Nourishing Ourselves and Others in Trying Times
CMA National Policy Report
The “Tripledemic” and Young Patients
ACES in Primary Care
…and more
5 Meet Your New SFMMS President: Heyman Oo, MD, MPH
Steve Heilig, MPH
15 Getting Started in Advocacy
Vivien Sun, MD MPhil
16 Saving Your Lungs Without Losing Our Minds
Lekshmi Santhosh, MD, MAEd
18 Reflecting on the Impact of the "Tripledemic" on Children's Hospitals
Jia Xin Huang, MD; Lindsay Braun, MD; Duncan Henry, MD; Sandrijn van Schaik, MD, PhD
20 Despite the Noise
Mauricio "Jimmy" Franco, MD, MS
21 Flat Lines and the Humans that Bring Them Back to Life
Elizabeth Shaw, MD
22 ACES in Primary Care—Beyond Screening and Toward Prevention
Cayenne Biermam, MSW, LCSW; Caren Schmidt, PsyD and Tracey Hessel, MD
24 Just Riding Along
Nelson Branco, MD, FAAP
25 SFMMS Advocacy Case Study: Quality Drug Education in Schools
Steve Heilig, MPH
26 Seeing with Your Heart
Jessie Mahoney, MD
28 Take Action This International Women's Day
Yalda Shahram, MD, MSc
SAN FRANCISCO MARIN MEDICINE
January/February/March 2023
Volume 96, Number 1
3 Membership Matters
3 President's Message: Connection is Critical Heyman Oo, MD, MPH
5 Executive Memo: Has the Time Come for Supervised Consumption Sites?
Conrad Amenta
6 CMA Federal Update
29 Kaiser News
Maria Ansari, MD
29 Drug Czar Issues Challenge to Docs: Help Us Devise Better Substance Use Tx Options
Joyce Frieden
OF INTEREST
32 In Memoriam: SFMMS and CMA Past-President
Bradford Cohn, MD
32 Advertiser Index
Editorial and Advertising Offices: San Francisco Marin Medical Society
312 Sutter, Suite 608
SF, CA 94108
Phone: (415) 561-0850
Web: www.sfmms.org
The California Medical Association (CMA) will host its 49th annual Legislative Advocacy Day on April 19, 2023, in Sacramento. CMA's Legislative Advocacy Day consistently brings together more than 400 of physician and medical student leaders from all specialties and modes of practice. Attendees will hear directly from our physicians in the state legislature about the state’s priorities for health access. CMA will host a panel discussion with Assemblymembers Joaquin Arambula, M.D.; Jasmeet Bains, M.D.; and Akilah Weber, M.D.; with CMA Council on Legislation Chair Kelly McCue, M.D., as our moderator.
Attendees will also have the opportunity to meet with legislators on priority health care issues. If you've never attended a Leg Day, it's a great way to get facetime with legislators and attend briefings and trainings, as well as network with other physicians. Any SFMMS/CMA member may join in.
For more information: Ian Knox: iknox@sfmms.org Registration is here: https://www.cmadocs.org/event-info/SESSIONALTCD/LEGDAY23/t/legislative-advocacy-day
As a result of our members' initiative, SFMMS leaders and staff have held several meetings with legislators and policymakers over the past few weeks:
• SFMMS PAC Chair, Dr. Joe Woo, alongside Drs. Gustin Ho and Kenneth Chang from the All-American Medical Group, co-hosted a press conference for HHS Secretary Xavier Becerra in Chinatown. Becerra spoke about the Inflation Reduction Act.
• Members of our SFMMS Marin Committee met with staff from State Assemblymember Damon Connolly's office to gather information about his bill to phase out the sale of tobacco products.
• Immediate Past-President Dr. Michael Schrader led a meeting with San Francisco District Attorney Brooke Jenkins to discuss violence against healthcare workers in hospitals and other care settings. Jenkins committed to delivering a webinar to SFMMS members about how to interact with her office and with police if they encounter violence in the workplace, and to exploring how California can replicate legislative protections for healthcare workers that other states have put in place.
• We have corresponded with Marin County Supervisors and Mill Valley City officials about the potential for ordinances related to the regulation of e-scooters and e-bikes following a series of rider and pedestrian injuries.
CMA and the physician groups sent a joint letter to CMS Administrator Chiquita Brooks-LaSure lauding the agency for incorporating the feedback of physicians and other stakeholders into the proposed rule and urged CMS to finalize the rule, which includes the following provisions:
• Medicare Advantage (MA) plans may only use prior authorization to confirm diagnoses or other medical criteria and ensure the medical necessity of services.
• MA beneficiaries must have access to the same items and services as they would under traditional Medicare. When no applicable coverage rule exists under traditional Medicare, plans must use current evidence from widely used treatment guidelines or clinical literature for internal clinical coverage criteria, which must then be made publicly available.
• MA plans must establish a Utilization Management Committee to review their clinical coverage criteria and ensure consistency with traditional Medicare guidelines.
• MA plans cannot deny care ordered by a contracted physician based on a particular provider type or setting unless medical necessity criteria are not met. continued on page 32
January/February/March 2023
Volume 96, Number 1
Editor Gordon L. Fung, MD, PhD, FACC, FACP
Managing Editor Steve Heilig, MPH
Production Maureen Erwin
SFMMS OFFICERS
President Heyman Oo, MD, MPH
President-elect Dennis Song , MD, DDS
Secretary Sarita Satpathy, MD
Treasurer Jason Nau, MD
Immediate Past President Michael Schrader, MD
SFMMS STAFF
Executive Director
Conrad Amenta
Associate Executive Director, Public Health and Education
Steve Heilig, MPH
Director of Operations and Governance
Ian Knox
Director of Engagement
Molly Baldridge, MPH
Senior Director, Advocacy and Policy
Adam Francis
2022 SFMMS BOARD OF DIRECTORS
Edward Alfrey, MD
Melinda Aquino, MD
Ayanna Bennett, MD
Julie Bokser, MD
Kristina Casadei, MD
Clifford Chew, MD
Esme Cullen, MD
Manal Elkarra, MD
Mihal Emberton, MD
Cindy Greenberg, MD
Gordon L. Fung - MD, Editor
Beth Griffiths, MD
Ian McLachlan, MD
Jason Nau, MD, Treasurer
Heyman Oo, MD, President
Sarita Satpathy, MD, Secretary
Michael Schrader, MD, Immediate Past-President
Yalda Shahram, MD
Neeru Singh, MD
Dennis Song , MD, DDS, President-Elect
Kristen Swann, MD
Kenneth Tai, MD
Melanie Thompson, MD
Matthew D. Willis, MD
Kristen Wong, MD
Andrea Yeung, MD
Helen Yu, MD
For questions regarding journal, including possible submissions, contact Steve Heilig: Heilig@sfmms.org
Cover Art: “The Staff of Life” by
Cynthia Fletcher, 20x16, oil on panel,http://www.cynthiafletcherart.com/
First off, Happy New Year to you all. I am excited and humbled beyond words to be writing to you as the new President of your medical society. I find that milestones like birthdays, holidays, and the starting of a new year not only give us a way to mark the passage of time, but also a much-needed moment to pause and reflect.
Earlier in January, our family celebrated another major milestone with the birth of our second daughter. As many parents know, even amidst the hazy exhaustion of 2am feedings, there are inexplicable moments of wonder, joy, and, most importantly, hope. You want nothing but the best for this tiny human, and you daringly hope that you (and the rest of the world) will be able to deliver on that promise.
Less than two weeks after our daughter’s birth, however, the headlines were once again filled with news of our uniquely American problem, multiple mass shootings, this time here in California, targeting members of the Asian community during Lunar New Year no less. I, like many of you, felt saddened, angry, and maybe even a little hopeless that we may never solve the problem of too many guns being too easily accessible by too many people intent on doing harm to others.
Then, I received a series of emails from physician leaders within SFMMS that not only echoed the same feelings of anger and frustration about the tragedies, but more importantly, strategized about what next steps we as physician advocates could take to move the needle on this issue on a local, state, and national level. As a result of our local physician leaders’ advocacy, within a few days, the California Medical Association Board of Trustees adopted a resolution calling on the U.S. Surgeon General to research and issue a report on firearm violence. What would have been just another heartbreaking news cycle, within just a few email replies, became quite the opposite. Instead of being alone in my despair and outrage, I felt empowered. And proud—proud to be a member of this medical society, proud to be among this group of dedicated professionals who refuse to lose hope.
There are many hazards in our work that threaten to take our power, our control, our hope, and our optimism away. We, after all, are human healers and not machines. Yet, the modern practice of medicine, for many of us, is filled with dehumanizing indignities. Understaffing, overscheduling, unnecessarily-complicated and inappropriately-crafted policies and procedures get between us and our care for our patients.
And yet, we work in a sacred space—hearing the most intimate of stories, bearing witness to moments in people’s lives when they face their greatest pain, their greatest loss, or as in the birth of a new life, their greatest joy. Our patients trust us with
their care, and that is truly an honor. While we can be grateful for, and humbled by that privilege of healing others, we can and shouldalso be incredibly frustrated by the barriers that separate the practice we envision with the practice we face. My hope is that the former will always outweigh the latter. Unfortunately, it does not feel that way for many of us who are overworked and underappreciated.
While the path to professional satisfaction will be different for each individual physician, I truly believe a critical element will be the strength of our connection to each other. It nurtures the hope that even in the face of horrific events like mass shootings, we can deliver change through collective action. Study after study has demonstrated that despite external adverse conditions, having a sense of belonging, having “found your people,” and feeling seen, heard, invested in, and understood by others, is a key factor in personal and professional health1.
So, in 2023, how do we come together as a medical community? My hope, and my goal during this Presidency, is that SFMMS can be a fundamental part of that process for you. Perhaps it will be through a new connection with a colleague during one of our book clubs or in-person socials, or via a spark of personal curiosity ignited at one of SFMMS’ sponsored wellness retreats, or maybe from the knowledge and skills learned as a newly-equipped agent for positive change through our political advocacy work. You may have a different idea of what you’d like to see from SFMMS that would help you. I would love to hear it! I invite, encourage, and challenge you to join your colleagues in any (and all) of the above activities. I hope you lean into both the positive and negative emotions we experience as physicians, as humans. And most importantly, I hope that together, we will refuse to lose hope.
Heyman Oo, MD, MPH is a primary care pediatrician and Site Medical Director at Marin Community Clinics in Novato. She also serves as an Information & Guidance Clinical Lead for the San Francisco Department of Public Health under the COVID-19 Task Force. She is a graduate of the UCSF Pediatric Leaders Advancing Health Equity (PLUS) Residency Program and obtained her MPH in Healthcare Policy and Administration at the Harvard T.H. Chan School of Public Health. She has been involved in organized medicine since the beginning of her medical school years at UC San Diego and has been a member of SFMMS for almost a decade.
Why did you choose a career in medicine?
Both of my parents trained as physicians in Burma, where it was less of a choice and more of an expectation for learners tracked into certain fields from an early age. Neither of my parents pursued recertification when given the choice after immigrating to the US. Therefore, I grew up only peripherally aware of medicine as a career path, and as not a particularly inspiring one. It was not until college, when I spent a summer in a Thai border town teaching refugees at a local clinic, that my interest in medicine blossomed. I realized the physicians I met there were not only clinicians, but also teachers, humanitarians, public health experts and adventurers. For the first time, I saw medicine as an opportunity to combine my various interests in science, humanism, activism, and public service.
Why did you choose your medical specialty?
I love working with kids because of the way they keep us adults honest. They do not tolerate our pretenses and are quick to see through hypocrisy. Additionally, parents, on the whole, are also much more willing to engage in hard conversations and make difficult decisions and lifestyle changes for the sake of their children in a way that they may not do for themselves (like quitting smoking). I find caring for the whole family makes my work even more impactful than if I were caring for a single patient.
Why are you
Being a member of SFMMS positions me to be a physician advocate at the table with policy makers. Early on in my training, it became clear that many “social factors” beyond the walls of the clinic room or hospital bed shaped the health outcomes of my patients. Whether or not a patient could afford their chronic disease medications was a root cause for why they were hospitalized. Whether or not a child had a safe, easilyaccessible outdoor space to exercise and play deeply impacted if and when they developed metabolic syndrome and Type 2 diabetes. Whether a family had insurance or documentation was critical in whether they were able to seek out and receive the same level of healthcare services as another person. Rather than viewing these factors as beyond or outside of my responsibility as a physician, I believe they are core to our role as healers who aspire to treat all patients with dignity. As patient advocates, strengthened by collective voice and action, we can guide policymakers regarding these connections to health.
I have been impressed by how SFMMS membership has grown and flourished despite the challenges of recent years, how we have increased physician engagement, and how we have provided even more value to members through our advocacy, activities and events. A recent survey of our Board of Directors underscored the primacy of activism as a core value. As SFMMS President, I plan to develop and expand opportunities for direct activism for our members both locally and at the state level. We have plans to offer skill-building workshops throughout next year and are looking for ways to expand and grow the influence of our SFMMS Political Action Committee (PAC). Also, having benefited immensely from mentors throughout my career, I am sensitive to the importance of investing
Interview by Steve Heilig, MPHin physician leadership pipeline and would like to develop partnerships with our many excellent training programs in the area to encourage and nurture a foundation of physician advocacy and leadership early in a trainee’s career.
What are some of the biggest challenges and opportunities that you see for healthcare in the next 3-5 years?
I see physician burnout/early career exit as the most salient challenge for our healthcare system. This stems from many problems of the current healthcare system such as consolidation, profit-driven rather than patient-driven incentives, lack of physician autonomy and practice control, increased administrative burden, and so on. As self-sacrificing members of a healing profession, we physicians have often deferred our own priorities and needs until, at present, we arrive at a breaking point.
Legislators, policy makers, hospital CEOs and other non-clinician administrators must really start to listen to physicians and representative organizations like SFMMS and the CMA to change these structural issues. For example, we can align incentives to encourage patient quality metrics rather than visit numbers, we can develop innovative ways to reward effective, team-based care, we can streamline documentation and prior approvals processes; in doing so, we can allow physicians to get back to spending time taking care of patients, rather than being a “cog in the wheel.”
What about you would surprise our members?
I love to host themed dinner parties that bridge the many cultures and traditions of my family and friends. For example, we host an annual dumpling-making party around Lunar New Year and back in medical school, my classmates and I made 700 dumplings by hand one year! Our family whips up latkes for Hanukkah and cranks out tamales and buñuelos for Christmas and I’m always looking for new and delicious traditions to explore.
Any advice for new physicians transitioning into practice from residency?
There are many stages in your career ahead, and your first job out of residency will not, and probably should not, be your last job. It can be stressful to not have a clear next step provided for you after so many years of achieving milestone after milestone. View career uncertainty as a gift of freedom and space to “choose your own adventure.” Everyone’s personal situation is different, and of course, medical education debt is often a central consideration. However, whenever possible, I encourage newly graduated physicians to reflect on what is most important to them about a potential new job, whether it is location, schedule flexibility, patient mix, mentorship/leadership opportunities or something else.
If you weren’t a physician, what profession would you most like to try?
I am obsessed with food and probably have watched too many Netflix cooking shows, but I think it would be interesting and fulfilling to open a small restaurant or food truck. It would be grueling work, but I can easily envision myself crafting meals with heart and soul, making people happy with my cooking, and receiving immense joy in return.
In 2020 and 2021, there were a total of 1,365 fatal drug overdoses in San Francisco. For context, compare that with the approximately 725 deaths from COVID-19 that occurred during the same period. Overdoses from drugs like fentanyl are one of the most severe public health epidemics of our time.
In 2022, the San Francisco Department of Public Health presented to the San Francisco Board of Supervisors the city’s plan to prevent fatal overdoses. At the core of the city’s plan was the establishment of several 'Wellness Hubs,’ which would scale up services provided, at that time, by a drop-in center in the Tenderloin neighborhood of San Francisco.
There were many services available at the Tenderloin drop-in center: food, laundry, and linkage to drug abstinence programs, to name a few. Also available at the Tenderloin site was ‘supervised consumption’ services, whereby individuals would be permitted to use illegal drugs under the supervision of trained staff, so staff could intervene with Naloxone in the event of an overdose to prevent it from becoming fatal. In 2022, 333 overdoses were reversed at the Tenderloin drop-in center because of the supervised consumption services it provided.
Supervised consumption is not currently legal under California state law, or federal law, though it is an accepted harm reduction strategy in many other countries. A state bill authored by San Francisco’s State Senator, Scott Wiener, which would have authorized the piloting of these sites in San Francisco, Oakland, and Los Angeles, successfully passed the Senate and Assembly in 2022, but was vetoed by California Governor Gavin Newsom. Had the bill been signed into law, supervised consumption services at the Tenderloin center, and the Wellness Hubs that were to follow, could have been routinized, improved, and made long-term.
In November 2022, the funding for the Tenderloin center lapsed. The Wellness Hubs were intended to begin in time
for a seamless continuation of services to at-risk individuals. But the veto of Senator Wiener’s bill threw into question the ability of the city to support such a model. SFMMS wrote to city officials at the time encouraging the appropriate funding and support for comprehensive harm reduction strategies. As of this writing, there are no supervised consumption services available in San Francisco.
In New York, a supervised consumption site operated by the nonprofit OnPoint NYC (www.onpointnyc.org) is funded using private dollars. They operate because of unofficial commitments from the New York City Mayor’s office and local District Attorneys not to prosecute. Similar commitments have been provided by San Francisco Mayor London Breed and City Attorney David Chiu. The nonprofit infrastructure also exists to operate such a site in San Francisco. As a result, OnPoint NYC represents a model that could be replicated in San Francisco. What is required now is the funding.
OnPoint presented to the Supervisors in San Francisco in early 2023. Among the statistics shared was that the costs of running their centers is 1.3 times less than continuing to fund the cost of the status quo, which involves police, ambulance, and emergency medicine departments and response services required to intervene during a potentially fatal overdose.
Momentum and support have been gathering for supervised consumption as an evidence-based harm reduction strategy in cities that continue to grapple with fentanyl addiction and abuse. Organized medicine, from local, to state, to national, has policy in support of this care model. At SFMMS, we’re eager to work with legislators, regulators, funders, and nonprofit organizations to help support the emergence of this model in our community.
CMA successfully urged Congress to provide 200 new GME residency positions; half of the positions
are dedicated to psychiatry and psychiatry subspecialties to meet the nation’s growing mental health
needs.
Congress stops 6.5% of the 8.5% Medicare Payment Cut – Allowing a 2% Cut to Take Effect
CMA aggressively fought to stop the entire 8.5% Medicare payment cut facing physicians and we are
extremely disappointed that Congress came up short and allowed a 2% cut to take effect in 2023.
Physicians will also experience a 1.25% cut in 2024. However, CMA is grateful to California
physician Congressman Ami Bera, M.D., for his legislation (HR 8800 – “Supporting Medicare
Providers Act”) and strong advocacy to stop the entire cut.
The expiring 5% bonus payment for Medicare Advanced Alternative Payment Models, including
Accountable Care Organizations was extended for one year at 3.5%.
CMA Newswire Article and Statement:
The United States Congress passed their year-end omnibus legislation last week, which includes a
Medicare physician payment cut of 2% in 2023. Physicians had been staring down cuts as much as
8.5%, but a nationwide advocacy campaign by the American Medical Association, California Medical
Association (CMA) and more than 150 organizations representing over 1 million physicians helped
stave off many of the reductions. However, physicians who care for Medicare patients and CMA are
very concerned about how the cut will impact patient access to care.
“Congress’ plan to cut Medicare demonstrates a lack of understanding of the access barriers already
plaguing our health care system,” says CMA President Donaldo Hernandez, M.D. “Physicians are
frustrated and demoralized because, at a moment when the entire health care system is stressed to its
limits, both parties in Congress have decided to ‘thank’ physicians working on the frontlines with cuts
that will have devastating impacts.”
I came of age in the shadow of the 1999 Columbine High School shooting. As a high school freshman on the East Coast a year later, we started practicing Code Silver drills in case of a gunman on campus. Instead of learning about the Cell Cycle, we locked the door, turned out the lights, covered the windows, and hid in the closet of our Biology classroom. The threat of gun violence felt as normal as the threat of fire or extreme weather.
A generation later, my eight-year-old niece recently experienced her first lockdown due to reports of an active shooter at her suburban elementary school. While the incident turned out to be a false alarm, the reality that this normalization of gun violence amongst our children has not changed over the last two decades is both sad and infuriating.
In 2020, there were 45,222 gun deaths in people of all ages, the highest number ever in the United States. In 2019, gun violence became the number one cause of death among children and adolescents in America, surpassing motor vehicle crashes. Among youth under 20 years old, homicide was the most common cause of firearm death, though suicide contributed to 41% of deaths in kids 10-14 years old and 33% of kids 15-19 years old. While children of all races and ethnicities are affected by firearms, the burden of firearm deaths are not shared equally across groups. Black youth are disproportionately affected; firearm deaths were 4.3 times higher in black youth as compared to white youth in 2019. Addressing pediatric gun violence is an urgent public health and equity issue.
As a pediatrician, I have long recognized the importance of screening for firearms in the home and discussing safe storage of firearms with patients and their families. However, I was reluctant to take the next step to become an “advocate” about gun safety. I felt uncomfortable discussing gun safety outside of a one-on-one clinical encounter. In contrast to clinical pediatric medicine, where I had received years of formal training, explicit teaching, and onthe-job experience, I had never been taught explicitly about gun violence, done research in the field, or had personal experience with gun violence. I felt unqualified to be an advocate given my lack of formal training on the topic.
When I spoke to friends outside of medicine about my reluctance to advocate for gun safety due to my inexperience, they offered simple advice: “Get over it, and get started.” They suggested that I could read on my own and delve deep into the subject. They suggested I find organizations that would allow me to find like-minded individuals and find advocacy opportunities. They suggested that I fake it until I make it—that small actions
in the space would reduce my feelings of inexperience and strengthen my identity as an advocate over time.
My friends were right—over time, advocating for gun violence prevention began to feel more comfortable. My family and I began marching in local protests demanding improved legislation for gun safety. My five-year-old son and some of his preschool classmates carried a sign across the Golden Gate Bridge that read, “Protect Kids Like Me, Not Guns.” I started attending meetings of my local chapter of Moms Demand Action for Gun Sense in America, and I met with some of our California legislators to encourage action on gun safety. I read deeply on the topic in both lay media and medical journals and started giving formal lectures to the pediatric residents at my institution about pediatric gun violence and advocacy. This expanded into teaching sessions about gun violence to pediatric residents from multiple institutions across California through the American Academy of Pediatrics.
Physician advocacy has been defined as an “action by a physician to promote those social, economic, educational, and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise.” Physicians are uniquely positioned to be potential advocates given their deep knowledge and observations of health and its social determinants. Physicians are also trusted voices in communities, regarded as one of the most honest and ethical professions in a general survey.
Even if we physicians are well-positioned to become advocates, I know firsthand how difficult it is to find your voice as a physician-advocate and take the first step into an unfamiliar space. I would offer the same advice that my friends gave me: get over it, and get started. The issues of today—be it mental health access, adequate nutrition, housing insecurity, health inequities, or structural racism, to name a few—need thoughtful, compassionate people to address them. They need you. We need trusted physicians in our community to highlight the issues that affect our health and offer solutions. Even if you are not the leading expert in the field, even if it’s not a subject you see multiple times a day, even if you have not received explicit teaching on the subject—you can still get involved as an advocate. For the sake of our community, I hope you do.
I hope you get over it, and get started. Go find your voice as a physician-advocate.
Vivien Sun, MD MPhil is a pediatric hospitalist in San Francisco. The views expressed here are her own.
After a very long day in the COVID ICU, before a very long night of finishing up notes and compulsive chartchecking, I sat with my hands patting the heads of two flopping toddlers attempting to sleep. Unable to sleep with the excitement of their brief sighting of Amma, they flipped and flopped and intermittently debriefed me on their days, “Calvin was not be nice to me!” As I sat in the dark room, with one hand patiently patting each little head, unable to move, unable to catch up on work, unable to stop the churning to-do list in my head reminding me of the things I would likely not get to tonight, I tried to break the cycle.
I tried to fill my lungs with air to pause my buzzing brain. I tried to forget the to-do list, the whining children, the man who begged not to be intubated because he would not be able to afford being hospitalized for weeks, the orphans I had to hug and say "I’m sorry" to, the patients I had to beg to get the vaccine, the colleagues I had to talk out of quitting. I remembered my rarelyused—yet often-recommended to others—Calm meditation app with a visual of an expanding and contracting circle to be timed with each breath. Instead of a circle, all I could visualize was my own head, comically disfigured, expanding and contracting with each breath, but mercifully not exploding.
Suddenly, it crystallized—it was obviously not a circle, not a cartoonish head, but the most beautiful and symmetrical unit we had fallen in love with in the first place—an alveolus. Much has been written about the importance of diastole for physician well-being, but why should cardiologists have all the fun? Allow me to introduce you to a pandemic’s guide to saving your lungs without losing our minds.
We, the healthcare workforce are in critical condition, in acute distress. We have lost our resilience and our elastic recoil, or have we lost our compliance and are shrunken, stiff, and immobile? It doesn’t matter. We hope we are not too refractory to rescue measures.
We cannot bear the barotrauma. The pressure has built over the pandemic and has become additive, with dangerously high spikes at times. By day we fight a highly transmissible global pathogen and by night we elaborately decontaminate to convince ourselves that we will not infect our families. We answer texts and emails and Whatsapps from friends, family, frenemies, casual acquaintances around the world, about their friends and families who are all sick too now, and we add them to the nightly evening phone-rounding list.
The volutrauma adds insult to injury. The sheer volume of tasks to juggle the Zoom schooling, the pivot to virtual teaching, the half-finished research projects, and the Sisyphean inbox and InBasket.
We scoff at the controversial P-SILI (patient-self-inducedlung-injury), and yet we wonder how much we have inflicted upon ourselves, how much we have only ourselves to blame, how many additional responsibilities did we really not need to sign up for? We then feel guilty for blaming ourselves and wouldn’t dare speak to a friend or patient that way, yet we wonder how much of it is true.
If you can keep your head when all about you, Are losing theirs and blaming it on you…
– RUDYARD KIPLING
A transplant would be too dire, a last-case resort, and aren’t we just trading one disease for another anyways? Surely a new host—a career change, an institution change, a move—would just bring different problems.
There are really very few therapies that will give us a mortality benefit. First, we must immediately go into lung-protective mode. We must drop our tidal volumes to the bare minimum, and permit that CO2 to rise as it may. We must shed the nonessential responsibilities, let the house be a mess and the laundry go unfolded, and skip the make-up. Curling into this 4cc/kg ball seems drastic, but it is the only way out, and we must resist the temptation to liberalize too early when we think we are better.
Next, we must diurese aggressively for net negative fluid balance. For our alveoli are clogged and overfilled and sluggish, and we must diurese before we end up like the numerous COVID autopsies we have seen, with thick coagulated blood filling the previously delicate air sacs. We must decompress and let go of the excess expectations and worries and fears and anxieties and doubts and let it flow outwards. We must talk about it all – the lumps in the throat swallowed after every failed Code Blue, the death paperwork signed, the grim daily update phone calls. We have tried to forget and we could not. We simply cannot bear to continue to hold them in. We must cry with catharsis as the water escapes and we begin to heal.
It seemed dire, and the prognosis was poor, but slowly and carefully with diligent attention and patience, we begin to heal. Our compliance improves as we diurese and unburden ourselves of the barotrauma, volutrauma, and maybe even the P-SILI. We are slowly able to liberalize our tidal volumes, stretch our lungs and legs, and return to the world from where we had retreated. Conversations with strangers no longer fill us with dread. Persuading patients to get the vaccine no longer feels hopeless. We are able to feel and think clearly again as the fog lifts. We will heal.
“Do we have a bed?” This single phrase was repeated countless times during the “tripledemic” in December 2022 and January 2023, a term that refers to the surge of COVID-19, respiratory syncytial virus (RSV), and influenza viruses. Even when the answer was yes, the question remained: How does one decide which child receives the last bed in the Pediatric Intensive Care Unit (PICU)? Once again, the U.S. healthcare system was significantly overwhelmed. Emergency rooms across the country were inundated by children with respiratory symptoms waiting to be seen by a healthcare provider. Many of these children were on the verge of respiratory failure, requiring support and monitoring that would normally take place in a PICU. However, many pediatric ICUs were already at maximal capacity, forcing emergency rooms to run mini-ICUs until they could find an accepting facility. Similarly, pediatric acute care units faced bed shortages and were also pushed beyond their comfort level as they cared for children requiring higher respiratory support. Beyond the immediate need, the paucity of PICU beds meant delaying or even cancelling necessary and urgent surgeries, creating additional stressors on the system. ICU capacity across the country has always been limited to begin with and overwhelmed under the extreme circumstances of the recent pandemics that created high demands.
The reduced capacity to care for children during this respiratory viral surge was further compounded by the national shortage of nurses. Data from the U.S. Department of Health and Human Services already showed a growing gap between the supply of and demand for available nurses prior to the COVID-19 pandemic. This gap has widened over time. One of the tolls of the pandemic has been worsening levels of employee burnout, leading nurses to leave their jobs in large numbers. Children’s hospitals across the country are impacted by this nursing shortage. In the short term, the answer is to increase patient to nurse ratios to acceptable maximums, though these ratios inevitably lead to worsening burnout, thus creating a vicious cycle. While there are ongoing efforts among hospitals to reduce nursing shortage and burnout, they were too late to meet
the needs of the tripledemic and leave us currently ill prepared for future ones.
The impact of the tripledemic on children’s hospitals is substantial, but the response to this crisis has been minimal compared to the response to the COVID-19 pandemic. While COVID was front page news for almost two years, media coverage of the tripledemic has been limited. The White House declined a request by the American Academy of Pediatrics to declare a state of emergency, which would have secured additional resources for children’s hospitals to take care of children during the surge. During the peak of the COVID-19 pandemic, many PICU and pediatric acute care beds were converted to adult ICU beds, yet the reverse has been more difficult to accomplish. In part, this is because in some areas adult hospitals were also impacted by the surge of non-COVID respiratory diseases, but additionally this appeared to be driven by finances. In fact, low federal reimbursement for pediatric patients compared to adult patients and overall limited revenue from pediatric healthcare has led to closures of multiple pediatric units and even whole children’s hospitals across the nation. Simply put, children’s healthcare has little financial leverage in our current economy.
The Bay Area is fortunate to have significant capacity to care for critically ill children given its multiple PICUs, but we are not shielded from the moral distress that comes with turning away sick children due to limited nursing and bed availability. For us, this occurred on a daily basis, multiple times per day. Nonetheless, the distress we felt is insignificant compared to that experienced by families with critically ill children awaiting an available bed. For some families, the closest PICU bed their child received was hundreds of miles away or even in a neighboring state, creating additional financial burden and logistical challenges. The need to transfer sick children over long distances highlights the inequities in access to care, especially in rural parts of the country where hospitals are often not equipped to care for critically ill children. Beyond the geographical impact of the tripledemic, we know that families from marginalized groups, families with limited resources, and families for whom English is
not their primary language already have worse health outcomes compared with others. The additional challenges created during the tripledemic further exacerbated healthcare inequity.
We must do more to ensure children have equitable access to healthcare before, during and after any epidemics and pandemics that come our way. It is appalling to see the paucity of legislative support and funding for pediatric hospitals. The Pediatric Access to Critical Health Care Act was introduced in 2022 to increase capacity for the care of children, but the bill never advanced past the assigned committee. Policy makers must continue efforts to increase support for pediatric healthcare services, as they were already inadequate prior to the start of the pandemics. There needs to be more legislative support to increase infrastructure for pediatric health services, increase Medicaid reimbursement rates, and funding for pediatric procedures that can help keep children’s hospitals financially viable and remain afloat. Investing in pediatric healthcare is investing in the future. If we want future generations to thrive, we have to ensure that our nation’s children receive the care they need when they get sick.
One thing is for sure: We, pediatric intensive care physicians, don’t want to have to decide who gets the last bed in our PICU. We want there to be sufficient beds, personnel and resources so we can do what we are called to do: take care of critically ill children, all of them, at any time.
Jia Xin (Jess) Huang, MD is a pediatric critical care fellow at the University of California San Francisco.
Lindsay Braun, MD is an Assistant Professor of Pediatrics at the University of California San Francisco with a clinical appointment in Pediatric Critical Care Medicine at UCSF Benioff Children’s Hospital. She is the Assistant Medical Director of the Pediatric Intensive Care Unit and the Transitional Care Unit.
Duncan Henry, MD is associate clinical professor at the University of California San Francisco with a clinical appointment in Pediatric Critical Care Medicine at UCSF Benioff Children’s Hospital San Francisco. He is the Medical Director of the Mission Bay Pediatric Intensive Care Unit and the UCSF Pediatric Complex Care Program (FLIGHT). He is also an Associate Program Director for Assessment in the UCSF Pediatric Residency Program.
Sandrijn van Schaik, MD, PhD is Professor of Pediatrics at the University of California San Francisco with a clinical appointment in Pediatric Critical Care Medicine at UCSF Benioff Children’s Hospital. She is the Baum Family Presidential Chair for Experiential Learning and Vice Chair for Education in Pediatrics.
It requires energy and intention to be a steward of your own life; it takes energy to grow into a space where you understand that your work as a physician is more than impressing those around you with your carefully curated words and presentation, proving your intelligence and your ability to meet your productivity quota. For me, it’s taken years of failure; small and large wins, and more importantly privileged moments with my patients to realize some of the more profound and life changing moments come from the care and bond I have built with patients be it 15 minutes, a day shift, a month long or year’s long journey with a patient. If we are lucky, despite the noise around us, we can learn to recognize our own transformation.
The currents of the world move us with or without our conscious participation; the weight of the world consumes us— even when we are unaware of it. People, life circumstances, world events are in a constant metamorphosis even in periods of our life where we feel we are static or unchanged. Even when we are not consciously navigating and adapting, the energy around us etches itself into our being. If you are not careful you can lose your footing and the tide will pull you deeper into a sea of confusion.
Residency has the power to make you feel like you are being pulled into a fog of doubt and sinking into a bottomless pool of imposter syndrome. These feelings blur and drown out the real world; it can make you lose touch with all the discrete and overt ways the world pushes up against the patients we care for and how real-world crises are a day-to-day experience for some of our patients. It blurs the impact on your well being and perception of self and location to the world around you. Much like other oppressive systems, it makes noise so you don’t hear your own thoughts. It makes you feel so exhausted and worn out that you have no energy to rise up, no space to fight back, so tired that your voice is nothing more than a whisper, so tired that your default becomes silence, so tired that when you are triggered and feel exploited you question whether or not it is all in your head.
Work culture/productivity culture can make you feel guilty for wanting time to process, to reflect and yet also urges you to give all of yourself and know yourself so well that you are constantly seeking to grow. It creates cognitive dissonance that feeds your guilt for not doing enough, for not saying enough, for being slow, for being on a different path than your colleagues, for not being present for your family. It creates confusion.
Mauricio “Jimmy” Franco, MD, MSYou see
Systems of oppression thrive on me not having space and time to process. Systems of oppression thrive on my need to survive. Systems of oppression thrive on me not having time to react to the micro/macro aggressions. Systems of oppression thrive on my task overload so I have less time to think critically about the ways in which it does not support me. Systems of oppression thrive on my isolation. Systems of oppression make noise.
The noise can get so loud that it muffles and drowns out the voices of those who stand beside you; the noise can get so loud that it makes you feel you are working alone. The noise is used to distract. The noise is a strategy.
Despite the noise, there is joy and beauty in our work.
Despite the noise, there are tender and vulnerable moments with patients and colleagues.
Despite the noise, we rise.
Despite the noise, we connect with our patients.
Despite the noise, we sit and bear witness to the strength of our patients.
Despite the noise, we bear witness to their pain.
Despite the noise, we bear witness to their dying.
Despite the noise, we are changed and moved by our patients.
Despite the noise, we heal.
I write and reflect to better serve my patients; I write and reflect to be a better physician and to be a better version of myself. I write and reflect to honor the illness narratives that I have been entrusted with. To be rooted in social justice and health equity requires me to take a critical lens to the systems that train me and the systems that my patients navigate.
Dr. Franco is a pediatrics resident at UCSF. Jimmy approaches his work with a commitment to intersectionality. He believes medicine needs to be radically transformed and is grateful to his mentors for showing him that he can show up as his full self—a queer Guatemalan from a family of immigrants—without shame to support others in leading authentically.
Elizabeth Shaw, MD
Flat lines are generally ominous signs in medicine. A flat line on a cardiac monitor represents a dire situation, but offers no hints about the underlying cause. Similarly, a flat trend line showing consistently subpar performance on a clinical quality measure is both troubling and unrevealing. As we learn early in medical training, a flat line is not a shockable rhythm.
These difficult situations highlight another truth in medicine, which is that the solution is to treat the patient, not the problem. When the cause of the pattern on the screen or the graph is unknown, it is critical to focus on the humans and stories behind the data and let them guide our actions. As a family physician at a federally qualified health center, I recognize that personalizing care for individual patients drives quality. Safety net providers know that anticipating barriers and molding care to our patients’ individual needs improves outcomes. In my role as Medical Director of Quality Improvement, I have learned that this same commitment to customized care on the population level is a powerful driver of health equity as well.
Perplexingly, breast cancer screening rates at my health center have defied years of improvement efforts tailored to overcome the most troublesome barriers for our patients. For example, when patients shared that transportation to off-site imaging centers was a hurdle, we responded with taxi vouchers and ride-share credits. Acting on feedback that scheduling mammogram appointments was cumbersome, we collaborated with our main imaging centers to reserve appointment blocks and now provide appointments to patients directly. In order to help our many Latinx patients feel comfortable accessing care outside their medical home, we recently partnered with a bilingual, bicultural nurse case manager to provide extra outreach and reminder calls to our shared patients. Despite these well planned strategies, patients’ high noshow rates for mammogram appointments persist, and our trend line for breast cancer screening has remained level.
In late 2022, faced with a flat line and dwindling options, we decided to try something completely different. For the first time in history, we took a chance and offered mobile mammography to patients at our health center facilities, with generous support from Partnership Health Plan of California. We had long suspected that removing the challenges associated with off-site mammography could be successful, but we lacked access to a local mobile mammography unit in Marin and we worried about the complexity of bringing an outside service into the community. To
our amazement, over the course of two days, we provided over 80 screening mammograms to health center patients. This amounted to nearly three times the number of women successfully screened in the reserved mammogram slots at our largest off-site imaging center in 2022. Beyond the numbers are the compelling stories of the women who were screened, several for the first time in their lives. Patients at both events shared profound gratitude, at times through tears, for the opportunity to access needed screening in a way that actually removed barriers, not just masked them. Yet again, we were reminded that equitable access to care happens when systems of care strive to conform to the needs of patients, and not the reverse.
In the weeks since these pilots occurred we have navigated responses from the local community. On one hand, we are learning from concerns shared by our local imaging centers about the technology used at the mobile events and the lack of continuity this approach creates around abnormal results. On the other hand, we have watched a wave of interest build around the possibility of a local mobile mammography unit, including attention from potential funders. Most importantly, we hear patients continue to share enthusiasm for this new approach and ask when “the bus” might return for their mothers, sisters and daughters.
Challenging the status quo to deliver care effectively is the daily work of those of us who serve the most vulnerable patients in our communities. However, we know that pilots are merely launching points and that true progress has to be sustainable for all involved. After all, when a flat line regains hopeful movement, it is usually due to the heroic efforts of a coordinated team with a shared goal: to save lives. I feel hopeful that we can come together as a health care community in Marin to do just that.
Dr. Elizabeth Shaw is a Family Physician and the Medical Director of Quality Improvement and Assurance at Marin Community Clinics. She obtained her medical degree from the University of California, San Diego and completed residency at the Ventura County UCLA Family Medicine Residency Program. She also serves on the Board of the North Bay Chapter of the California Academy of Family Physicians.
Cayenne Bierman, MSW, LCSW; Caren Schmidt, PsyD and Tracey Hessel, MD
The California Surgeon General’s office has made screening for Adverse Childhood Experiences (ACEs) in California’s primary care settings one of its core priorities. Launched in 2019, the ACEs Aware Initiative was created to train primary care providers in health care settings to systematically screen for ACEs in pediatric patients. As one of the early adopters of screening for ACEs, Marin Community Clinics has been at the forefront of these efforts and benefited from the support of multiple funding and research collaboratives.1
In conjunction with the State’s ACEs Aware Initiative, Marin Community Clinics helped create a model case study of implementing screening practices for interested healthcare sites across the state of California. As a result of these efforts and collaborations, we now have a robust screening program across our clinics. We screen all pediatric, obstetrics, and adult patients for exposure to ACEs. California as a whole has made great gains in this area, and we are moving towards a point in which screening is the rule, rather than the exception. As is now true for many health organizations in California, our medical assistants and primary care providers are trained in how to introduce the screeners and the topic of ACEs in a strengths-based, traumainformed manner. We have made great strides to reduce the stigma of discussing traumatic experiences—building resilience amongst patients and staff alike.
As healthcare professionals, we view screening as an integral first step in addressing ACES, with response to positive screening representing a critical next step. We recognize the need for a multifaceted approach to interventions and supports to truly promote healing and resilience. Marin Community Clinics has increased our response to positive screenings with a variety of evidenced-based interventions and supports for families. We are fortunate that Marin Community Clinics has developed robust integrated behavioral health, complex case management, nutrition, and alternative healing programs, and we are able to provide many services to patients on-site. However, the manifestations and treatment of trauma are often
complex—requiring support that goes beyond the traditional scope of primary care settings. And, the need for these supports is everincreasing.
As ACEs screening and response is becoming the standard of care in health care settings, it is time to set our sights on a larger goal: prevention. Many groups are looking towards this goal and Marin Community Clinics is fortunate to be supported by two large efforts including RBN (funding partnership with Genentech Charitable Giving and the Center for Care Innovations (CCI)) and PRACTICE (funding supported by UCLA-UCSF ACEs Aware Family Resilience Network (UCAAN) in collaboration with the Office of the California Surgeon General (OSG), the California Department of Health Care Services (DHCS), and the Population Health Innovation Lab (PHIL), a program of Public Health Institute (PHI)).
The California Department of Health Care Services (DHCS) has spent considerable time and effort creating new funding and reimbursement streams to support preventative work for the first time. The crown jewel of these initiatives is CalAIM, California’s ambitious plan to transform how Medi-Cal delivers care to the state’s most complex and vulnerable residents. This initiative inherently recognizes the interplay between trauma, Social Determinants of Health (SDOHs), and health, and provides opportunities to integrate new supports into healthcare practice.
For the first time, there is a sustainable pathway to integrating social workers and community health workers into primary care where they belong—working with individuals, families, and communities to build on existing strengths while addressing barriers to care (including marginalization by healthcare systems). This enlightened understanding has allowed clinics like ours to add preventative pediatric programs including Healthy Steps and Triple P to existing supports such as Comprehensive Perinatal Services Program (CPSP). These efforts mitigate risk factors and provide skills and support to families before they are in a crisis. At Marin Community Clinics,
we believe the care trifecta of primary care, behavioral health, and complex case management addresses ACEs in a meaningful way. We are grateful to work in a state that increasingly recognizes and values the tenets of whole person care. The changes being made at the state level allow clinics like ours to address the cycle of trauma and unmet psychosocial needs in a way that expands preventative opportunities and promotes resilience. Both RBN and PRACTICE are particularly committed to finding ways to prevent the effects of ACEs and support our most vulnerable patients: children.
These are unprecedented times in healthcare. While DHCS and Managed Care Plans are creating new and exciting funding opportunities to implement supports to respond to ACES such as the Dyadic Services Benefit, Community Health Worker reimbursement, and CalAIM case management and housing supports, it has not been an easy lift for frontline providers. As these new benefits roll out, healthcare as a whole is experiencing critical staff shortages, provider burnout, and increasingly traumatized patients. To understand and implement these new services involves a significant administrative burden at the local level. For safety net clinics already operating beyond their bandwidth, it can feel overwhelming, if not impossible, to successfully add these services. We are here to tell you it can be done. Groups like Aliados Health (formerly Redwood Community Health Coalition) are bringing together “peer networks” of Federally Qualified Health Center (FQHC) providers implementing these services to share experiences and best practices with agencies newly contemplating them.
Similarly, RBN and PRACTICE have brought together missiondriven providers and provided expert coaching and education— providing a roadmap to accessing new reimbursement streams and services. Beyond implementation and reimbursement, peer networks like these provide opportunities for mutual support and shared advocacy opportunities to report back up to the managed care plans and state agencies like the Department of Health Care Services (DHCS). The greatest resource we share is our commitment to serving the most vulnerable patients. If we continue to support each other in these efforts, our clinics, staff, and patients can succeed. It is our hope that other healthcare providers will join us in these efforts to move beyond screening, and work towards preventing the effects of trauma for the next generation.
For more information: CCI- https://www.careinnovations.org/ UCAAN/ACEs Aware https://www.acesaware.org/
Cayenne Bierman, MSW, LCSW, is the Director of Complex Care services at Marin Community Clinics. She is a project co-Lead on MCC’s RBN and PRACTICE grants. Caren Schmidt, PsyD is a child psychologist and the Associate Director of Behavioral Health at Marin Community Clinics. She is a project co-Lead on the PRACTICE grant and a Team Member on the RBN grant.
Tracey Hessel, MD, is the Associate Medical Director of Pediatrics at Marin Community Clinics. She is the Provider Champion on the PRACTICE grant and a Team Member on the RBN grant.
1 The National Pediatric Practice Community on Adverse Childhood Experiences (2017); Resilient Beginnings Collaborative (2018-20); California ACEs Learning and Quality Improvement Collaborative (2020-2021); ACEs Aware (2020-2021); Resilient Beginnings Network (RBN) (2021-2023); and Preventing and Responding to ACEs-Associated Health Conditions and Toxic Stress in Clinics Through Community Engagement (PRACTICE) (2022-2023).
Yes, I remember my first bike. A red Schwinn Bantam with training wheels and a red and white saddle. It was my first brand new bike, and the last new bike until the mountain bike I bought myself as an adult.
I can now appreciate that my parents must have worked many overtime hours for that bike. “Playing bikes” was a way to get outside, explore and be with friends. Despite strict restrictions on where I could ride, and a “streetlights on” curfew, it was freedom.
In medical school, biking became a way to ride beside my (now) wife Nell as she ran along the Charles River in Boston. In the early days of our relationship, that was how I got in shape, rode off the stress of medical school and added precious time together. Moving to California for residency made me into a cyclist. We lived a mile from the hospital—commuting by bike just made sense. But the route to work was downhill and getting home after a tough call night made me question the decision. On weekends and post-call afternoons, I’d be in Tilden Park or on Mt. Tam exploring with friends. We talked through a lot of tough cases and residency challenges while navigating the rocky trails.
Residency is also when I first tried road biking. It’s a bit of foreshadowing that my first century ride was the Waves to Wine fundraiser for MS. On a borrowed bike two sizes too small, I rode 100 miles on Saturday, 50 miles on Sunday and joined the confederacy of cyclists who ride for donations. Anyone who has received an email from me in the last 10 years knows that I will pedal if you will support the cause. I’ve ridden the coast of California for Best Buddies, across Massachusetts in the Pan-Mass Challenge, up Mount Tam for World Bicycle Relief, around Napa for ALS, through Sonoma for at-risk youth and others that I no longer remember, at least not until I come across that old t-shirt or jersey in the drawer.
After residency, I moved to Shiprock, NM to work on the Navajo Nation. Mountain biking and other outdoor pursuits were a way to explore the area and connect with others who had moved there to work on the reservation. Many miles on the trails throughout the Four Corners in Moab, Telluride, Sedona, Durango, Shiprock and Farmington helped nurture relationships that are still strong over 20 years later. Along with a good friend from the local 4H, we held bike repair days at the local Boys and Girls Club and started a Trips for Kids
Nelson Branco, MD, FAAP
group. We lubed, adjusted and fixed flats, then sent kids home with a new helmet and a way to get out and have fun in a healthy way. The kids who joined Trips for Kids rode donated mountain bikes around Shiprock and the Four Corners area with adults from the local community.
Cycling has, if anything, become even more part of my life in the 20+ years since returning to California. I’ve introduced my kids to biking, traveled to Oregon, Utah and Colorado to ride with them in beautiful places and am pleased that they use bikes to get around in college. I have a group who I ride with regularly, several of whom are fellow physicians and colleagues, and all of them good friends who challenge and support me when I need someone to help me burn off stress, think through a problem, stay in shape or improve my riding. I logged many #COVIDmiles during the pandemic—initially solo, then in small groups wearing face protection, and eventually back to our normal rotating cast of characters. The COVID quarantine was challenging for all, but I found silver linings—the weeks when all of my kids were home and we got to spend time together as a family, the connection to my colleagues and practice staff as we learned about this virus and navigated repeated new challenges, and extra miles on the bike.
Cycling has always been about more than fitness, speed and gear—though I care about all of those things as well. It’s a hobby that has connected me to others, including some of my closest friends. It provides a way to relieve stress and think through problems and it’s given me a reason to travel and spend time outside in beautiful places. As we focus on wellness and work-life harmony, it’s clear to me that my family, my connections to colleagues through boards, committees and the AAP and SFMMS, and cycling are all methods that I use to manage my own wellness. I’m grateful for all of it. Let me know if you want to get out for a ride and talk about it sometime.
Nelson Branco, MD, FAAP is a primary care pediatrician at Tamalpais Pediatrics and on staff at MarinHealth Medical Center. In addition to clinical practice, he is a managing partner at Tamalpais Pediatrics, the president of the American Academy of Pediatrics California Chapter 1, the Pediatric Medical Director for Meritage Medical Network, and the incoming board chair at the Marin Community Clinics.
Steve Heilig, MPH
Drug abuse and addiction have long been one of our nation’s most prevalent health problems, too often resistant to efforts to reduce it. One aspect of “prevention” is drug education, especially of youth, but that too has long been mired in debates about impact and what works best. In 1999, SFMMS co-convened a major conference titled “Just Say Know: New Directions in Drug Education.” The meeting drew hundreds to hear learn from an expert faculty on all aspects of drug education, with a consensus that fact-based, non-“scared straight” or “just say no” approaches are best.
Within a couple years there was a notable postscript of the conference when the San Francisco Chronicle reported that a drug education program called Narconon was offered in many local schools. The program, not affiliated with the well-established recovery network Narcanon (Narcotics Anonymous, but the very slight difference in spelling seemed no accident), was part of the controversial “Church” of Scientology, even though they publicly deny the connection. It was offered for free, which made it attractive to cash-strapped school districts (and ironically reminded some of us of the old “first ones free” approach said to be used by drug dealers).
The Chronicle article spurred much concern and soon the San Francisco Superintendent of Schools, having sent multiple health education staff to our conference, was on the phone to the SFMMS, seeking peer review of the Narconon program. We agreed, and they sent over large binders of material. I farmed it out to five addiction medicine and drug education experts for review—which is where things got more interesting. Because the SFUSD is a public body, their communications are open to the public. Within days Narconon representatives began showing up at the SFMS offices, asking to meet with me. The first couple times I did speak with them briefly and took more of their material, but told them this had to be an impartial review with no “lobbying” (explaining to them what an IRB is, as an example). But they kept arriving, and demanded to know who the other reviewers were. I was glad that had been kept out of the correspondence with SFUSD, even if it left me the sole contact.
Our receptionist was “creeped out” by the continued efforts to get into the building. This came to a head when two strangers showed up at an SFMS board meeting, insisting on speaking to the group “as concerned citizens.” I had to forcefully tell them to leave, which they reluctantly did. I was also able to learn that one of them was a physician, with long affiliation with Scientology. Then a military psychiatrist I had met via other work, who was involved in surveillance of terrorist and “hate groups,” got in touch to tell me I was being angrily discussed by Scientologists around the nation, with one Narconon official saying he really wanted to punch me in the face. Now I was getting some feelings of creepiness too.
The expert review came in promptly, with the consensus that the “science” underlying Narconon didn’t reflect scientific or educational standards. I put this conclusion into a short letter, writing that the Narconon curriculum “often exemplifies the outdated, non-evidence-based and sometimes factually inaccurate approach, which has not served students well for decades.”
The school district took quick action and removed Narconon programs from their drug education efforts. Even better, the Chronicle reported “Heilig’s letter set in motion a chain of events, and California’s education department recommended that all public schools reject Narconon as unscientific, a claim that was unanimously backed the next month by the California Medical Association”—endorsing an SFMS policy resolution. The AMA soon followed suit. We’d “gone statewide and national”— something SFMMS often hopes to do in our policymaking work.
One unintended effect of this victory was that I was asked to “put my money where my mouth is” and volunteer for drug education in local schools. I gladly did this for years until I perceived I’d become too old to have credibility on this topic with adolescents. But also, the Chronicle eventually returned for another look at SFUSD drug education and found that Narconon had slipped back in somehow. That was soon remedied. It seems that eternal vigilance is the price of good education.
"When you see with your heart you notice things you have never noticed before. When you look at everyone and everything with your heart you see things that you would not see if you only looked with your eyes. You see the light that is hidden in everyone and everything. You can see below the surface of things, the appearance of things, and discover extraordinary things in ordinary people. To see with your heart is to see the future.”
These are the words of Dr. Rachel Naomi Remen in the authors notes of her new book, Birthday of the World. Dr. Remen was one of my wisest teachers in medical school, so long ago. She is also the NYT bestselling author of Kitchen Table Wisdom and My Grandfathers Blessing.
In Honor of Dr. Rachel Naomi Remen’s 85th birthday, enjoy a recording of a book club with Dr. Remen, sharing her book and wisdom, and practice the most recent Mindful Yoga for Healers session dedicated to seeing with your heart by scanning the QR codes with your smartphone.
The SFMMS Physician Wellness Committee has curated a list of SFMMS 2023 Reads books:
“Being Mortal” by Atul Gawande
“My Operation: A Health Insider Becomes a Patient” by Sholom Glouberman
“The Doctor Stories” by William Carlos Williams
“When Breath Becomes Air” by Paul Kalanithi
“The Children’s Hospital” by Chris Adrian
“Devotions” by Mary Oliver
“Musical Tables” by Billy Collins
Stay tuned for 2023 SFMMS Book Club dates.
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.
Honoring Diastole Retreat: Friday, May 19th; Saturday, June 10th; Sunday, August 27th; Sunday, September 24th and Saturday, October 27th
Connect in Nature Mindful Healers Retreat: July 14-16th, 2023
Nourish & Transform: A 4-5 night all-inclusive intimate physician wellness retreat opportunity for women physicians in Santa Margarita, CA.
Find out more and sign up here: https://www.jessiemahoneymd.com/retreats.
Stay tuned for a second round of SFMMS Membership retreat sponsorships in Spring 2023.
SAVE THE DATE: Mindful Yoga for Healers
Join SFMMS on Sunday, October 15th 10am - 12pm. IN-PERSON yoga and community building at the Old Mill Park Amphitheatre in Mill Valley. 60 minutes of ALL levels yoga will be led by SFMMS Physician Wellness Committee Chair, Dr. Jessie Mahoney. Yoga will be followed by socializing and community building with your SFMMS physician colleagues.
Are you interested in practicing Mindful Yoga for Healers before this event? Join Dr. Mahoney on Zoom most Saturdays at 9am or on YouTube. For more information visit: https://mindfulyoga.jessiemahoneymd.com/orhttps://youtube.com/c/JessieMahoney.
SFMMS Women in Medicine: Stay tuned for our Annual Women in Medicine gathering coming this May/June. Date TBD.
Read our Monthly SFMMS Wellness Blog
Each month, as part of the Physician Wellness leaders' work, they curate wellness resources around a common theme for our monthly wellness blog. Read, listen, and attend the monthly resources the committee has curated for SFMMS members by visiting: https://www.sfmms.org/news-events/sfmms-blog. aspx?Category=physician-wellness or by scanning the QR with your smartphone.
Have you missed a recent Wellness Event?
You can learn more about upcoming wellness events or view recordings of past events on the SFMMS Wellness Page at www.sfmms.org/get-help/physician-wellness.
Following the murder of Zhina (Mahsa) Amini by the “morality police” in September 2022, the movement for “Woman Life Freedom” spread across Iran and the globe. The oppression of women is a global tragedy, including in the United States where socioeconomic and racial characteristics intersect with structures of violence. In Iran, the feminist revolution has shocked many given the bravery of young men, women, and children, rising up against brutal security forces. At University of California San Francisco (UCSF), a number of students, staff, and faculty, many with Iranian heritage, came together with the aim of supporting the people in Iran.
The torture and death of a street medic, Dr. Ayda Rostami, galvanized the group to take action by starting a petition for accountability and justice. They partnered with @KimiyaSF (she/her), to create this video: https://www.instagram.com/reel/ CojGDPWgYoz/?utm_source=ig_web_ copy_link to promote the petition: Kimiya is a local Architect/Artist currently residing in the Bay Area; she grew up in Wales, UK and later moved to Mashhad, Iran, where she became a social rights activist from an early age. Her biggest inspiration is the extraordinary resilience of the Iranian people, and their ongoing fight for freedom. The petition on change.org/AydaRostami has been signed by over 1,000 people, with over 420 healthcare professionals and university faculty around the world, and at least 120 of whom identify UCSF at their Institution/Organization. To sign as a healthcare professional or university faculty, sign here: https://docs.google. com/forms/d/e/1FAIpQLSceGGWYHzJ8Csorb3O_WiLBrrnShjr5ln0Ee017mQH9m0-Gjw/viewform
The WomanLifeFreedom at UCSF group has achieved so much in so little time; the Voice of America (VOA) News website describes their work to support the people in this recent article:https://ir.voanews.com/a/women-life-freedom-groupat-ucsf-to-support-protests-and-academics-in-iran/6945248.html
Upcoming events include a Norooz Celebration on March 25, at 2:00-5:00 pm in Mission Bay. All are welcome! Woman Life Freedom at UCSF group meets every Thursday. Email womanlifefreedom@ucsf.edu if you are interested to join us, or if you have any questions, comments, and suggestions.
The mission of the Woman Life Freedom at UCSF group is to partner with and learn from marginalized, immigrant, refugee, and undocumented communities to build a coalition in the struggle for freedom, justice, and human rights. They are (1) raising awareness among the UCSF community about the current uprising in Iran; (2) developing practical solutions to assist healthcare providers and protesters in responding to physical and mental health traumas; (3) supporting Iranian scholars by creating funds and advocating for universities outside of Iran.
Yalda Shahram, MD, MSc, is a hospitalist and clinician-educator investigating the impact of antiracist education and critical consciousness to address structures of oppression in health care. She is on the Board of Directors of the San Francisco Marin Medical Society and was selected as a recipient of the UCSF Society of Hellman Fellows award, with the designation as a Diversity, Equity, and Inclusion award for her commitment to DEI and health equity at UCSF and beyond.
Throughout its more than 75-year history, Kaiser Permanente has had a strong commitment to support the communities we serve, acting on the belief that where we live, learn, work and play has the greatest influence on our health. We are also driven by a commitment to improve health equity, recognizing the long-term effects of historical and systemic racism, economic inequity, and chronic disinvestment in communities most in need. For these reasons, Kaiser Permanente has chosen to direct our organizational resources towards improving conditions for health in the communities most impacted by health inequities.
The Patient Protection and Affordable Care Act (ACA) requires non-profit hospitals to conduct Community Health Needs Assessments (CHNAs) and file Implementation Strategies (IS) with the IRS for each licensed hospital facility every three years.
To determine the best strategies for the San Francisco Service Area, we sought input from community partners to help us understand local needs. We also shared data with the San Fran-
cisco Health Improvement Partnership (SFHIP), a collaboration that includes the San Francisco Public Health Department, local hospitals, and health equity coalitions, presenting early findings and incorporating their feedback. Our four key priority areas are:
• Access to Care: Provide coverage options, support eligibility screening and enrollment in public programs, strengthen safety net services, and build a diverse workforce.
• Mental and Behavioral Health: Improve access to community services, support workforce development, prevent and mitigate the impacts of trauma, and reduce substance misuse.
• Income & Employment: Reduce racial wealth gaps and improve financial well-being through college and career support, small and diverse business growth, and food security programs.
• Housing and Homelessness: Address affordable housing, prevent evictions, strengthen systems of care, and reduce homelessness.
We look forward to putting our 2023-2025 implementation strategy into action through grantmaking, access to care programs, and continued expansion of our community partnerships.
by Joyce Frieden, Washington Editor, MedPage Today
WASHINGTON — The Biden administration's drug czar has a challenge for America's doctors, especially members of the American Medical Association (AMA): help figure out the best way to treat substance use disorder (SUD) patients.
"While the Biden administration has improved access to care for millions of people with OUD [opioid use disorder], we've got a lot more work to do," Rahul Gupta, MD, director of the White House Office of National Drug Control Policy, said Tuesday at the AMA's National Advocacy Conference here. "This is where we need your help. We need more docs screening and case-finding for SUD across all subspecialties. We need more curriculum on SUD because I can tell you, if we're not taught something, we're not interested in it ... and that has a lot of consequences."
"We really need more folks across our profession to help figure out how to treat patients with SUD," he continued. "I don't think it's any different than diabetes or hypertension or heart disease; it's another thing we can do for our patients. And we can't do that without your help. My ask is, let's help ourselves build an addiction infrastructure that we need by becoming a part of it."
A bigger workforce is also needed, Gupta said. "One of the things we're working on is making sure we have the workforce of the future. We've got more providers, more loan repayment programs, minority fellowships, and other things we can do to get more providers into the country. We need the next generation of providers."
Gupta concluded his remarks with a personal plea to his fellow AMA members. "I've been a member of the AMA since my first year of internship," he said. "I've been president of my county medical society and state medical society ... I know the power of organized medicine. When the AMA gets behind an idea, it changes hearts and it changes minds. And most importantly, you can help change this policy."
(From MedPage today, February 2023).
On December 29, 2022 in Napa, Dr. Brad Cohn passed away at the age of 95. A third-generation Californian, born in San Francisco, he was educated there and in Santa Rosa. After serving in the Navy during WW II, he graduated from U.C. Berkeley and completed his medical studies at U.C.S.F. and postgraduate education at McGill and Harvard. A board certified pediatrician, Dr. Cohn joined his father in practice in San Francisco where he continued to minister to children for 40 years, retiring to Napa.
Dr Cohn was a U.C.S.F. Associate Professor of Pediatrics and Chief of Pediatrics at St Mary's Hospital, maintaining an active role in teaching colleagues. He was President of the San Francisco and California Medical Association, and was Chairman of the California Delegation to the A.M.A. and the Professional Liability Committees of the American Academy of Pediatrics. He had a career spanning role with both the California Legislature and the Congress in promoting quality medical care for all Americans, and sound child health legislation. Dr Cohn was a founder of Medical Insurance Exchange of California and Chairman of its Board.
Dr. Cohn is survived by his loving wife, Cheryl, a son Lee of San Rafael, and a daughter Caren of Rohnert Park.
Donationstothechildren'scharityofyourchoice.
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• MA plans’ prior authorization approvals must remain valid for the duration of the course of treatment.
• MA plans must provide beneficiaries with a 90-day transition period where a PA would remain valid for any ongoing course of treatment when beneficiaries change plans or enter MA.
• After PA approval, MA plans cannot retroactively deny coverage for a lack of medical necessity.
• HOW YOU CAN HELP: Share your unique experience as a patient, physician or health care professional so we can fight back to ensure California policy puts patients first. https://www.cmadocs.org/survey/testcd/CMA_PRIORAUTH/ cd/-1
What physicians need to know about the end of the COVID-19 state of emergency
See: CMADocs.org
After three years of pandemic operations, both the State of California and the federal government are winding down the COVID-19 public health emergency. California’s State of Emergency ends on Tuesday, February 28, 2023, while the federal public health emergency is scheduled to expire on Thursday, May 11, 2023. CMA has published a guide – End of the COVID-19 Emergency: What Physicians Need to Know – to help physicians navigate the end of the state’s emergency authority.
870 square feet, first floor medical office right off lobby. Lots of natural light. Fully functioning surgery room; private restroom. Plenty of on-site parking. $3.50 per square foot + PG & E. Call Karen, 415-339-2222.
