15 minute read
Health Care Plans Must Embrace Food and Nutrition-Based Medical Interventions
How healthy eating can become part of S.F.’s health care strategy
Katie Ettman
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Introduction by SFMMS Past-President and Pediatrician Kimberly Newell Green, MD:
In 2019 I was asked to be a Champion Provider Fellow. CPF is a statewide two-year fellowship with the goal of training healthcare providers to engage in policy, systems and environmental (PSE) change activities around obesity, and dental and chronic disease prevention. The goal of the fellowship is to give providers the skills and support needed to partner with their local health department to affect policy change in their communities and throughout California. Recognizing that this process could arm me with skills to magnify the health advocacy work that I was doing through SFMMS and CMA, I jumped at the chance.
Along with trained chef and San Francisco fellow Emma Steinberg, MD, I partnered with Dr Rita Nguyen, the lead of San FranciscoDepartmentofPublicHealth’sFoodasMedicineCollaborativeandhercolleaguesPritiRaniandErinFraney. This powerfultrioofhealthadvocatessteeredustojoinacoalitiondoingworktofindtangiblewaysforhealthsystemstothinkabout food insecurity and to treat it as a medical issue.
Through work with an incredibly passionate coalition of advocates from many organizations including leaders from SFDPH, SPUR and several community-based organizations including food providers and advocates, we focused much of our work on the CalAIMprocess.Aftermonthsofadvocacyandefforts,facilitatedinpartbySFMMS’relationshipswithstatelegislatorsandDHCS leaders, we were thrilled to have an important success. The words “medically-supportive food and nutrition” were inserted into the CalAim legislation. With these 5 words, a universe of food supports became possible for patients who need them. Now,whenthetreatmentforyourpatient’sdiabetes,cardiacdisease,orrenaldiseaseisfood,conditionappropriatehealthy food can be covered by Medicaid. The food supports come in many forms, including direct prescriptions to hospital-based food pharmacies, medically-tailored meals, and “vouchers for veggies” which can be brought to local markets. The legislation also supports counseling to promote nutritional behavior change.
But the work has only begun. As health plans begin to implement the complex and comprehensive new approach to care delivery encapsulated in CalAIM, they will need to build the infrastructure and systems to support this work. And so the work continues. The OpEd that we reprint here by my partner and colleague Katie Ettman begins to outline the work to be done.
Please join us in the vital work towards moving the healthcare system to provide the appropriate, cost-effective and high quality treatment for many chronic diseases that cause so much suffering and death: food. – Kimberly Newell Green, MD
At the end of 2021, the federal agency that oversees Medicare and Medicaid made a big decision that made little
news. With all the fanfare of papers getting a stamp of approval, California received permission to pilot new approaches to providing healthcare to the more than 13 million Californians who rely on Medi-Cal.
With that approval, the onus is now on local health plans, including the San Francisco Health Plan, to implement strategies thatcouldprofoundlyimprovepeople’shealthandlives.One cutting-edge aspect of the reforms is Community Supports, of which there are 14 designed to address social drivers of health, such as lack of access to food.
But these are optional services, meaning individual health plans must opt into providing them. To prevent, treat and reverse chronic conditions, the San Francisco Health Plan and health plans across California should opt into providing medically supportive food and nutrition, one of the 14 Community Supports. Medically supportive food and nutrition interventions include produce prescriptions, food pharmacies, healthy groceries and medically tailored meals.
Evidence strongly suggests that this spectrum of interventions can help reduce average blood sugar in those with diabetes, blood pressure and preterm birth. Many of these conditions put individuals at greater risk for COVID-19 hospitalization
A San Francisco Department of Public Health staff member supporting the Food as Medicine Collaborative’s Southeast Health Center Food Pharmacy. (Photo by Chris Gill)
and death. By investing in upstream interventions, California can be better prepared for our current health crisis — and the next one.
But is San Francisco, and California generally, prepared to greatly expand access to these food-based interventions?
My sense is yes. SPUR — in collaboration with the UCSF Center for Vulnerable Populations, the Harvard Center for Health Law and Policy Innovation and the Food as Medicine Collaborative — recently published “Integrating Food into Health Care,” a report based on a survey of 145 organizations across the state. The research shows there is already a strong network of community-based organizations, government agencies and traditional health care providers offering — and poised to expand — food-based services. In San Francisco, more than a dozen organizations provide at least one medically supportive food and nutrition intervention. However, to build upon the existing network of providers, the Department of Health Care Services, which administers Medi-Cal, and health plans must address barriers to growth.
Nearly 70% of providers surveyed reported a lack of sustainable funding as a barrier to offering food and nutrition services. These interventions are primarily funded through philanthropy,hospitalcommunitybenefitdollarsandother external sources, rather than insurance. In other words, they lacklong-termfinancialsustainability.
Yet researchers have estimated these interventions couldsave$40-$100billioninhealthcarecostsnationwide. Transitioning these services from pilots to standard plan benefitswouldensuretheirsustainabilityandenablemore patients to improve their health while also reducing overall health care costs.
While some may argue that inadequate healthy food access is a problem to be solved by social services agencies, Dr. Kim Newell Green, former president of the San Francisco Marin Medical Association, explains, “If a new drug came to market that showed these health outcomes and no side effects, we would immediately prescribe it to patients.”
A future where we pay for the prevention — and not just the treatment — of chronic disease is within our grasp. The San Francisco Health Plan must take the lead by seizing this rare opportunity to improve care by providing medically supportive food and nutrition interventions. “Anappleadaykeepsthedoctoraway”isn’tjustawise adage.It’sevidence-basedmedicinethathealthplansshould embrace.
Katie Ettman is the food and agriculture policy manager at SPUR, a nonprofit public policy organization in the San Francisco Bay Area.
WELLNESS
BECOMING A PHYSICIAN IS HARD. BEING ONE IS EVEN HARDER.
Jessie Mahoney, MD
This is why I became a physician wellness leader in 2002 and it is why I continue to do this work twenty years later.
Practicing Warrior 3, amidst wind gusts, on an old and unstable pier is much like practicing medicine these days. Many of the challenges are the same and many of the solutions are the same.
This pier, on Tomales Bay, could and should be more stable. Ideally it would not be rotting. The circumstances could be better. No wind for example. I could choose to practice yoga somewhere else. Perhaps where there is no wind, no tipping pier, perhaps in a place with props, and even with some heat. But then I would also have no view and no fresh air.
What helps the most for both a successful warrior 3, and practicing medicine "well" is inner work. Beingintentional,findingcalm,strength,andequanimity. Focusing purposefully on choice, simplicity, and ease. Transitioning with mindful intention. Choosing not to waste unnecessary energy and allowing the challenging pose to happen without resistance.
Enjoying the pleasure of accomplishment and "relaxing in" when you get there.
A successful warrior 3 in the wind on a rotting pier requires attention to your health, strength, and wellness.
It requires setting yourself up well. It requires ongoing strength, stability, and health to stand on one leg and balance in the wind.
Practicing medicine "well" requires similar approaches.
Purposeful choices, strategic support, and decision-making.
Knowing there will be a lot of balance and challenge and chaos along the way. Success- being a whole and healthy human and healer- requires a decluttered mindset.
It requires focusing on simplicity and ease amidst the heavy winds. It requires a healthy and stable inner core.
All of this is what coaching and mindfulness (and yoga) can help you do.
Physicians are currently asked to live their lives and practice medicine in ways that aren't healthy or sustainable. We are practicing in the wind and on rotten tippy piers. Our healthcare system is a big problem that makes it hard to be a well and healthy human healer. The system should be different. AND we, as both individuals and communities of healers, can also still improve our own lives and take control of our experience practicing medicine and living our lives. When we do this is when change happens. Not because we are the problem but because we are smart amazing humans with tremendous brains creativity and determination. We ultimately want to be healthy humans who are showing up as the best most healthy versions of ourselves, living our best lives, and helping others do the same. Decluttering our mindsets and healing and nourishing ourselves fully allows us to become the healthiest and highest functioning humans we can be. In this state, we also make the best and most impactful healers. Unhelpful thought patterns that are trained into physicians in medical training get in our wayoften.Untilwenoticethemand“unlearn"themwedon’t show up with optimal empowerment, clarity, and energy.
“We can make ourselves miserable or we can make ourselves strong the amount of effort is the same.” – Pema Chodron.
When we step out of victimhood, depletion, and exhaustion, we advocate more effectively. When we are calm, grounded, nourished, and present, we can contribute to creating systemic solutions that actually work. In medicine and beyond.
Why am I sharing these thoughts? Becauseit’spossibletobecomehealthy,whole,inspired, hopeful, and alive again.
Even when the system hasn't changed YET.
Practicing warrior 3 on a broken rotten tippy pier in the wind can still be of value and even fun.
True Wellness
Are you done with token wellness offerings?
Most physicians I know are over watching videos, and signing up for “programs” and talks they hope will help but ultimately don’tlessenburnoutandexhaustion.MostphysiciansIknoware tired of goody bags, branded trinkets, sweatshirts, water bottles, and conferences and lectures in large, windowless ballrooms.
True wellness does not come through a checklist, a lecture on wellness, a meal, or a sweatshirt. It comes from nourishing yourself fully, slowing down, learning to listen and then acting accordingly.
True wellness comes from quieting the snow globe, becoming clear, calm, and grounded. And then choosing to move forward from a place of mindful intention and alignment.
How do you achieve this when you are burnt out, exhausted, busy, and frustrated?
In my experience, through coaching, mindfulness, community, connection, and full mind, body, spirit, and soul nourishment. Whenyouaredepletedandyournervoussystemisinfightor flight,itishardseewhat'sinthewayandhowtomakeeffective changes. Whendiastoleissufficient,yourheartisfull,youcanbreathe deeply and you feel safe and calm and grounded, it is possible to learn and implement effective tools and strategies with ease. Inordertofindtruewellness,youhavetoslowdownenough to listen. "You cannot change what you cannot see." Whenyouslowdownandrefillandnourishyourself,youare able to notice and own your unhelpful thought patterns and old habits, and consider whether you want to make changes.
True wellness comes when you have agency and feel empowered.
It comes when you know what works for you.
When you value and trust yourself.
And when you give yourself permission to act accordingly.
There are solutions but they don't likely look like what you have tried already. That hasn't worked. If you continue to feel stuck, unwell, and exhausted, why not try something new?
Physician coaching has led many physicians to meaningful change. It is experiential and active. Small immersive experiential wellness retreats work similarly.
These are the two interventions, that in my 20 years of wellness leadership experience, provide sustained relief, change, and hope, as we wait for the healthcare system to change.
It is always nice when studies back your experience up. A new study released in JAMA in May 2022 last week demonstrated a significantpositiveimpactofcoachingforresidents.Previous studies published in JAMA in 2019 and 2020 have also shown an impact on burnout, and quality of life for attendings after just 6 weeks.
As an FYI, you don't have to be burnt out or "broken" to benefitgreatlyfromcoaching.Everyoneneedseffectivecoping skills to perform at their highest level and live their best life. Professional athletes know this well. They regularly engage in mindfulness and coaching, and even yoga.
True wellness is experiential. It should be done in a way that is in and of itself well. It works much better that way.
It doesn't have to, and probably shouldn't be, done at work. It doesn't have to paid for by work. It doesn't have to be done inside - or on zoom. It doesn't have to be done with those you work with.
Effective wellness programming can be done in spectacular, healing locations with amazing interesting people from all over the country- without a windowless ballroom or conference center in sight.
Effective wellness interventions can be done from home, even from bed. They can be a way to build new communities and make new connections. They can be done in groups and spaces where you feel like you belong and they can be done 1:1.
You can even cry, laugh, smile, and breathe deeply while you learn and grow and begin to feel "Well" again.
When CME and wellness are shared in ways that are "well" the impact is far greater.
The Value of a “Retreat”
Being the best possible parent, spouse, friend, doctor, colleague, and contributor to a better world are not possible from a place of depletion. "Even a short period of retreat is a benevolent rest, a stepping outside of busy daily routines and our ordinary identity. Released from the tyranny of time, we are invited into the reality of the present. They are food for the heart. Take a long retreats, short retreats and mini retreats....breathe with compassion for your busy self, and then put down all your plans. Open yourself to wonder. Let your heart be fed and your spirit renewed. So that you can tend your family, your community, the world, you can do so with a stronger, more peaceful heart.” –JackKornfield
TO NOURISH
Kto provide food and other substances necessary for growth, health, and good condition. K to cherish, to cultivate, to tend, to sustain K to nurture, to support, to supply
Living your “one wild and precious life” WELL is about nourishing your mind, body, soul, and spirit fully.
Retreats, even short ones, offer a chance for full mind, body, soul, spirit, heart, lungs, nervous system, and belly nourishment. Whenwearefullynourishediswherethehard-to-findsolutions become clear.
Dr. Jessie Mahoney is a Pediatrician, a certified life coach for physicians, and a yoga instructor. She is the Chair of the SFMMS Physician Wellness Task Force. She practiced Pediatrics and was a Physician Wellness leader at Kaiser Permanente for 17 years. She is the founder of Pause and Presence Coaching where she supports and empowers her physician colleagues using mindfulness tools and mindset coaching. She specializes in helping ease career transitions and burnout, parenting struggles, and relationship challenges. She is a leader of the Mindful Healthcare Collective and is co-host of the Mindful Healers Podcast. She teaches virtual weekly yoga to physicians and other healthcare providers and leads yoga, coaching, and wellness retreats in spectacular natural locations. You can read her blog at www.jessiemahoneymd. com. You can connect with her at jessie@jessiemahoneymd.com.
April/May/June 2022 | Wellness Articles By Dr. Jessie Mahoney
SFMMS WELLNESS EVENT HIGHLIGHTS
SFMMS Members Attend the Nocturnists’ Live Event in SF in June: TOGETHER AGAIN
Since 2016, the Nocturnists have uplifted the voices of over 350 healthcare workers through sold-out live performances and their acclaimed podcast. Their live performances help clinicians develop their stories for the stage, enabling them to speak publicly about the fears, doubts, joys, and passions that shape their personal and professional lives. WiththegeneroussupportoftheNocturnists,SFMMSWellnessraffledticketstoour membership to "TOGETHER AGAIN," their live performance on the evening of Friday, June 10th at the Brava Theater in San Francisco. Attendees heard from 8 wonderful storytellers, each with a unique spin on the theme.
Mindful Yoga for Healers
AmonthlyweekendofferingoffreeMindfulYogaforHealers.Thisisspecifically for SFMMS members to join their colleagues in order to heal, replenish, restore, andconnect!Signupat https://mindfulyoga.jessiemahoneymd.com/ tobenotified of class dates and times.
Wellness Retreats
Backbypopulardemand,SFMMSWellnessraffledsponsorshipforourmembers to attend one of three one-day retreats at Pie Ranch on either Sunday, June 12th, Thursday, June 23rd or Saturday, September 24th. The Honoring Diastole Wellness Retreats are led by SFMMS Wellness Committee Chair, Dr. Jessie Mahoney and SCCMA Physician Wellness Leader, Dr. Gail Wright of SCVMC Pediatric Cardiology. You can sign up and learn more here: https://www.jessiemahoneymd.com/honoring-diastole
– Chief Infectious Disease, TPMG
– Marin Endocrinologist
45-minute Intro Physician Coaching Session
What is physician coaching? Physician coaching is an evidence based intervention to decrease burnout and improve quality of life. (JAMA 2019) It is a safe space to explore your career and life frustrations, resentments, dreams and desires. It is preventive care for a sustainable and enjoyable career in medicine. It provides you with a toolbox of strategies to help you optimize you potential, productivity, and joy. It helps minimize stress and ease struggle. Professional athletes have coaches; physicians need them too. SFMMSWellnessraffled45minuteintrocoachingsessionswithlocal,certifiedphysiciancoachtoourmembershipinJune. WeplanonrafflingmoreopportunitieslikethistoourmembershipinFall2022.Ifyouareinterestedinlearningmore,please email Molly Baldridge, SFMMS Director of Engagement at mbaldridge@sfmms.org.
To view recordings of past events or to register for upcoming events, visit the SFMMS Wellness Page at www.sfmms.org/gethelp/physician-wellness.
SUMMER READS
Our Physician Wellness Committee curated an SFMMS Summer Reads list of books for Summer 2022. In lieu of an SFMMS book club meeting this summer, members were randomly selected to receive the Summer Reads book of their choice. You can still enjoy the following curated list this summer:
"Can't We Talk about Something More Pleasant?: A Memoir" by Roz Chast "The Conscious Parent: Transforming Ourselves, Empowering Our Children" by Dr. Shefali Tsabary "The Menopause Manifesto: Own Your Health with Facts and Feminism" by Dr. Jen Gunter "Things That Matter: Overcoming Distraction to Pursue a More Meaningful Life" by Joshua Becker "An Invitation to Pause... again: musings from a mindfulness coach about life and dementia" by Janet Archer "Life's Messy, Live Happy: Things Don't Have to Be Perfect for You to Be Content" by Cy Wakeman
