Jay W. Lee, MD, MPH; Sophia Henry (chapter staff); Ashby Wolfe, MD, MPH, MPP; Michelle Quiogue, MD; Elene Brandt, MD; Andrea Angelucci, DO; Scott Nass, MD and Kelly Jones, MD.

“It’s not the position you hold that makes you a leader, [but] it’s taking advantage of every opportunity where you are.” That was all the delegates needed to hear.

What followed was nothing short of a frenzy of activity motivated by the drive and experience of a group of people who identify themselves, first and foremost, as Family Physicians.

Twitter messages began flying back and forth during Dr. Satcher’s speech, as people became more involved in high-tech communication, aided by the ever-popular smartphones and our own growing sense of interconnectedness. Facebook was also a popular mechanism to connect delegates from all states with one another. The Facebook site for the NCSC kept a running commentary of events and daily images of the activities both at the NCSC and the Annual Leadership Forum (ALF) — another forum taking place simultaneously.

Following the keynote, we were off and running to business sessions to discuss topics pertinent to each of the five special constituencies. Lively discussions could even be heard in the hallways outside the sessions, as people debated whether local challenges would translate into national policy, which issues were pertinent to the AAFP and what position the AAFP should take on proposed topics. Writing on these topics was quick and efficient, and everyone was encouraged to get

involved in developing, researching and drafting policy recommendations. Each constituency had the opportunity to review the others’ resolutions and ask questions about the origin or intent of the statements. Leaders, or “conveners,” of each constituency spoke for or against specific resolutions and there were some impassioned discussions on many topics ranging from debate over AAFP’s place on the Relative Value Scale Update Committee (RUC) to improving continuity of care for migrant workers.

In addition to debate, attendees were asked to volunteer to review the resolutions in five Reference Committees.

I had the privilege of serving on the Reference Committee on Advocacy, which reviewed 11 resolutions developed over the course of the day. It was incredible to see so many people involved in developing the policy agenda, and AAFP staff members were knowledgeable and generous with their time as we worked to develop our final report.

Our last day represented the culmination of our experience; all the official state delegates from each of the Special Constituencies had the opportunity to hear the Reference Committee reports and vote on each resolution. I was particularly impressed with the caliber of the discussion and thoughtful

Leadership at NCSC > 29 California Family Physician Summer 2011 13

Leah Newkirk

Twenty-Five Things Family Physicians Should Know about ACOs On March 31, 2011, the Centers for Medicare and Medicaid Services (CMS) proposed a new rule governing Accountable Care Organizations (ACOs). The proposed rule details the requirements for eligibility and participation in the Medicare Shared Savings Program, Medicare’s ACO program. The Patient Protection and Affordable Care Act (PPACA) established the Shared Savings Program to encourage providers to create a new type of health care entity, or ACO, that can be held accountable for improving the care and health of patients, and reducing the rate of growth in health care spending.

Before the regulations were released, the ACO was a confounding entity — sometimes compared to a mythical beast.

The complexity of the new regulations potentially adds to the confusion and frustration surrounding the ACO. CAFP urges California family physicians to educate themselves about the model and stay abreast of developments in the Shared Savings Program. The ACO model, and the excitement it generates, has the potential to change family physicians’ practices. There may be new opportunities and leverage

rently conceived. Beneficiaries are retroactively assigned to ACOs based on who gives them a plurality of their primary care services. The primary care provider is viewed as the leader of patients’ health care with the ability to improve quality and decrease costs. Physicians eligible for primary care provider status include family medicine, internal medicine, general practice and geriatric medicine specialists.

4. Patient and provider participation in the Shared Savings Program is purely voluntary. Primary care providers may only participate in one ACO and beneficiaries will only be assigned to one ACO. However, a hospital or nonprimary care provider can participate in more than one ACO. 5. The proposed rule specifies that an ACO may include a variety of types of organizations: • ACO professionals (i.e., physicians, physician assistants, nurse practitioners and clinical nurse specialists) in group practice arrangements; • Networks of individuals practices of ACO professionals;

1. The Medicare Shared Savings program is scheduled to go into effect on January 1, 2012. ACO agreements will be for three years with one-year performance measurement periods. The regulations provide for a once-a-year start date of January 1.

• Partnerships or joint venture arrangements between hospitals and ACO professionals;

2. The program creates incentives, the “shared savings,” for providers to work together in ACOs to treat an individual patient across care settings and rewards ACOs that lower costs while meeting performance standards on quality of care and patient experience.

6. An ACO must have at least 5,000 beneficiaries. If an ACO accepted into the program falls short of the 5,000 requirement, it will be placed on a corrective action plan.

3. Primary care providers have a distinctive role in the program, as it is cur14 California Family Physician Summer 2011

• Hospital employing ACO professionals; and • Critical Access Hospitals that bill under Method II.

7. Seventy-five percent of the governing body of an ACO must be ACO participants (providers). CMS is encouraging

providers to gain control over the ACO’s decision-making process. The board of an ACO must also include some Medicare beneficiaries.

8. ACOs choose one of two program tracks. The “one-sided risk” track allows an ACO to share savings only for the first two years and share savings and losses in the third year.

The “two-sided risk” track allows an ACO to share in a greater proportion of savings, but also requires the ACO to share losses for all three years.

9. The calculation for ACO savings is complex. CMS will establish benchmarks by doing a retrospective review of three years of aggregate beneficiary-level data for the assigned population. “Savings” or “costs” will be the difference between actual spending and these benchmarks beyond a minimum rate (generally 2 percent).

The higher the number of beneficiaries, the lower the minimum rate.

For smaller populations (e.g., 5,000 beneficiaries), the minimum savings rate can be higher (up to 3.9 percent).

However, there are exceptions to the rule for rural ACOs. 10. The ACO entity is responsible for distributing savings to participants. ACOs have significant flexibility when it comes to distribution.

11. To be eligible to receive shared savings, the ACO must also meet certain quality standards. There are 65 quality measures that CMS proposes ACOs will be evaluated on in the first year of their operation. The measures fall into five categories: Patient experience of care, care coordination, patient safety, preventive health and at-risk population/frail elderly health. These measures will be reported to CMS through surveys, claims submission and data collection. ACOs will be given points

PRAC TICE MANAGEMENT NEWS

for performance on each measure and each category will have its own score. They weighted score will determine the maximum sharing rate for which the ACO is eligible. Patient survey results and quality measures will be made available to the public by the ACO in a standardized format.

12. An ACO must develop a process to promote evidence-based medicine, patient engagement and coordination of care. ACOs must have a process for evaluation the health needs of the population it serves and have systems to identify high risk beneficiaries and develop individual care plans for target populations.

13. An ACO must maintain a database of all ACO participants and their National Provider Identifiers and report this.

14. ACOs must have a compliance plan and conflicts of interest policies and means to screen ACO providers. ACOs must get approval for any changes in ACO providers during the three-year contract period.

15. Providers participating in ACOs will be required to post signs in their facilities indicating their participation in the program and to make available standardized written information to beneficiaries whom they serve. Additionally, all Medicare patients treated by participating providers must receive a standardized written notice of the provider’s participation in the program and a data use opt-out form.

16. At least 50 percent of an ACO’s primary care physicians must be meaningful EHR users as defined by the HITECH Act and subsequent Medicare regulations.

17. The regulations set forth 16 grounds for termination of an ACO’s agreement with CMS. Examples of these grounds include failure to report quality standards and avoidance of at-risk beneficiaries.

18. CMS can change the program during a contract term, but cannot change the rules regarding the eligibility requirements of an ACO, calculation of the

shared savings rate and beneficiary assignment.

19. CMS and the OIG have issued a guidance that proposes waivers with regard to Civil Monetary Penalty, Antikickback and Stark laws solely as to relationships wholly related to an ACO. For Stark and Antikickback, the waiver applies only to distributions of shared savings (not any other financial relationships).

20. The IRS has issued preliminary guidance to provide tax-exempt entities information on participating in ACOs. 21. The FTC and DOJ have also issued a proposed statement of antitrust enforcement policy as to ACOs.

23. Aggregate start-up investment and first year operating expenditures for ACOs are estimated to be between $131.6 million and $263.3 million.

24. Given the start-up costs, the scope of the regulations and the number of actions and approvals to qualify, participate and be accountable as an ACO, the Shared Savings Program will likely attract large, well-integrated groups with substantial administrative capabilities. Many organizations, including CAFP and AAFP, are concerned by the likely exclusion of small- to mediumsized primary care practices and the failure to comprehensively change health care delivery for Medicare beneficiaries.

22. CMS estimates that the number of 25. Family physicians with questions or participating ACOs will initially be concerns about ACOs should contact 75-100 and that the number of MediCAFP Director of Health Policy Leah care beneficiaries receiving care from Newkirk at lnewkirk@familydocs.org providers participating in the program or1(415) 345-8667.1:03 PM Page 1 SCI_CA Phys Ad_12.18.10.qxd:Layout 12/20/10 will beFamily five million.

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California Family Physician Summer 2011 15

CAFP FOUNDATION

The Future Faces of Family Medicine (FFFM) Program: Inspiring a Future Primary Care Workforce

By Randi Sokol, MD; Alisha Dyer, DO and Charlene Hauser, MD

The Future Faces of Family Medicine program will receive the AAFP Foundation’s 2011 Outstanding Program Award in September at the AAFP Foundation’s Celebration Dinner in Orlando, FL.

If you are reading this, you understand the incredible importance of primary care: we all know that health care systems that focus on primary care produce better outcomes, at lower costs, and provide greater access to care.

And if you are reading this, you are also aware of the impending shortage of primary care physicians (PCPs) our nation faces: The Patient Protection and Affordable Care Act (PPACA) will be adding approximately 32 million new patients to the system by 2014. For a country that already has a huge shortage of primary care physicians, this added patient load poses daunting primary care workforce shortage issues, with a shortfall of approximately 46,000 PCPs predicted by 2025.

The Council on Graduate Medical Education (COGME) estimates that to provide adequate access and hence optimal outcomes for our nation of patients, 40-50 percent of our workforce will need to be primary care physicians. Yet our medical schools continue to produce more physicians interested in sub-specialty care.

So, as PCPs who deeply believe in the importance of our role, what can we do to garner a future of primary care physicians who make up the majority of the workforce and are leaders within our medical communities?

16 California Family Physician Summer 2011

In Sacramento, residents from UC Davis and Sutter Family and Community Medicine Programs, in coordination with the CAFP Foundation, put our heads together to tackle this task.

We know that targeting students early is a key to exciting them about careers in primary care and guiding them down a pathway to family medicine. So with the help of funding from the CAFP Foundation (CAFP-F), and assistance from CAFP staffers Callie Langton and Cody Mitcheltree, the Future Faces of Family Medicine (FFFM) program was created to inspire a class of high school students to pursue careers in family medicine.

FFFM was modeled after a similar program, Decision Medicine, a pipeline program developed by The San Joaquin County Medical Society designed to increase the number of minority high school students who become physicians. With the support of multiple hospitals and universities in the area, Decision Medicine offers a free, two-week intensive “summer camp” type course to 24 individuals, inspiring students who otherwise might not believe a career in medicine was possible.

We wanted to offer a similar type of experience, but ensure the emphasis was on primary care.

As a medical student at Tulane University, Randi Sokol, MD, MPH served as the student representative to the Louisiana Academy of Family Physicians (LAFP), helping spark student interest in Family Medicine and setting up a mentorship program between medical students and local family medicine docs.

After spending a month doing research on the pipeline to a career in primary care medicine, however, she realized the pipeline starts much earlier than medical school; to truly promote the production of more family physicians, the outreach to students had to begin sooner — at the high school level. With the help of Alisha Dyer, DO and Charlene Hauser, MD, who shared similar goals and passions, FFFM was born.

Alisha Dyer, DO recalls how early experiences in medicine, specifically family medicine, shaped her desire to pursue a career in primary care. During high school she participated in the Medical Pathways program sponsored

by Kaiser Permanente, exposing her to the ‘world’ of medicine. After a wavering pathway that included joining the Army National Guard, Dr. Dyer’s passions for primary care were rekindled when she had the opportunity to work one-on-one with Winters, CA family physician Carla Kakutani, MDfor four weeks through CAFP’s Summer Family Medicine Preceptorship Program. Now a second-year family medicine resident at Sutter and Chair of CAFP’s Residency Council, Dr. Dyer strives to inspire a new class of family physicians.

“The Future Faces of Family Medicine program that my colleagues and I created is one way that I can give back, by helping to produce compassionate, and dedicated family physicians,” she said.

Similarly, Charlene Hauser, MD, MPH, now a (future) chief resident at UC Davis Family Medicine Residency Program, had a rocky pathway. After completing her intern year of surgery residency, Dr. Hauser realized that “the patients on whom I was operating weren’t getting better. A procedure to remove a diabetic foot, bypass clogged blood vessels or remove a colon cancer was a mere temporizing measure in the progression of obesity- and smoking-related disease. If I actually wanted to help these patients, I needed to put my efforts into preventing their poor lifestyles.”

Dr. Hauser “left surgery to the surgeons and converted to family medicine, where public health and prevention are the treatment of choice.” Her early exposure to public health,

QI CORNER

earning an MPH while in medical school, fueled her desire to provide high school students with early exposure to preventive medicine.

Together, we set in place a program that exposes students to primary care and does so in a longitudinal way to steer them down a pathway toward primary care. In partnership with a Sacramento-area high school, we recruited 20 motivated students through an application process. We then garnered the support of our residency programs to give family medicine residents allocated time in their curriculum to teach and inspire this group of students.

Throughout the four-month program, residents from Sutter and UC Davis worked together to launch a curriculum that exposes high school students to lively discussions, hands-on workshops, and patient care, while employing their leadership skills. A total of six 75-minute weekday sessions and two half-day weekend sessions were conducted. Sessions including such topics as “What is Primary Care?,” “Adolescent Health,” and a panel of family medicine residents who shared their struggles and victories down the road toward medical careers.

Students had the chance to get their hands wet practicing medical skills in “The Physical Exam” and “OB Delivery” workshops and had the opportunity to explore a cadaver lab, practice patient care scenarios in a state-of-theart simulation suite and become CPR-certified.

They also shadowed pre-med students, medical students and residents at a local volunteer clinic serving a medically underserved population. And, students honed their leadership skills as they prepared and taught a health topic to their ninth grade health class. Students had reading assignments and wrote reflection pieces along the way.

To ensure the program truly becomes longitudinal, graduates from the FFFM program were paired with local family physicians for mentorship, providing more opportunities to shadow in clinic and additional support as the students head down the long academic road to medicine. At the same time, volunteer mentors earn CME credits for their time — a true winwin for both mentor and student.

We plan to continue offering this experience in Sacramento and are committed to expanding it to other high schools. We also hope this model of collaboration across family medicine residency programs will serve to inspire other residency programs to similarly unite and lead programs that amplify our future family medicine workforce.

Jane Cho

Continuous Flow: What Is It and Why Is It Important?

The Institute for Healthcare Improvement (IHI) recently held an educational program, Efficiency and Reliable Design in the Office Practice, designed to introduce the latest quality improvement topics. One session focused on continuous flow; faculty described what it is and why it is important for an office practice.

Continuous flow is a single workflow process designed to improve productivity, build in quality, maximize efficiency and reduce cost. Continuous flow is what practice teams should seek to achieve with each work task. To achieve continuous workflow, start by identifying and addressing the source of common obstacles in the office: Physician — Sometimes the physician is the bottleneck and waste may come from his or her having multiple interruptions and distractions or completing other tasks that could be performed by another staff person.

Staff — Bottlenecks can arise when staff becomes specialized in certain tasks and flexibility is lost. Cross training and fluidity in job responsibilities can improve flow.

Equipment — There may be constraints in equipment set up and inventory. The office staff should have the proper equipment and tools to do their job with no interruption.

Office — The physical office space may not be conducive to continuous flow. For example, an office may have a waiting room and provider office, but not enough space for a sufficient number of exam rooms. One group of providers in a Pennsylvania family practice decided to give up individual offices and, instead, share them to create more exam rooms.

These obstacles can be eliminated by shifting the work of a practice team in a number of ways. One is to create standing orders and develop protocols in a move toward continuous flow. Labs, diagnostics, referrals and prescriptions can easily be written in advance and approved by a physician. The main point of continuous flow is to have staff buy-in and support. Once the group comes together and identifies clear roles and responsibilities, each person is held accountable in the effort to obtain continuous flow.

One of the best ways to identify barriers and improve workflow is devising a “flow map.” Flow mapping can help your staff visualize the sequence of steps involved in a work function. Mapping each step can help your team evaluate whether each process can be optimized to decrease non-value-added time (waste) spent doing routine clinical activities. For more information about office processing mapping, please read CAFP’s Practice Management News article, Mapping Your Way to Leaner Workflows (http://www.familydocs.org/news-media/practice-management-news/ february-2009.php), so your team can better understand this group exercise. CAFP also has mapping worksheets available in our PCMH Resource Center resources (http://www.familydocs.org/pcmh.php) and group activity worksheets to facilitate your next meeting’s flow mapping. Your team will outline each step in one workflow process and, once the opportunities for change have been identified, can begin making small changes to improve a work function. The most important part of the exercise is to bring your staff together to communicate about existing challenges and consider productive changes that can add value and improve workflow.

Motivation and buy-in from those who are making the change is crucial to success.

Jane Cho is CAFP’s Manager of Medical Practice Affairs.

California Family Physician Summer 2011 17

The Future of Family Medicine is in Your Hands!

2011 Family Medicine Summit and California Residency Fair It is an exciting time to be a family physician as health care reform and new models of care form a perfect storm for change in our health care system. As students and residents, you represent the future of family medicine and your leadership and advocacy will ensure great success for the specialty in the future.

Join the discussion while learning the real deal about family medicine at the California Academy of Family Physicians’ 2011 Family Medicine Summit, October 15-16 at the Sheraton Gateway LAX in Los Angeles. The Family Medicine Summit is for students, residents and faculty mentors.

Hone your leadership skills, learn about new models of health care delivery, participate in procedural workshops and spend a weekend networking with your peers. If that is not enough to get you there, do not miss our social event on Saturday night where you’ll have a chance to battle it out at our Family Medicine Trivia night for prizes and bragging rights.

For more information or to register, log on to www.familydocs.org/students-residents/family-medicine-summit.php

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FAMILY INDUSTRIAL FITNESS PREVENTION

Busy solo urban practice physician is seeking an associate.

The practice is located on the ground floor of a four story medical office in the Baldwin Hills area of Los Angeles. This physician is seeking a fellow doctor willing to invest financially and with time and effort become a partner in this stable thirty year practice.

Interested parties contact Elizabeth Covington, MD 323.290.2107

18 California Family Physician Summer 2011

FAMILY PHYSICIAN Beautiful Coastal Northern California nestled among the famous Sequoia Redwood Forests United Indian Health Services, a non-profit consortium of eight tribes and California’s premier American Indian Health Clinic, is seeking one full-time Board Certified or Board Eligible Family Practitioner to work in the Klamath-Smith River Clinics. Hospital on-call responsibilities include medicine, pediatrics and possibly obstetrics.

Competitive salary.

Interested applicants please FAX CV to: UIHS (707) 825-6747 attn. Trudy N. Adams; (707)825-4036. In accordance with PL 93-638 American Indian Preference shall be given.

Kaiser Permanente Southern California: We take your administrative concerns and offer you a balanced call and work schedule.

We give you the support, resources, and autonomy you need to give your patients the exceptional care they deserve.

Full-Time Family Medicine Opportunities: Antelope Valley • Bakersfield • Moreno Valley Redlands • San Bernardino • Victorville Oxnard (Spanish Bilingual Preferred)  Physician-lead practice that equally emphasizes professional autonomy and cross-specialty collaboration  Comprehensive support network  An excellent salary, comprehensive benefits  Stability during times of change in healtcare nationwide Send E-Mail with your CV to: Bettina Virtusio — bettina.x.virtusio@Kp.org / Phone: 800/541-7946 We are an AAP / EEP employer

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22.0 P www.asccp.org (301) 733-3640 cnoonan@asccp.org American Society for Colposcopy & Cervical Pathology

8/11 - 8/14 Office Cynecology and Anaheim Women’s Health

www.cme.ucla.edu UCLA School of Medicine

22.0 P (310) 794-2620

8/11 - 8/13 High Resolution Anoscopy (HRA) 17.75 P

San Francisco

www.asccp.org (301) 733-3640 cnoonan@asccp.org American Society for Colposcopy & Cervical Pathology

8/12 - 8/15 Intensive Medical Spanish and 45.0 P San Francisco Cultural Competency Workshop

www.medspanish.org (520) 907-3318

convesp@aol.com Rios Associates 8/12 - 8/14 Geriatric Medicine for Primary 11.0 P San Francisco Care Physicians

www.mer.org (720) 473-6112 melissa@mer.org Medical Education Resources

8/24 - 8/28 Wilderness and Travel Medicine

23.50 P Squaw Creek www.wilderness-medicine.com (800) 522-8747

veronica@mountaindestinations.com

Wilderness and Travel Medicine, LLC 8/27 - 8/27 New Medical Director’s Training

San Diego

6.25 P www.NACHC.com (301) 347-0400 kMcNamara@nachc.com National Association of Community Health Centers

September..................

9/21 - 9/24 28th Annual UCLA Intensive37.75 P Los Angeles Course in Geriatric Medicine

and Board Review

icinfo@ucla.edu(310) 312-0531 UCLA School of Medicine, Geriatrics http://www.geronet.med.ucla.edu/ geronet-calendar/eventlist

October ......................

10/15 - 10/16 2011 CAFP 2011 Family Medicine Summit

Los Angeles www.familydocs.org • (415) 345-8667 cafp@familydocs.org See page 18 for details.

California Family Physician Summer 2011 19

Alicia Bachus,

MD

MEMBERSHIP

From One Family Physician to Another: How Do You Achieve “Work-Life Balance”?

Editor’s note: This article was first published in the October 2010 issue of Los Angeles Academy of Family Physicians’ Chapter News. We thank LAAFP for reprint permission.

Engrossed late and soon in professional cares ... you may so lay waste your powers that you may find, too late, with hearts given away, that there is no place in your habit-stricken souls for those gentler influences which make your life worth living.

— Sir William Osler

Physician wellness is clearly not a new concern — but, it is a growing one. Burnout is the experience of long-term emotional exhaustion, decreased job satisfaction, and decreased sense of personal accomplishment. As demands on primary care increase, rates of physician burnout are trending up, with some studies citing that up to 66 percent of physicians are experiencing burnout at any one time. As we look around at our department and friends, that statistic is easy to believe.

Striking a good work-life balance is difficult, but is key to avoiding burnout. I remember when I first started working after residency— the work seemed endless and I began to feel overwhelmed. I stopped exercising, reading, and doing other things that I enjoy. It was hard to connect with patients and give them compassion they need and deserve.

At that point, I realized I needed change. But, that was hard to accept. As physicians we’re never encouraged to think about ourselves or ask for help.

But, I altered my schedule and started to prioritize things that make me happy. I started to exercise more regularly, and found ways to make my job more enjoyable. And, not surprisingly, I now find it easier to be efficient, engaged, and compassionate in my job.

Be kind to yourselves. Take time for the things that bring you joy and balance to your lives. I encourage you to take a walk, enjoy a cup of coffee, or call a good friend. After all, if we don’t take care of ourselves, who will take care of our patients?

Alicia Bachus, MD, is a board-certified family physician in practice at Kaiser Permanente Woodland Hill and a member of LAAFP’s Executive Board.

20 California Family Physician Summer 2011

The following are several ways members like you — medical students, residents and active practicing physicians — strive to achieve work-life balance.

“Balance is if you enjoy what you do and wake up every morning thankful to have another opportunity to do it again.”

— Davis Liu, MD, Sacramento “Balance to me is spending the right amount of time on each activity that a I prioritize in my life. In my case, that means my family and my work.”

— Elise Singer, MD, Palo Alto

“Balance is the ability to do what you love without falling down (or getting killed or severely maimed).”

— Gary Seto, MD, Pasadena

“Balance for me has been achieved through reducing my work hours to a more manageable number. With three kids and multiple extracurricular activities, I have found balance through reducing my hours so that I work no more than 30-35 hours per week at the office.”

— Melissa Vourlitis, DO, San Diego, CA “Your health is as important as that of your patients. Put your oxygen mask on first before helping others. Demand a lifestyle that includes time for you, both your physical and emotional health.

Settle for no less. I redefined my way of practicing, and building in time to take care of myself was essential to that new definition.”

— Stacey Kerr, MD, Santa Rosa “Balance is making time to do all of the important things in life and accomplishing the best things in life.”

— Matthew Abinante, Vallejo, CA “Make sure you truly love what you are doing and always keep the balance between working hard and your home and family life.”

— Randall West, DO, Folsom “Balance is finding whatever you need to do in your off time so that you wake up every day excited to be a doctor.”

— Steve Kramer, MD, Sunnyvale “I will tell you when I find it, but I do know it involves taking a day off in the week and protecting it like a mother bear protects her cub.”

— Douglas Jimenez, MD, Santa Rosa, CA

WORK-LIFE BALANCE What Part of “Balance” Don’t I Understand?

By Carla Kakutani, MD

When I was asked to write about work-life balance, I laughed. The editors of this magazine must be looking

for a contrarian view! Aren’t I the poster child

of what not to do? Am I not famous in CAFP lore

as the person who never said no? My biggest fear as a family medicine preceptor and leader is that my “have-itall-or-die-trying” lifestyle has scared more people away than it has inspired.

Scratch that: my biggest fear is that my children will grow up to be ax murderers and tell the court psychiatrist about all those times they sat in my office, looking for the hidden pictures in an old copy of Highlights, while the other kids were basking in the glow of their mothers’ undivided attention.

I guess my chances for ever achieving balance were ruined by residency, back in the days before work hours restrictions. There was no such thing as work-life balance then. There was work … and there was collapsing on the couch in a deep sleep, the kind where you wake up disoriented, with drool on the upholstery. It was crazy and probably unnecessary, but it did have the advantage of simplicity. When you don’t have choices, you don’t waste a lot of time second-guessing them.

Obviously, life didn’t stay that simple and now choices abound, but they never seem to get me any closer to this unrealistic picture I have in my head of what work-life balance ought to look like. Isn’t it supposed to be an effortless amalgam of Kelly Ripa and Marcus Welby, with both the family and the practice running smoothly as you find time for exercise, volunteer work, building a medical home and eight hours of sleep? Instead, on most days, balance feels more like a tightrope walker using every muscle to stay up on the high wire. It is challenging and tiring but frequently exhilarating.

Listening to my patients reminds me why I’m so lucky to have such a problem. Many work two jobs, get called for mandatory overtime, have no sick leave or work opposite shifts from their spouse to save childcare costs. Paid up rent and food on the table is all the balance many people can hope for.

I should strive for a little less angst and a lot more gratitude.

The joy of family medicine is that it adapts to your personal definition of balance. Work for yourself, work in a group, do procedures, don’t do procedures, full-time, part- time: if you can dream it, you can find a way to make it happen. You have the skills to meet our country’s huge need for primary care, which exists in every state, from the biggest city to the smallest town. So get out there and follow your bliss. If it feels harder than you are making it look, then you’re probably on the right track.

Carla Kakutani, MD is a family physician from Winters, CA. She is also the Chair of the Family Physicians Political Action Committee (FP-PAC and a CAFP past president.

California Family Physician Summer 2011 21

WORK-LIFE BALANCE Promoting Work-Life Balance Could Help You Get Ahead in the Hiring Game

By Callie Langton, MPA

Whether you’re a solo physician in Humboldt or director of a large medical group in Los Angeles, you’ve probably wondered how you can continue to attract young physicians to your practice. California has the highest percentage of the total number of physicians over age 60 in the nation (29 percent in 2010); that number is expected to increase in the coming years.

Coupled with California’s rising population density and our stagnant number of medical school graduates, practices face fierce competition for new physicians.

You may be wondering what you can do to make your practice appeal to those discerning new family physicians as they enter the workforce. Here are five things you can offer new physicians to entice them into joining your practice:

1. Work-Life Balance and Flexibility

It’s no secret that schedule and hours flexibility is key to attracting young physicians to your practice.

In fact, the Association of American Medical Colleges finds that it is the second most important factor next to location in determining where a resident ultimately chooses to work. Offering opportunities for job-sharing, part-time work, sabbaticals and limited call schedules can make your practice stand out.

2. Patient Centered Medical Home

Residency programs and medical schools are constantly evolving their curricula to embrace changes in health care delivery and are often the first to implement new practice concepts.

As a result, students and residents leave training expecting the same level of collaboration with non-physician clinicians and may be turned off by practices that do not embrace the team approach to care. If becoming a recognized Patient Centered Medical Home seems overwhelming, start with small changes or invest in additional health information technology; they can have a significant impact on the efficiency of your practice and the perception of your practice’s future.

3. Technology

Young physicians expect practices to use technology and are often surprised when they do not. Electronic Health Records (EHRs), iPad applications and virtual access to patients, pharmacies and referrals can help your practice attract young physicians.

With current Medicare and Medicaid incentive programs for achieving meaningful use of EHRs, there is no time like the present to implement an EHR. EHR adoption will likely affect your office’s productivity for a few months, but the benefits you reap will be worth it.

4. Debt Repayment Assistance

The cost of medical school has grown rapidly in recent years, causing increased debt loads.

Money isn’t everything, but debts of $150,000 or more can be overwhelming for new physicians. Offering to share that burden with them, whether through a signing bonus or assistance in paying loans off over time, can be a great incentive and make them feel supported as they leave residency and enter the real world.

5. Professional Growth

Young physicians want the ability to grow and explore, both in and out of the office. Offering funds for professional development, outlining the ways in which they can move up in the practice and even offering to carve out a percent of their time for a passion project that would also help the practice can be very enticing to a new graduate deciding between multiple competing job offers.

If you are feeling a little overwhelmed right now, you’re not alone.

Attracting and retaining young physicians, particularly family physicians, is one of the biggest challenges facing practices and medical groups in California today. The good news for you is that most employers are still applying old hiring techniques with limited success, leaving ample opportunities for those interested in getting ahead.

Implementing any or all of the recommendations above will help ensure your practice has a head start in the hiring game.

Callie Langton, MPA is CAFP’s Associate Director of Health Care Workforce Policy.

RESOURCES AAMC Study on Young Physicians and Initial Practice Preferences: http://www.nejmjobs.org/content/employers/YoungPhysician_Practice_Preferences.pdf Centers for Medicare and Medicaid Services EHR Incentive Program: https://www.cms.gov/ehrincentiveprograms California Healthcare Foundation’s 2010 Physician Facts and Figures Report: http://www.chcf.org/~/media/Files/PDF/C/PDF%20

CaliforniaPhysicianFactsFigures2010.pdf

22 California Family Physician Summer 2011

WORK-LIFE BALANCE When It Comes to Balance Things Take Time

By Catherine Sonquist Forest, MD, MPH

“Ironic, you think?” my colleague asked me when I told her I agreed to write an article on balancing work and community service. Picture Despite her me on the eve of leaving for a 10-day spring break trip that would busy work schedule, include visits to the East Coast to see my daughter’s college culminaCatherine tion project, to the Midwest see an elderly friend and then Disneyland Sonquist Forwith my teenage son. I was charting until late into the evening, tying est, MD is still up loose ends and coaching my son as he created a flyer for our fundable to find raiser for tsunami victims in Japan. I had packed a little ‘light reading’ time to attend (for the CAFP CME Leaders Institute on my return) and my laptop to community develop my revised seventh-grade sexuality and reproduction module events such as the Using Open for my son’s public school, and uploaded an app for Disneyland. I Innovation also packed Cutting For Stone, a novel by Abraham Verghese, MD, to Reinvent who was the keynote speaker at this past Annual Scientific Assembly Primary Care (Before medical school, I made a pact with myself to keep a novel goEvent. (Photo ing at all times). I was still doing the laundry and perhaps my patience courtesy: Hope was a tad thin. My kids call it mom’s PTFO (pre-trip freak out — not a Street Group). pretty sight).

“No, not ironic, just the dance we dance,” I responded. “I guess I still have a lot to learn.”

My mother used to say “Start from where people are.” By that, she meant when people are invested in something, engaging them to think differently and work toward improving, that ‘something’ is more effective. As an adult, I have tried to live by that credo.

In my family of origin, the word ‘extracurricular’ was not used. Neither was ‘community service.’ The expectation within my extended family was that the world should be a better place because each person walked on it. Our family activities were fun things we did together, and often, but certainly not always, were aimed toward making the world a better place ranging from ‘Trick-or-treat for Unicef’ to raise money for hungry kids in Africa to civil rights teach-ins in Detroit in the 1960s. Being actively involved was just a part of how my parents organized their own lives and ours.

Now, when we can (and sometimes we just can’t), we all need to build in some time to try to change the things in this world that are broken, to make the work just a little better. There is plenty to do so you can start just about anywhere. That means supporting one another in whatever boundary-making is required to have a reasonable life at work and at home.

The hardest lesson I have had to learn is that being well-rounded in life is not rewarded in medical circles. While we purport to believe in balanced lives for our patients, we physicians foster a community among ourselves that supports balance, breadth and depth. I have experienced this both within medicine (how often have I heard a specialist say to me “Gee, you are intelligent, why are you a GP (sic) and not a specialist?”) as well as within our own family doctor ranks (how often have I heard, and, yes, participated, in the image and practice of sacrifice of self to our patients?).

Being unable to support boundary-setting and balance comes at the cost of our ability to say yes to other things that matter, such as attending PTA meetings, raising money for people suffering overseas, fixing houses for the poor, cleaning up the environment (never mind exercise, yoga, down time and conversations).

These things take time.

Of course, the mystery is how? How do people manage to be engaged in the world outside of medicine? My secret (thanks to my mama for sharing it with me) is to start in close. I try to do the most organizing on topics close to my heart and with people I see. I help build our community by doing the things I care about with people I care about.

Considering that I have been a family physician for nearly 20 years, a mother of two living in a co-housing community and have been involved in health care change, you can only imagine the patchwork of organizations with which I have been involved ranging from Neighborhood Watch to the school board in my children’s school district, from the California Organization of Interns and Residents Physician’s Advisory Group to Hospice, and from a children’s non-profit “All About Theatre” scholarship drive to working on political campaigns (to name just a few). I find that the joy in working alongside those I work, live, parent and have common concerns with has made all the difference — all this while still caring for patients.

Remember: Things Take Time (direct quote from my grandfather — a doctor who made a difference).

Catherine Sonquist Forest, MD, MPH is a Family Physician at the Santa Cruz County Health Services Agency and Clinical Instructor at the Department of Family and Community Medicine at the UCSF Medical Center.

California Family Physician Summer 2011 23

WORK-LIFE BALANCE It’s Sink or Swim When It Comes to Finding Balance

By Steven Green, MD

Balancing our work with the rest of our lives is one of the biggest, most important challenges we family physicians have. We went into medicine wanting to help people and, if we are not careful, can end up putting our patients ahead of ourselves and our families. If we allow it, our practices can become all encompassing, leaving no time for family, friends and ourselves. We’ve all seen doctors who don’t take time for themselves and their families; while they may enjoy their practices, they pay a high price.

Family physicians should be role models for our patients. How would we counsel a patient who said he or she worked 14-hour days, never exercised and didn’t have outside interests or hobbies? If we don’t have balance in our lives, it’s hard to fathom how we can counsel our patients to do so. If we wait to find the time for ourselves and our family and friends, it won’t happen. We have to make the time.

Sometimes the challenge is to figure out how to get that workout in during a busy day and still spend time with our family.

After my wife and I had our third child, I needed to be at home to help with the kids to the point where I essentially gave up taking care of myself. I stopped exercising and managed to gain 80 pounds and was usually tired and grumpy, but I felt it was what I had to do. My solution to the weight problem was to buy bigger pants.

Fortunately, I had an epiphany when I was leaving the house to buy some size 40 pants. I realized my own health needed to be a priority if I was going to be able to feel good enough to help my patients and

24 California Family Physician Summer 2011

enjoy my time with my family and friends.

I went back into the house and put on my somewhat snug biking clothes and went for a ride. Since then, I’ve exercised six or seven days a week. I lost the excess weight and feel better than ever.

I went from just cycling to adding running and then moved to triathlon. I realized my swimming needed work and decided to focus on that. I like the challenge and technical aspects to swimming. I went from being the slow guy in the slow lane at the pool to holding my own with some reasonably competitive swimmers. Ocean swimming is my current sport, and I train most days. Sometimes it means being in the pool or ocean before the sun is out, but it’s a priority for me, so I do it. Last summer I became the 179th person to swim from Catalina to Long Beach and am attempting the English Channel this

September. My family is supportive of my efforts and help as they can. Hopefully by seeing me exercising regularly, my kids will continue to do so. One of the nice things about ocean swimming is there are no pagers or cell phones, and even though it may be cold and choppy, it’s a complete change of pace from patient care and work.

I’m not claiming to have the answer for how to balance work and life and family and friends, but it’s important to try to do so. As family physicians, our careers are important to us; however, we need to avoid the trap of letting them become all encompassing.

Steven Green, MD is CAFP’s President-Elect.

Steve Green, MD (without the shirt) uses swimming as a way to stay in shape and maintain a healthy work-life balance.

WORK-LIFE BALANCE To Find Balance, Find What Best Works for You

By Richard Gibbs, MD and Tricia Gibbs, MD

We were flattered to be asked to write an article on how we balance work and life. Yet writing about us is a bit uncomfortable.

In discussing any one path, it is so easy to sound preachy. As we convey in the story, our basic belief is that there is no one-way to do anything. So we ask for the reader’s indulgence in allowing us to talk about ourselves and for your understanding that our story is simply that — our story.

In 27 years together, we have juggled a lot of things — medicine, children, previous careers, a free clinic and new projects. In thinking about how we balance work and life, two things come to mind. The first is how becoming a partnership changed both of us. The second is best said in a magazine photo we once saw of Pope John Paul II. The great spiritual leader was hiking the Alps, striding along in sturdy boots with his papal cassock flying. Rather than seeming out of place, the scene had a feeling of hope. As the article explained, the mountains were a lifelong habit with the pontiff and one of several ways that he found truth and sense in things.

It was enlightening to know that this Pope’s spiritual inspiration was not only the grandeur of St. Peters. Here was the head of one of the world’s most populous religions doing things in a way that was uniquely his.

When we married as third-year medical students, we never intended that our life together would be filled with so much that is slightly off-center, but it has been. And at the heart of every decision, we have made a partnership that is stronger than its parts. In coming together, work and life blended into a shared adventure that has permitted us to take some chances.

We came to medicine after having first careers (Tricia with the US Ski Team and Richard from a decade in professional dance). Heeding the adage there is no best time to have a baby, we had our first child in our fourth year of medical school. More children soon followed, and we were parenting five by the time we entered private practice. It wasn’t easy raising children during residency, but we badly wanted each child. Things that helped were creative scheduling (the one doing an out-patient rotation did the night feedings) and the use of nannies whenever possible. Most important, however, was

our relationship to one another — truly sharing every duty, no roles and no gender bias.

We opened our own practice straight out of residency. With a team of two, what should have been difficult was an adventure. When we realized that 20 percent of the population in our community had no health insurance, we changed the practice to a free clinic. Many people in the medical community helped (including CAFP) and for the past 17 years, this work has been more rewarding than we can ever describe. We both stayed connected to previous careers. Tricia founded the only residential ski academy in the far western states. Together we had the opportunity to create a dancer-oriented medical program for one of the world’s great ballet companies.

Richard continues to supervise their care and teach ballet on the side. Tricia is completing a novel and is on her way to a master’s degree in religious studies. Richard is just now passing the torch as the founding chair of a national Taskforce on Dancer Health.

Over the years, we never found a rule that says there is only one-way to do something. Nor have we seen the converse — one must do only one thing in life. Doctoring skills are needed in so many different settings. Should the long years of medical training restrict one’s life or free it? Becoming physicians did not mean parting with the downhill racer and the dancer. Being busy does not preclude children, and all of the above does not remove a desire to explore something new. A key lesson in residency is that we are capable of more than we previously thought. Expanding our capabilities and juggling several balls at once came from the joy we found in working together. It means honestly believing that work, self-advancement, tending the home and rearing the kids is a true 50-50 effort. We have balanced work and life by not separating the two, but by allowing our work to become a life together. In that union, we have been blessed with the freedom to do many different things, and do them in a way that is uniquely ours.

Patricia Gibbs, MD and Richard Gibbs, MD are co-founders of the San Francisco Free Clinic, an award winning, unique model of shared giving by private charities and the San Francisco medical community.

California Family Physician Summer 2011 25

2011 AWARD WINNERS 2011 Family Physician of the Year: Peter Broderick, MD The California Academy of Family Physicians presents this prestigious award to an individual who exhibits the finest qualities of family physicians and who goes above and beyond in service to patients and community.

It is doubtful that his parents knew how significant his name “Peter William,” would be when they named their newborn 48 years ago.

“Peter” of Greek origin, means “rock;” “William” means “protector.”

There are no two better words to describe Dr. Peter W. Broderick — a family physician, residency program director, teacher, mentor, patient advocate, father and friend.

As rock and protector, for the past six years Dr. Broderick has served as the Program Director of the Stanislaus County Family Medicine Residency Program. Within a month of accepting the position of Program Director, Dr. Broderick was faced with a crisis in the County that threatened the program’s existence.

Little did he know then that this training by fire was his preparation for what would befall the residency program just four years later.

In 2005, the County of Stanislaus, the institutional sponsor of the program, was facing a significant financial crisis within its health services agency. The common best thinking, including recommendations of consultants, was to close the program. Loss of this program — a residency program that focuses on service to the underserved residents of Stanislaus County — was clearly not an option.

Dr. Broderick, with the support of the County and the community, began the process of saving the residency — by completely re-creating it. Throughout the complex process, Dr. Broderick was instrumental in reminding all involved to “warm the stone” and help build consensus among a diverse group of partners. He provided protection to the residency program and the principles and values of family medicine when some at the federal level recommended untenable “solutions.” He was consistently an advocate for the residents, program, and integrity of the specialty. He was the rock on the “bad days” when the options looked few and outcomes grim. And he did this, with the support of his faculty, residents, colleagues and friends, while continuing in

26 California Family Physician Summer 2011

his “real job” of physician, teacher, administrator, advocate, and community leader. Today, the Stanislaus Family Medicine Residency program has been transformed as the new Valley Family Medicine Residency program. Dr. Broderick and his team were just awarded one of 11 prestigious grants from Health Resources Services Administration (HRSA) to become one of the first Teaching Health Centers in the country!

Dr. Broderick’s tenacity doesn’t end at his residency program. He is an advocate for his patients, encouraging them to take the next right step and facilitating their efforts, even if that means going to the store and purchasing medical supplies if they don’t have the resources. When Dr. Broderick noticed a dearth of GI physicians in his area, he went in pursuit of privileges at his local hospital and surgical centers to do colonoscopies to ensure access to this important procedure for patients in the community—even giving his fees to his mentors to ensure that he could complete enough procedures to obtain hospital privileges.

Finally, Dr. Broderick is protector and rock of his community. He appears to seamlessly move between his many roles, always serving as a teacher and mentor in each.

Administratively, he is the program director, the CEO and DIO of Valley Consortium for Medical Education, which is the sponsor for Valley Family Medicine. He is a practicing clinician, taking call in rotation with the rest of the faculty, and always is there to lend support to his residents.

Dr. Broderick is also active in his community, involved in planning of the proposed UC Merced School of Medicine, health initiatives in the San Joaquin Valley, Board of Directors of Golden Valley Health Centers. In addition, he is Presidentelect of the Stanislaus Medical Society, a member of the CAFP’s Residency Funding Task Force and Medical Student and Resident Affairs Committee, and a member of the Board of Governors for Doctors Medical Center.

Dr. Peter Broderick is truly a role model of the quintessential family physician, who is both a jack and a master of all trades. We are thrilled to honor him as CAFP’s 2011 Family Physician of the Year.

2011 AWARD WINNERS

Work-Life Balance, Gibbs, from page 25

Barbara Harris Award for Educational Excellence: David E.J. Bazzo, MD

The California Academy of Family Physicians is proud to name David Bazzo, MD, as the 2011 recipient of the Barbara Harris Award for Educational Excellence.

“David Bazzo is a leading family medicine educator nationally,” said incoming CAFP President Carol S. Havens.

“His tireless work to ensure clinical expertise has shaped the practice of thousands of physicians and countless patients over the span of two decades.”

Dr. Bazzo has served as the family medicine lead and codirector of the Primary Care Core Clerkship at UCSD since 1999. In this unique program, third-year medical students are able to experience a full year of outpatient primary care, instead of the briefer clerkships more commonly available. At this time of a national primary care physician shortage, the program provides an important opportunity to recruit highly interested and motivated students into family and internal medicine specialties.”

Since 2001, Dr. Bazzo also has served as associate director of the UCSD Physician Assessment and Clinical Education (PACE) Program, which is dedicated to assisting peer physicians who develop practice difficulties related to clinical competency. One important component of this program included assessing and providing remedial education for 300 primary care physicians in the California Department of Corrections and Rehabilitation, which helped improve the quality of care delivered over several years. Since 2008, he has continued this work as director of the UCSD California Correctional Health Care Improvement Program (C-CHIP).

In addition to his PACE efforts, Dr. Bazzo has also contributed significantly to continuing medical education for his peers, developing programs for the San Diego Academy of Family Physicians, the California Academy of Family Physicians and the American Academy of Family Physicians, presenting at medical conferences and publishing in medical journals; to high school students, under a long-running National Institutes of Health grant; and to the community at large, through scores of television and newspaper interviews over the past few decades. Dr. Bazzo is a member of the CAFP’s Committee on Continuing Professional Development, and a member of the CME Leaders Institute faculty.

Congratulations to 2011 Barbara Harris.Award winner David Bazzo, MD.

California Family Physician Summer 2011 27

2011 AWARD WINNERS 2011 Philanthropist of the Year: Jimmy Hara, MD Several years ago, there was an advertising campaign at the Venice Family Clinic titled: “Why Dr. Hara is a Lousy Golfer.” The campaign was a creative way to explain Jimmy Hara, MD’s tireless schedule as a family physician, volunteer and philanthropist.

Although he has received numerous accolades for his service to his patients and community, Dr. Hara quietly continued his relentless work as a humanitarian. Born in a Japanese internment camp during World War II, Dr. Hara knew at a very young age that he wanted to help others. While at medical school at UCSF, he began volunteering at one of the first free clinics in the country – Haight Ashbury Free Clinic.

Dr. Hara continued his volunteer work throughout his residency, and despite sitting on more boards than one could imagine (on top of his already-hectic schedule as a physician), his desire to give back never wavered. His generosity includes making personal donations over the past five to 30 years to organizations having an impact to health care, including the Venice Family Free Clinic, Health Professionals Education Foundation Albert Schweitzer Medical Student Fellowship Program and Los Angeles Physicians for Social Responsibility.

Dr. Hara has especially made an impact on students and residents, who struggled financially in the early stages of their careers. He would take some students and residents to dinner every night before volunteering at the Venice Family Free Clinic. He paid for all nine senior residents at Kaiser Sunset to attend the UCLA Family Practice Board refresher course. And he paid out of pocket for food at the FMIG talks at UCLA and USC. Given all that Dr. Hara does for family medicine, primary care and our communities, it is no wonder he has been such a leader within our field.

“Now, as he is turning the page to the next chapter of his life, he has just retired from Kaiser Permanente after more than 35 years of service, I think it’s time to shed some light on the little known side of Dr. Hara, and his quiet philanthropy. The funds he and his wife Diane donate to these causes help support and strengthen the programs and students that will take family medicine down the path of service that his long career and generosity have exemplified,” said Jose Avalos, MD. Congratulations to our 2011 Philanthropist of the Year, Dr. Jimmy Hara. And happy retirement! You can now catch up on your golf game.

2011 Resident of the Year: Ashby Wolfe, MD, MPH The California Family Medicine Resident of the Year award is given to a resident who represents the finest characteristics of family medicine. This year, CAFP honors Ashby Wolfe, MD, MPH, MPP. Dr. Wolfe is being recognized for going above and beyond the call of duty to raise awareness about the unique role family physicians play in health care transformation.

Dr. Wolfe is chief resident at the Department of Family and Community Medicine at the UC Davis Medical Center. As chief resident, she is an exemplary peer, student, leader and family physician. In her many roles, she represents the characteristics of a successful resident.

She is passionately committed to actively advocating on behalf of her patients and the specialty of family medicine and inspiring her peers.

As chief resident, Dr. Wolfe has an instrumental role in day-to-day problem solving and planning for the future success of the residency program. With several fellow residents, she created a Health Policy and Advocacy Committee (HealthPAC) at UC Davis, which provides a forum for medical students, residents and faculty from multiple departments to discuss active health policy issues that affect the health and well-being of the families for whom they care.

Dr. Wolfe is extremely passionate about health policy and advocating for her specialty. She raises health care, public health and health policy issues at www.ashbywolfe.com. Last November, she was featured in a PBS News Hour story on the primary care physician shortage.

28 California Family Physician Summer 2011

Dr. Wolfe has also represented CAFP in legislative matters on several occasions, including an event with California Assembly member Richard Pan, MD at which she spoke in support of the Medical Injury Compensation Reform Act (MICRA) on behalf of CAFP. She’s also participated as: • Policy co-lead, Sacramento Local Action Network, National Physician’s Alliance. Dr. Wolfe attended monthly meetings and coordinated with local and statewide members to attend legislative hearings and community health advocacy meetings.

• Co-leader, Resident Policy and Advocacy Committee, UC Davis Medical Center. Dr. Wolfe developed a resident-run policy interest group in the Department of Family Medicine at UC Davis. She coordinated group meetings, found guest speakers and planned monthly advocacy events.

• Physician Consultant and Acting Medical Officer, Centers for Medicare and Medicaid Services, Region IX, San Francisco, CA. Dr. Wolfe coordinated regional outreach and education for the Physician’s Quality Reporting Initiative (PQRI). She was the co-lead for regional office pandemic flu and emergency preparedness and developed and provided training to surveyors and providers of long term care in California with a team from the Division of Survey and Certification.

Finally, she regularly submitted analysis to the Regional Administrator.

Dr. Wolfe received her medical degree from the School of Medicine at Stony Brook University Medical Center and her Masters of Public Policy and Public Health at UC Berkeley.

Congratulations to 2011 California Family Medicine Resident of the Year Dr. Ashby Wolfe.

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is frustrated about the destination being up in the air, and I’m working my contacts with missionaries who have been distributing goods in nearby Sendai.

A commonality to these disasters was that in each, we arrived a week after the disaster and, although the cellular voice networks were often overwhelmed, we could use short message service (SMS) and access the internet on mobile phones. It was a way we could upload photos and videos live to our Facebook and Twitter feeds to let our supporters know what we were up to. Taking this lesson home, I’ve suggested that my employer, a large clinic of 1,000 physicians, create a disaster situation website and add mobile phone numbers to my clinic’s disaster preparation plans. That way, we can give updates via online and do SMS blasts to give updates to all employees, or ask for particular specialists to help. Right after a disaster, cell phones were overwhelmed for calls, but SMSs could get through.

You may wonder how we operated these devices while in disasters where the electrical grids are down. We had solar power thanks to donations from WeCareSolar, which builds battery filled suitcases powered by donated Everbright Solar panels, a

local manufacturer. This helps charge our headlamps so we can look down throats and see what’s in front of us in the dark. Portable solar lights donated by OneMillionLights were distributed in Haiti last year, and now in Japan. They miraculously provide eight hours of light so we can see at night.

I’m excited to go to Japan and organize more trips of teams willing to help survivors. If you’re interested in following our progress, you can “like” us on Facebook and read how our first trip went. You can donate to our efforts using PayPal: http://bit.ly/Donation 2Japan or by mailing your tax deductible donation to “Jordan International Aid” at 12860 Llagas Ave, San Martin, CA 95046.

Email me if you're interested in going to Japan or Haiti at enochchoi@gmail.com. Join us in helping a country even more prepared than we are recover from their "perfect storm" — help them more fully celebrate their season of Sakura.

Our last day represented the culmination of our experience; all the official state delegates from each of the Special Constituencies had the opportunity to hear the Reference Committee reports and vote on each resolution. I was particularly impressed with the caliber of the discussion and thoughtful opinions on all sides of the debate. It was very rewarding to both participate in development of the resolutions and to see action taken on some of the issues at the close of the conference.

One of the best aspects of the NCSC, and one that I didn’t anticipate, was the fact that the entire AAFP leadership, including AAFP President Roland Goertz, MD, President-elect Glen Stream, MD and Board Chair Lori Heim, MD were at the conference, attending the simultaneous ALF. Additionally, every AAFP board member

– bilingual in Spanish a plus — To permanently join our group practice of three physicians and six providers in the San Diego/Chula Vista area.

Family Medicine or Internal Medicine preferred.

The opportunity can become full time as well as eligible for partnership in this well established (30 year) group. The office is exceptionally well run, efficient and friendly, and is completely on E.H.R. Respond by email with CV to: sharpgate@yahoo.com or contact our Office Manager Connie Espinoza for additional information Email: conniee4@gmail.com

Want to know how to get the attention of family physicians?

Here's how: advertise in the California Family Physician quarterly and in the CAFP Annual Scientific Assembly Guide.

For ad rates and insertion dates contact Liana King by phone at 510.525.3990 or by email at CalFamPhys@gmail.com.

http://www.facebook.com/pages/ Enoch-Choi-Foundation/417718500061 http://www.JordanInternationalaid.org/ http://www.facebook.com/JordanInter nationalAid http://bit.ly/Donation2Japan

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see so many people involved in developing the policy agenda, and AAFP staff members were knowledgeable and generous with their time as we worked to develop our final report.

Looking for a part-time physician

was in attendance at the NCSC. There was a genuine sense of camaraderie, and everyone had an opportunity to interact, connect and engage with every other attendee, whether a first-time attendee (like me), a seasoned member of a state delegation, or a member of the national leadership team.

It made for a very special sense of engagement and contributed to my sense of team responsibility for our work.

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I was inspired by this incredible group of physicians and impressed by the amount of energy all the attendees devoted to the conference from beginning to end. CAFP members — including medical students and residents—are invited to partake in the next NCSC taking place May 2-5, 2012 in Kansas City, MO. Given my experience this year at NCSC, I can’t wait until next year.

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Ashby Wolfe, MD, MPH, MPP is Chief Resident at the Department of Family and Community Medicine at the UC Davis Medical Center in Sacramento and holds a medical degree as well as master’s degrees in public health policy and public health.

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California Family Physician Summer 2011 29 6/1/06 12:42:43 PM

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Susan Hogeland, CAE

EXECUTIVE VICE PRESIDENT’S FORUM

How to Take the Right Steps Toward Balance I am SO not the right person to write an article about work-life balance, the theme of this issue of California Family Physician; then again, I’m not sure I know anyone else who’s the right person either, despite the fact that there IS content in this magazine.

Why would I take up valuable space in the magazine with my thoughts on this matter when I could be sharing vital information with family physicians about so many issues of importance to them — Patient Centered Medical Homes, Accountable Care Organizations, Health Care Reform, Health Information Technology, Medicare, Medi-Cal, etc., etc., etc. ? Maybe we DO need a break.

Let’s look at work-life balance on the scales. On the work side, like family physicians, I get to work in an intellectually stimulating and challenging environment in which new issues, problems and opportunities arise every day. I also share with them the privilege of working with really smart people on a variety of issues, a majority of which have meaning to me and a positive impact on society at large. Family physicians and I get to work not only with people who are smart, but people whom we like and respect (our CAFP members, leaders, staff, colleagues and, for FPs, their patients). And I, along with most family physicians I know, have not been able to draw a hard and fast line between my work life and my personal life and, for the most part, that’s been just fine.

Now, the “life” side of the scales: it’s true; similar to family physicians, I work more than 200 hours per month, which seriously cuts into the life side of things. Remember, of course, that some of the “life” side of the scale is work of a different kind — the hot tub has to be cleaned weekly (I know, luxury problem), bed changed, clothes washed, dried and put away, cleaning dropped off, cards written and sent, presents purchased, wrapped and mailed, dinners made, dishes done.

But I’ve taken some steps in the last two years to reclaim a little more balance on the life side of things, or at least to be a little healthier for the work side: for example, I took up Hot Hatha Yoga (it’s not a movie title) and do an incredible one-hour-10-minute-long workout about four times a week when I’m not traveling. I try to take a 2.5-mile walk on the days I don’t go to yoga. Thanks to this regimen, I have either trimmed down or firmed up — I’m still not sure which — but I feel better and am told, ever so tactfully, that I look better.

Another thing I’d highly recommend — go on a vacation during which you are completely out of communication, if you possibly can. I recently had a fantastic two-week trip to four countries in Africa — Zimbabwe, Zambia, Namibia and Botswana — and except for the hotels at the front and back end of the trip, there was no telephone, Internet, voicemail, text messaging, NADA. Somehow, everything and everyone managed just fine without me. I’m betting that if you arranged things in advance (yes, the pre-trip preparations just about killed me), you could be incommunicado for two weeks also.

So the scale is balanced just about the way I like it most of the time. How about your scale?

Well … next issue we’ll get back to all the heavy stuff. Thanks for reading.

30 California Family Physician Summer 2011

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