July/August 2012

SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y

Patient Education Are Patients Afraid to Ask You Questions?

Strategies for Cultural Literacy New Research: Healthy Physicians Make Better Role Models Talking to Patients about Health Care in America

VOL. 85 NO. 6 July/August 2012

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IN THIS ISSUE

SAN FRANCISCO MEDICINE

July/August 2012 Volume 85, Number 6

Patient Education

FEATURE ARTICLES

MONTHLY COLUMNS

12

14

4

Membership Matters

7

SFMS Advocacy Activities

9

President’s Message Peter J. Curran, MD

Knowledge Speaks; Wisdom Listens: Tailoring the Ask-Teach-Ask Technique to Address Emotional Reactions Shieva Khayam-Bashi, MD Cultural Literacy: Strategies for Addressing Diversity in Patient Education Angela Marks and Sunita Mutha, MD

18 Tell a Story: The Power of Storytelling to Improve

American Health Care

John Maa, MD

19 Chronic Disease: Education for the Long-Term Patient

Descartes Li, MD 21 Online Patient Education: FamilyDoctor.org Tools

Facilitate Communication

Angelike Gaunt

23 Wellness Education at SFGH: Underserved Patients

Find Resources at the Wellness Club

Blue Walcer, MPH

11 Editorial

Gordon Fung, MD, PhD 28 Hospital News 30 In Memoriam

OF INTEREST 29 Proposition 29: Letter to the CMA 30 California Pre-Existing Conditions Plan

25 Are Patients Afraid to Ask? New Local Research on

the Fear of Being “Difficult”

Steve Heilig, MPH

27 Physician as Role Model: Research Shows Healthy Physicians

Make Better Role Models

Carolyne Krupa

Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 | E-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members Help Make Health Policy for California and Beyond Frustrated with the vagaries of today’s health care system? Would you like to see something done to fix it? Do you have some new and/ or innovative policy ideas you would like to share? The SFMS delegation to the CMA House of Delegates (HOD) would like your input about issues and concerns you have as a San Francisco physician.

Our delegation, chaired by SFMS Past-President Stephen Follansbee, MD, has a record of bringing successful ideas to the state and national levels, where they have been translated into professional policy and even legislation.

Resolutions adopted at past CMA and AMA sessions include banning sugar drinks in schools, encouraging universal immunizations for children, and assisting students and residents with medical education debt.

Please submit any issues or concerns and potential policy solutions we can bring to the table on your behalf by leaving a comment at http://bit.ly/KRHfWN or contacting Steve Heilig at heilig@sfms.org. The deadline for resolutions to CMA is August 15

Highlights from AMA Annual Meeting

tendees took advantage of the opportunity to connect with colleagues from the local community (business cards and emails were exchanged) in an intimate setting. With great attendance and positive feedback from all, SFMS plans to organize similar social networking events in the coming months. If you would like to get more involved on the local chapter level, or for information about upcoming SFMS events, please contact Jessica Kuo at jkuo@sfms.org or (415) 561-0850 extension 268.

Health Care Reform and California Physicians

The biggest recent health policy news has of course been the United States Supreme Court’s upholding of federal health reform. What does this mean for California? The CMA and AMA have prepared resources for physicians. For regular CMA updates, visit CMANET.org and search “ACA”. SFMS representative to the AMA, H. Hugh Vincent, MD, notes that AMA has prepared a comprehensive physician primer on Accountable Care Organizations, a center of health reform. Dr. Vincent notes “It is a good reference for doctors who really need to have a knowledge of what these things are and how to deal worth them; ACOs will be topic number one among those trying to corner the medical market. Docs will be caught in the squeeze and should know how to not only protect themselves, but do the best they can to be in the drivers’ seat as they develop.”

For a copy of the AMA document, contact Steve Heilig at the SFMS, heilig@sfms.org.

Membership Desktop Reference

Several SFMS-initiated, CMA-sponsored resolutions were passed at the AMA House of Delegates in Chicago in June 2012.

AMA adopted policies on ensuring truth and transparency in pregnancy counseling centers, taxing sugary beverages, and expanding current AMA policy opposing the sale of tobacco by pharmacies.

SFMS would also like to congratulate H. Hugh Vincent, MD (AMA delegate and past SFMS president), on his election to serve as the chair of the AMA Council on Long-Range Planning and Development.

The 2012–2013 SFMS Membership Directory and Physician Desk Reference will be mailed out in July. The annual directory is one of the most valued benefits of membership and is the only pictorial directory of physicians in San Francisco.

This resource is complimentary to all SFMS physician members currently practicing medicine and is used throughout the year by physicians and their staff. For questions or information about the directory, please contact Lauren Estrada at (415) 561-0850 extension 200 or lestrada@sfms.org.

Residents, fellows, and local physicians met and shared their experiences as emerging physicians at the SFMS Young Physicians Mixer on June 29 at UCSF. At-

Shannon Udovic-Constant, MD, SFMS president-elect and pediatrician at Kaiser Permanente San Francisco, was selected as the recipient of the 2012 Martin Gershman, MD, FAAP Child Advocacy Award. She is pictured left with Chuck Wibblesman, MD.

Young Physicians Networking Mixer a Success

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San Francisco Medicine July/August 2012

SFMS Member Honored by AAFP for Child Advocacy Efforts

www.sfms.org

This prestigious award is given annually by District IX (California) of the American Academy of Pediatrics (AAP) to honor a California pediatrician whose dedication and commitment to advocacy for children has been demonstrated through community, state, or private-sector activities.

Please join SFMS in congratulating Dr. Udovic-Constant for her achievements. We are proud to have her as a member of SFMS. In her own way and her own style, she has created a model of brilliant and successful advocacy.

Save the Date: CMA President’s Reception and Awards Gala

CMA and the CMA Foundation invite all SFMS members to attend the 2012 President’s Reception and Awards Gala. This annual awards dinner is hosted in conjunction with the CMA’s House of Delegates meeting to honor leaders in both organizations. The event hosts more than 600 California physician leaders, key staff from both the CMA and CMAF, and national and state health care stakeholders. Please visit http://bit.ly/KGrsbN for event details and registration.

SFMS General Meeting—All Members Welcome

RSVP today for SFMS’ General Meeting, September 10, from 6:00 p.m. to 7:30 p.m., at the Golden Gate Yacht Club. This is a good opportunity both to meet with SFMS leadership and to learn firsthand the issues for which SFMS and CMA are advocating on behalf of physicians and their patients in San Francisco and California.

Dinner will be provided. Please RSVP before September 3, 2011, to Posi Lyon at (415) 561-0850 extension 260.

Complimentary HIPAA Compliance Webinar

The HIPAA rules have changed with the publishing of a final rule related to the HITECH Act. The requirements for compliance are now more complicated and the penalties and enforcement actions higher than ever.

Learn about changes required by the final rule, gain an understanding of how HIPAA and Meaningful Use go together, and receive practical tips for compliance at the SFMS/ACCMA webinar on September 11. Registration is free for members and $199 for nonmembers. Visit http://www.sfms.org/ Events.aspx for event details and view other upcoming events.

SFMS Members Deliver Inspiring Care; Receive Health Care Heroes Awards

Three SFMS members were honored at the 2012 Health Care Heroes Breakfast on July 25. Organized by the San Francisco Business Times, this annual event recognizes individuals and organizations from the local health care community and their dedication and commitment to the enhancement of the value and quality of health care.

Toni Brayer, MD, past SFMS president and chief medical officer of Sutter Health West Bay Region, was recognized for leading medical missions to disaster areas. She worked long hours in challenging conditions to deliver care to people in crisis in Haiti and New Orleans.

Vivian Reyes, MD, an emergency medicine physician, was honored for developing the Emergency Response Team at Kaiser Permanente. The team specializes in helping keep hospitals ready for natural disaster or emergency that could affect the entire region.

Gina Gregory-Burns, MD, an internal medicine physician, was acknowledged for helping Kaiser Permanente San Francisco achieve health equity by spearheading programs and strategies for delivering culturally competent care in diverse communities.

SFMS would like to congratulate our members, whose tireless commitments to health care are invaluable to a thriving medical community. www.sfms.org

July/August 2012 Volume 85, Number 6 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Nancy Thomson, MD Stephen Askin, MD Erica Goode, MD, MPH Toni Brayer, MD Shieva Khayam-Bashi, MD Linda Hawes Clever, MD Arthur Lyons, MD Peter J. Curran, MD Stephen Walsh, MD Sashi Amara, MD SFMS OFFICERS President Peter J. Curran, MD President-Elect Shannon Udovic-Constant, MD Secretary Jeffrey Beane, MD Treasurer Lawrence Cheung, MD Immediate Past President George A. Fouras, MD SFMS STAFF Executive Director/CEO Mary Lou Licwinko, JD, MHSA Assistant Executive Director Steve Heilig, MPH Associate Executive Director for Membership Development Jessica Kuo, MBA Director of Administration Posi Lyon Membership Assistant Lauren Estrada BOARD OF DIRECTORS Term: Jan 2012-Dec 2014 Andrew F. Calman, MD Edward T. Melkun, MD Roger S. Eng, MD Kimberly L. Newell, MD John Maa, MD Richard A. Podolin, MD Elizabeth K. Ziemann, MD

Term: Jan 2010-Dec 2012 Gary L. Chan, MD Donald C. Kitt, MD Cynthia A. Point, MD Adam Rosenblatt, MD Lily M. Tan, MD William T. Prey, MD Joseph Woo, MD

Term: Jan 2011-Dec 2013 Jennifer H. Do, MD Benjamin C.K. Lau, MD Man-Kit Leung, MD Keith E. Loring, MD Terri-Diann Pickering, MD Adam Schickedanz, MD Rachel H.C. Shu, MD

CMA Trustee Robert J. Margolin, MD AMA Representatives H. Hugh Vincent, MD, Delegate Robert J. Margolin, MD, Alternate Delegate

July/August 2012 San Francisco Medicine

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San Francisco Medicine July/August 2012

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SFMS Advocacy Activities A PROFESSIONAL VOICE FOR COMMUNITY HEALTH SINCE 1868 The San Francisco Medical Society (SFMS) has been involved in community health issues since the 1800s. As the only medical association in San Francisco representing the full range of medical specialties and interests, SFMS health advocacy has been broad. Via policy-making efforts with state and national medical and political leaders and an award-winning journal, SFMS has often been influential far beyond the city. The SFMS agenda and activities continue to focus on the community and the following areas of involvement: • Forming HealthShare Bay Area (see below) to improve patient care and reduce costs • Working with the physician community to promote the adoption of electronic health records to better serve patients • Advocating against cuts to Medi-Cal and Medicare reimbursement to provide continued access to care for all San Franciscans • Preserving the health care safety net and public health programs in times of severe budget cuts • Supporting antitobacco legislation and San Francisco’s law banning the sale of tobacco in pharmacies and smoking in restaurants and other businesses, and eliminating tax credits for films showing smoking • Supporting the Healthy San Francisco program and participating in legal defenses to preserve the program, while helping to monitor the program’s progress • Providing physicians for medical consultation for San Francisco schools and for volunteer care at community clinics • Working on legislation to allow minors, without parental consent, to receive vaccines to prevent STIs; to prevent bans on medical procedures such as circumcision; and more • Cosponsorship of the Hep B Free program in San Francisco • Advocacy for improving end-of-life care in the Bay Area via new policies, use of new advance directives (such as POLST), and educational outreach to physicians and patients

HOW SFMS SERVES THE COMMUNITY

HEALTHSHARE BAY AREA As a founding member, the SFMS

worked under the auspices of the SFMS Community Service Foundation guided by a diverse board of Bay Area health care industry professionals to develop HealthShare Bay Area to provide the infrastructure for a unified electronic health record system. The project originally targeted San Francisco but now includes partners from the East Bay. This service allows providers to have access to secure community-wide patient data. It also permits patients to gain a complete view of their medical records, irrespective of where individual records may reside. HSBA is scheduled to launch in late 2012.

UNIVERSAL ACCESS TO CARE SFMS leaders have long advocated that every San Franciscan should have access to quality medical care. Recent SFMS participation in this effort has included the Mayor’s Health Care Reform Task Force, the San Francisco Health Care Services Master Plan Task Force, and the Mayoral Task Force, which designed the Healthy San Francisco program. SFMS also joined in the lawsuits to preserve that program. SFMS has advowww.sfms.org

cated for community clinics since the founding of the original HaightAshbury Free Clinics in the 1960s.

MEDICAL LIABILITY PROTECTION The CMA and SFMS were

instrumental in passing MICRA, which saves virtually every doctor many thousands of dollars in liability premiums annually and saves hospitals and health systems much more. We have successfully defeated repeated attacks on MICRA by trial lawyers through the years.

REBUILDING/PRESERVING SAN FRANCISCO GENERAL HOSPITAL SFMS spokespersons took a lead in advocating for full

funding of the seismic rebuild and in advising, as members of the Mayoral committee, where and how that would occur.

HIV PREVENTION AND TREATMENT The SFMS was at the center of medical advocacy for solid responses to the AIDS epidemic, being among the first to push for legalized syringe exchange programs, adequate funding, and more.

SCHOOL AND TEEN HEALTH SFMS helped establish and staff a citywide school health education and condom program, removed questionable drug education efforts from high schools, worked on improving school nutritional standards, and provides medical consultation to the SFUSD school health service.

ENVIRONMENTAL HEALTH SFMS established a nationwide educational network on scientific approaches to environmental factors in human health; has advocated on reducing mercury, lead, and air pollution exposures; and much more.

REPRODUCTIVE HEALTH AND RIGHTS SFMS has been a state and national advocate for reproductive health and choice.

BLOOD SUPPLY SFMS has long been a partner of the Blood Centers of the Pacific and seeks to help increase donations.

ORGAN DONATION SFMS has been a leader in seeking improved

donation of organs to decrease waiting lists, via education and new polices regarding consent and incentives for organ donation.

OPERATION ACCESS SFMS is a founding sponsor of this local organization providing free surgical services to the uninsured and has provided office space, volunteers, and funds.

DRUG POLICY SFMS has been a leader in exploring and advocat-

ing new and sound approaches to drug abuse, including some of the first policies regarding syringe exchange, medical cannabis, and treatment instead of incarceration.

MEDICAL ETHICS SFMS has developed and promulgated for-

ward-looking policies and approaches regarding end-of-life care, patient directives, physician-assisted dying, and other topics of interest to patients, physicians, policy makers, and the general public.

July/August 2012 San Francisco Medicine

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Spine Symposium 2012

Essentials for the Primary Care Practice A continuing medical education (CME) event providing an overview of the newest evidence-based treatment options for conditions affecting the spine. Presenters include specialists from John Muir Health’s Neurosciences and Orthopedics Services.

Friday, October 5, 2012 The Claremont Hotel Berkeley, CA

John Muir Medical Centers, Concord and Walnut Creek, California

9

San Francisco Medicine July/August 2012

Register by September 28: Contact nancy.carol@johnmuirhealth.com or call (925) 947-4466 ext 35426.

johnmuirhealth.com

www.sfms.org

PRESIDENT’S MESSAGE Peter J. Curran, MD

Why We Walk Your San Francisco Medical Society is sponsoring the American Heart Association Heart Walk in Golden Gate Park on September 15. The executive committee of the SFMS Board voted unanimously to sponsor a booth at the event to showcase organized medicine’s commitment to local health improvement efforts.

Volunteers and survivors representing several local hospitals will walk a scenic three-mile course in Golden Gate Park to raise awareness for fighting heart disease. An additional benefit of supporting the walk is the message it gives the community about physicians’ resolve in advocating for health in our own neighborhoods. Much appreciation for the work of Dr. Shannon UdovicConstant, Ms. Jessica Kuo, and the membership committee at SFMS in organizing this and other community-related activities.

Community service is not new to organized medicine in California. John Frederick Morse, MD, historian and journal editor for the CMA during the cholera epidemic of the nineteenth century, praised physicians’ selfless commitment during the calamity: “Not one educated physician turned his back upon the city in its distress and threatened destruction.” Seventeen physicians died in that epidemic, which represented a third of the physician population in California at that time. Other notable physician advocacy initiatives include involvement with HIV/AIDS care and research, childhood vaccination, and the tobacco cessation legislation that began at a grassroots level with community service campaigns and charity fund-raisers. Effective health care advocacy must start with the community the physician population serves.

The SFMS membership has pioneers in local community advocacy. The San Francisco Free Clinic, founded in 1994 by SFMS members Tricia Hellman Gibbs, MD, and Richard Gibbs, MD, was awarded the Public Health Heroes Award for Health Care Delivery in 2006 for its service in providing medical care to the uninsured “working poor” in San Francisco. In addition to providing a vital service to the community, the clinic has given primary care training to young physicians and students from several medical schools, including UCSF. Similarly, SFMS member Marcus Conant, MD, one of the first physicians to diagnose and treat AIDS patients in 1981, founded the San Francisco AIDS Foundation and, later, the Conant Foundation, which expanded AIDS www.sfms.org

awareness to the legislative arena on behalf of patients. Adam Schickedanz, MD, a UCSF pediatric resident, started the Financial Fitness Program at San Francisco General, which provides crucial financial information and services to underserved patients with needs that go beyond health issues. Schickedanz’s program was awarded a $10,000 grant by the SFMS and the San-Cop Foundation and continues to grow. And we likely all know about longtime member David Smith, MD, and his pioneering work founding the Haight-Ashubry Free Clinics in 1967 and leading addiction medicine activities ever since. There are many more.

At a time when organized medicine is struggling to remain relevant in the midst of health care delivery reform, perhaps it is simplistic to think that participating in a local Heart Walk will change medicine’s fortunes or even grow membership within SFMS. But public health and advocacy, which remain tenets of our mission at SFMS, are relevant regardless of the political climate of the times if they are done with conviction in support of the greater community benefit.

That is why we walk. Please lace up your walking shoes and join me on September 15 in Golden Gate Park. Training recommended but not required.

Dr. Curran is a cardiologist at Breall & Associates and is director of Cardiovascular Rehabilitation at St. Mary’s Medical Center.

July/August 2012 San Francisco Medicine

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EDITORIAL Gordon Fung, MD, PhD

Patient Education In March 1985, Dr. Lester Breslow, dean emeritus of UCLA School of Public Health, published an article in the Bulletin of the New York Academy of Medicine titled “Patient Education in Historical Perspective.” He noted that, historically, people tended to live healthy lives through regular physical activity and balanced traditional diets that were reasonably healthy.

It wasn’t until the past few centuries of European colonization and exploitation of indigenous peoples that these traditional patterns were disrupted in much of the world. In the U.S. and other developed nations, searching for a healthy life often takes the form of dieting, exercising, visiting spas, and the like. The question Breslow raised was, “How does the physician enter the process of achieving a healthful lifestyle?”

He stated that in the past, physicians were believed to be responsible for one’s health. However, the many trends occurring in medicine over the past several decades include the transition of medical training to a more scientific and evidencebased approach. Technological and pharmaceutical advances streamlined acute management of diseases, bringing the very ill from the brink of death back to full and productive lives. Research pinpointed risk factors and disease markers to identify who was at most risk of developing certain diseases or cardiovascular events. Large clinical trials demonstrated that treating risk factors could prevent diseases and therefore their morbidity and mortality rates. Screening procedures were developed to discover cancers early, before they spread. Vaccines eliminated a significant number of diseases, including polio and smallpox.

This changed the conceptual development of making people responsible for their own health. These changes in medicine to focus more on prevention than on reaction, with more emphasis on chronic disease management, are highly dependent on active participation of patients or healthy individuals who don’t want to become patients.

The main question became, “Where does one get health education?” Numerous studies have shown that people trust nurses, pharmacists, and physicians in general and specifically for their health information (a story I remember from my youth about trust in physicians was that patients will listen to their doctors’ advice to stop smoking even when the doctor is giving them this advice while smoking). But there are projected shortages of every workforce in health care delivery; the number of providers will be insufficient to educate the entire patient population on health. So in order to help educate the population, health organizations like the American Heart Association have published risk-assessment brochures. The American Cancer Society publishes cancer screening guidelines. The federal government, through the Centers for Disease Control, participates www.sfms.org

in funding projects focused on educating and engaging the public in disease prevention of the more common diseases like cardiovascular diseases, hepatitis, diabetes, and obesity. An entire industry has developed to educate the public about health education. Companies are offering health promotion programs as part of their human resource packages for employees.

With all these efforts going on in patient education we must ask, “Is it doing any good?” “What are the best, most effective ways to educate the public on health matters?” “What measures are we using to determine the effectiveness of our efforts?” With individuals increasingly accepting responsibility for their own health, we—the physicians and health experts and specialists—need to be in charge of the curriculum. Most health education is designed by health care educators with physician input, and some is done directly by physicians. But this approach is limited in its outreach, and most physicians still see their patients at the time of a clinic visit or during a hospitalization focused on a particular problem. Most physicians are in a position to make a significant impact on health care decisions when they reach a patient during a teachable moment—for example, advising the patient to stop smoking after he or she has had a heart attack, or reminding someone to get a flu vaccine prior to next season when the patient comes in for flu treatment this season. Here we see the greatest impact of physician influence on patient education, with resultant changes in behavior that can lead to longer and better quality of life—the two most common criteria of any intervention. But more research will be necessary to answer the basic questions above.

In this month’s issue, we are fortunate to have articles from several authors who address patient education in a variety of ways. I hope this issue is informative and helpful for you as a patient educator. Enjoy this issue, and have a great summer.

July/August 2012 San Francisco Medicine

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Patient Education

Knowledge Speaks; Wisdom Listens Tailoring the Ask-Teach-Ask Technique to Address Emotional Reactions Shieva Khayam-Bashi, MD Mrs. Jones was sitting anxiously in the exam room, waiting to hear the results of her blood tests. In the

adjacent room, the resident showed me the patient education handouts that she would use to explain her new diagnosis of type II diabetes to Mrs. Jones. She prepared well, planned to speak slowly, would focus on only the two or three most important concepts, would use shorter statements, and would try to engage Mrs. Jones. She knew that physicians generally do too much of the talking, and it was her goal today to talk less and listen more.

She said that she would use the Ask-Teach-Ask technique, in which she would first ask Mrs. Jones to describe her understanding of type II diabetes and its treatments, then she would teach her the additional information in a way that built on her stated understanding, and then she would ask what she understood and felt about the information given. At the end, she would not ask, “Do you have any questions?” but rather would invite and normalize questions by asking, “What questions do you have?” And, of course, she would be empathetic throughout.

The resident knocked on the exam room door, and we entered together. She shook Mrs. Jones’s hand and sat down next to her. She asked how she was doing in general and made some time for small talk. She then explained that the results of her blood tests were back and that she had type II diabetes.

She started to remove the patient education handouts from her folder, but first she noticed that Mrs. Jones looked away toward the window for a moment.

The resident was astute enough to stop and to be silent. She had a lot of knowledge to share, but she had the wisdom to know that this was a time to listen.

She was ready to ask about Mrs. Jones’s understanding of diabetes, but something told her to ask, instead, what she was feeling. Mrs. Jones was silent for a minute, then smiled nervously and said she knew this would happen eventually. The resident asked, “Who do you know who has diabetes, and how have they done?” This question resulted in about five minutes of valuable emotional processing about her prior experiences and expectations from the disease—her uncle Bob had had diabetes and went blind and had to go on dialysis for years before he died.

Her aunt Gladys had diabetes when she was in her thirties, lost one of her legs when she was fifty, and later had several strokes and heart surgery. She was afraid of this disease, and she was tearful as she spoke about her family’s suffering.

The resident allowed for this sharing, expressing empa12 13

San Francisco Medicine July/August 2012

thy for her family, and then she brought the conversation back to Mrs. Jones. “What are you most worried about, for yourself?” Mrs. Jones said she was worried about her vision more than anything else, as she had noticed some blurring lately.

The resident reflected back, reassured her that she would do a careful eye exam, have her seen by an eye specialist yearly, and that the goal would be to avoid all of these complications by managing her diabetes well. She then expressed hope for Mrs. Jones’s future and asked if she was ready to hear more about the basics of diabetes and how to treat it.

Mrs. Jones wiped her tears, took a deep breath, and nodded. She thanked the resident for letting her cry. She said that she didn’t think she would have been able to look at the handouts “if I hadn’t been allowed to get out my feelings first.”

Handing her another tissue, the resident gave her a hug and allowed another few moments of silence. Then they both took deep breaths, and the resident continued as planned, using Ask-Teach-Ask. Now having an understanding of Mrs. Jones’s emotional reactions, the resident asked her to tell her what she knew about how diabetes works. Mrs. Jones expressed her basic understanding about high blood sugar and not enough insulin, and then the resident built upon this. She took a blank piece of paper and drew a diagram of the digestive tract, the pancreas, a blood vessel, and sugar levels, and she explained the basics of how food, stress, and medication affect blood sugar.

She numbered and wrote down the three main points that she wanted Mrs. Jones to remember. She kept it short and simple, and she explained what Mrs. Jones could do to ensure her health in the future.

It was clear that Mrs. Jones felt better by the end of the session. She felt heard, understood, and educated. The resident then asked Mrs. Jones to repeat back what she would remember by asking, “What will you remember about this explanation? For example, can you tell me what you will tell your husband when you get home?” Mrs. Jones was able to repeat back three main points, and the resident beamed with pride.

Then she said, “Wonderful. You do understand this well, Mrs. Jones. And, may I ask, how do you feel right now, compared to before?”

Mrs. Jones teared up again and looked into the resident’s eyes. She said that she was not afraid anymore, that the simple way of explaining diabetes really helped to dispel the myths, and that she had hope that she would be able to take this on.

She did not think she would have the same fate as her family members now, because she knew she was more motivated to take care of herself. She said, too, that she felt supported by her wonderful doctor, who cared about her emotions as much www.sfms.org

as about her physical health, and she reached out to squeeze her hand across the desk.

After Mrs. Jones went on her way, the resident and I were able to discuss her wisdom in choosing to address her emotions before going into the patient-education discussion. She said that it was an intuitive decision. She had sensed that a “wall went up” as soon as she mentioned diabetes—at that moment, the resident knew she had a choice: to keep talking and just give the education anyway, or to pause and allow the emotions to be addressed first. Her intuition told her that to try to talk over her patient’s emotions would not work. She knew from personal experience that the initial wave of emotions, if unexpressed, can close a person’s mind from being able to take in the rest of whatever is being said. She was right.

There is a great deal of research that shows that patients understand and remember less than half of what clinicians explain to them. Some studies have shown that 40 to 80 percent of the medical information that patients receive is forgotten immediately, and that almost half of the information that is retained is actually incorrect. One simple way to close the gap of understanding is to use the Ask-Teach-Ask technique.

As revealed in Mrs. Jones’s story, it is often most effective to tailor the Ask-Teach-Ask technique, to assess emotional reaction as well as understanding. Asking about the patient’s emotional reactions before teaching will allow the clinician to address the“wall” of emotion that might otherwise shut the patient down and prevent understanding.

Modified Ask-Teach-Ask

Ask first, to assess emotional reaction as well as understanding:

(1) Who do you know who has the condition, and how was his/her experience with it?

(2) How do you feel/what are you most worried about, for yourself?

(3) What do you know about the condition?

Teach Use simple language and short sentences focusing on only two to three points, draw a simple diagram, and write key points for the patient to take home and remember.

Ask at the end, to reassess understanding and emotions:

(1) I want to be sure that I explained this correctly. Can you tell me what three main points you will remember?

(2) How are you feeling now?

(3) What are you most worried about now?

(4) What questions do you have?

www.sfms.org

Assessing emotions and understanding at the beginning and at the end of the session in this way can lead to improved adherence, health outcomes, patient satisfaction, and clinician satisfaction.

One year later, Mrs. Jones is thriving—her HbA1c is 6.2, her vision is superb, she exercises daily with her neighbors, and she hosts a monthly “Cooking for Diabetes” class in her home for her friends.

Shieva Khayam-Bashi, MD, is a clinical professor in the Department of Family and Community Medicine at UCSF and medical director of the Skilled Nursing Facility at San Francisco General Hospital. She is also a member of the San Francisco Medicine editorial board.

July/August 2012 San Francisco Medicine

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Patient Education

CULTURAL LITERACY Strategies for Addressing Diversity in Patient Education Angela Marks and Sunita Mutha, MD tant for all patients, including those who speak English. We discuss each of these three issues in greater detail below.

The Role of Culture in Patient Education

cul•ture (noun): Patterns of behavior that include lan-

Patient education is an integral part of patient care. It is particularly important for managing chronic condi-

tions, as education can improve understanding, confidence, and the skills needed to follow a treatment plan. A key to effective patient education is a physician’s ability to provide information and instructions in a way that meets the needs of the individual patient. Thus, providing effective education to diverse populations requires an additional level of thoughtfulness. The good news is there is a wealth of readily available resources to help you tailor information to your patients’ needs and preferences.

The goal of this article is to highlight some essential strategies for effective patient education for our increasingly diverse patients.

Two factors influence whether information is tailored to the patient: how the information is provided (e.g., verbally or in written form) and what information is included. To determine if the information you provide meets the needs of your patients, it is helpful ask three questions. The first is whether the content is aligned with the patient’s cultural values, beliefs, and traditions. For example, do the recommendations for diet include references to foods that are culturally relevant, such as rice rather than bread? The second question is whether the content can be communicated in the patients’ preferred language? For example, if the patient prefers to have discussion about his or her health care in Chinese, can you convey the information in that language? Finally, can you communicate the content at the appropriate level of health literacy? This last question is impor14 15

San Francisco Medicine July/August 2012

guage, thoughts, actions, customs, values, etc., of racial, ethnic, religious, or social groups.

Every patient-education encounter is effectively a crosscultural encounter, as patients and physicians rarely share all dimensions of culture, particularly the culture and language unique to health care. Many types of cultures come into play during patient-physician interactions, including the racial or ethnic background of the patient and the physician. Culture shapes a patient’s attitudes about medical care; health beliefs and attitudes about the cause of illness; beliefs about the roles of the physician and staff; specific customs related to diet, use of medicine, and other behaviors; the degree to which individuals believe they can control events that affect them; and the role of individual, family, and community in making health decisions.

As a result, culture can influence communication patterns, understanding of information, the patient’s degree of acceptance of what is conveyed, and the readiness to learn and make changes that affect his or her health.

Effective communication skills are essential for educating patients. The four approaches listed below can help assure your discussions are culturally appropriate: • Develop self-awareness about your own values, beliefs, and biases that may impact the content of your messages and the way they are delivered.

• Develop skills for eliciting information about your patient’s cultural background, particularly as it relates to health behaviors.

• Use staff from other cultures in patient-education activities.

• Develop a plan for ongoing provider and staff education on cross-cultural communication.

Tip: Questions to ask your patients

• What are you most concerned about?

• What are important things for me to know about your culture and beliefs regarding my taking care of you?

• What do you think will help improve your health?

RESOURCES: Online trainings in cross-cultural communication

• Quality Interactions—A Patient-Based Approach to CrossCultural Care, http://www.qualityinteractions.org/index.html www.sfms.org

• Unified Health Communication 101: Addressing Health Literacy, Cultural Competency, and Limited English Proficiency, ftp://ftp.hrsa.gov/healthliteracy/training.pdf

Understanding the health beliefs relevant to your patients’ cultures is a good starting place for discussion with your patients and their families. However, be cautious about inadvertently stereotyping patients based on assumptions of their cultural beliefs, values, and preferences, as there is much heterogeneity among members of a cultural group.

RESOURCES: Health Beliefs and Preferences for Various Cultural Groups

• HRSA Culture, Language & Health Literacy Resources: Race/Ethnicity provides helpful information on various racial/ ethnic groups and special populations. http://www.hrsa.gov/ culturalcompetence/race.html • Culture Cues™ provides tip sheets with information about concepts and preferences for a variety of cultures.

Also includes tip sheets about end-of-life care. http://depts. washington.edu/pfes/CultureClues.htm • Providers’ Guide to Quality and Culture: Common Beliefs and Cultural Practices is a website that provides information on key health beliefs commonly found in different world cultures. http://erc.msh.org/mainpage.cfm?file=5.3.0.htm&mod ule=provider&language=English

Similar communication principles apply for written patient educational materials. There are extensive resources for written patient education materials (see below), so it is rare that clinicians need to create these materials from scratch. Key considerations when evaluating or creating written materials are: Was the target community involved in developing the materials? If you are using existing materials, consider asking patients for feedback. Is the information tailored to reflect specific cultural beliefs and customs? Are culture-specific pictures and images used?

Limited English Proficiency and Patient Education

lim•it•ed eng•lish pro•fi•cient (adj): The U.S. Census Bureau’s definition is a patient’s self-reported ability to speak English less than “very well.”

Although language is intrinsically a part of culture, language barriers and the challenges they present in effective patient education warrant a separate discussion. There has been much attention paid to improving limited English proficient (LEP) patients’ access to qualified medical interpreters and translated materials.

RESOURCE: Identifying a Patient’s Language

If your practice does not yet have a systematic way of identifying a patients’ primary language upon their arrival, consider using “I Speak” cards. These easy-to-distribute cards enable patients to identify their language in their language. http:// www.lep.gov/ISpeakCards2004.pdf Patients generally remember a limited number of meswww.sfms.org

sages from a medical visit. Thus, written materials in the patient’s preferred language are an important way to improve understanding and reinforce patients’ ability to manage their own care. Patient education materials in multiple languages are readily available and cover a variety of clinical topics and conditions.

RESOURCES: Patient-Education Materials in Multiple Languages

• EthnoMed provides patient-education materials covering twenty-three topics in ten languages. (http://ethnomed. org/patient-education) • Health Information Translations provides educational materials in nineteen languages covering sixteen health topics. https://www.healthinfotranslations.org/ • CPMC Sutter Health provides educational materials in Chinese, Russian, and Spanish on more than thirty topics. http://www.cpmc.org/learning/multilanguage.html • SPIRAL: Selected Patient Information Resources in Asian Languages provides a collection of links to materials in eight different Asian languages covering more than forty topics. http://spiral.tufts.edu/topic_list.shtml • National Network of Libraries of Medicine provides links to patient information in thirteen languages, including American Sign Language. http://nnlm.gov/ • Foundation for Health Communities provides a directory to help find translated health forms and documents. http:// www.healthynh.com/fhc/resources/translateddocuments.php If you chose to create your own multilingual education materials, remember that the accurate translation of patienteducation materials is a complex process. Make sure to consider cultural nuances of words and phrases and to keep the wording simple and concise.

RESOURCE: Translation

For further information about proper translation process and a detailed pan to help your organization improve the quality of your translated materials, access the Hablamos Juntos: More than Words Toolkit at http://www.hablamosjuntos.org/ mtw/default.toolkit.asp.

Health Literacy and Patient Education

health li•ter•a•cy (noun): The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

Health literacy encompasses reading and writing ability, listening and speaking ability, numeracy skills, and critical thinking and decision making, all of which are influenced by culture and language. It has received increased attention over the last decade as it has become clear that poor health literacy impacts health outcomes and quality of care. Poor health literacy affects a wide range of patients, including those who speak English, are elderly, and have formal education, as well as patients who are not English speakers. Because of the high

Continued on page 17 . . .

July/August 2012 San Francisco Medicine

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San Francisco Medicine July/August 2012

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Cultural Literacy Continued from page 15 . . . prevalence of poor health literacy, there is a momentum to ensure that information is communicated in a way that is easy to obtain, process, and understand by all patients across all languages and cultures.

Examples of strategies for overcoming low health literacy include: • Teach-back method: This method is used to help assess whether the information that was communicated was understood by the patient. A key part of this is to begin by asking, “I want to make sure that I did my job well. Can you show me how you’ll take this medicine when you get home?” Or, “Can you tell me what signs you’ll watch for after this procedure?”

• Implement Ask Me 3 to encourage patients to ask and understand the answers for the following questions: What is my main problem? What do I need to do? Why is it important for me to do this?

• Use written materials developed using low-literacy principles and review them with your patients.

• Speak in plain language and avoid using jargon.

RESOURCE: Low Literacy

To learn more about how to review medications and communicate effectively over the phone, and for more details on strategies to overcome low literacy: • Health Literacy Universal Precautions Toolkit, http:// www.ahrq.gov/qual/literacy/ • Health Literacy and Patient Safety: Helping Patients Understand, http://www.ama-assn.org/resources/doc/amafoundation/healthlitclinicians.pdf • Plain Language Thesaurus for Health Communications, http://depts.washington.edu/respcare/public/info/Plain_ Language_Thesaurus_for_Health_Communications.pdf

Enhancing necessary knowledge and skills for providing high-quality care to diverse patient populations is an ongoing process. Using strategies for tailoring patient education to addresses the culture, language, and health literacy needs of your patients is a key step on the path toward delivering equitable, high-quality care for all.

Angela Marks is program manager at Center for the Health Professions, University of California, San Francisco. She manages various initiatives focused on improving organizational capacity to provide culturally competent care, the intersection between quality improvement and health care disparities reduction, and leadership development among health care professionals and leadership teams.

Dr. Sunita Mutha, MD, is professor in the Department of Medicine and is interim director at the Center for the Health Professions at the University of California, San Francisco. She is a practicing internist whose scholarly work focuses on educational and organizational approaches to improving the quality of care for diverse populations. Her recent efforts focused on the intersection between quality improvement and health care disparities. She is the lead author of a nationally distributed curriculum, “Toward Culturally Competent Care: A Toolbox for Teaching Communication Strategies.” www.sfms.org

Key Highlights for Busy Clinicians Tips for Effective Patient Education for Diverse Populations* • Elicit information about your patient’s cultural background, particularly as it relates to health behaviors. Consider this information when providing health information and behavior change recommendations.

• Ask your patient how he or she prefers to receive information (for example, by reading, hearing, or viewing).

• Use qualified interpreters for patients with limited English. Speak in plain language to all patients, including those who speak English.

• Use approaches such as the teach-back method or Ask Me 3 to evaluate and improve patient understanding. Do not just simply ask if he or she understands.

• As a supplement to discussion, use low-literacy, languageappropriate materials that are tailored to your patient’s cultural background to reinforce messages during the visit and to serve as a reminder back at home. * Adapted from the Joint Commission: Advancing Effective Communication, Cultural Competence, and Patient- and FamilyCentered Care: A Roadmap for Hospitals. Oakbrook Terrace, IL: The Joint Commission, 2010. http://www.jointcommission. org/assets/1/6/aroadmapforhospitalsfinalversion727.pdf.

References 1. U.S. Department of Health and Human Services. What is cultural competency? Office of Minority Health (HHS), Available at http:// minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=11.

2. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy people 2010. Washington, DC. Available at http://www.cdc.gov/nchs/ data/hpdata2010/hp2010_final_review.pdf Accessed June 1, 2012.

3. Health literacy: A prescription to end confusion. Institute of Medicine. 2004.

4. Schillinger D et al. Association of health literacy with diabetes outcomes. JAMA. 2002; 288(4):475-482.

5. Wolf M, Gazmararian J, Baker D. Health literacy and functional health status among older adults. Arch Intern Med. 2005;165(17):1946-1952.

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Patient Education

TELL A STORY The Power of Storytelling to Improve American Health Care John Maa, MD

“Listen to your patient, he is telling you the diagnosis.”—William Osler On hearing the words “Once upon a time . . . ” a child instantly recognizes that a story will follow, perhaps

a fable or fairy tale of a courageous hero that will capture the imagination and simultaneously educate, empower, and inspire hope in the young mind. The art of storytelling is practiced and mastered throughout our lifetimes as we share stories that reveal the valuable lessons we have learned from our successes and failures to create a deeper bond with others. Regardless of your profession, your chances of success are greater if you can fully master storytelling to engage your listeners and thereby move them to action. Patients and doctors should harness the power of storytelling to strengthen both the delivery of patient care and health care reform efforts in America.

During a Department of Surgery Grand Rounds at UCSF in 2012, Dr. Neal Baer, the executive producer of the hit television shows ER and Law & Order: Special Victims Unit, shared a story from his days as a third-year medical student in Boston. He was mystified by the chest pains of a healthy 65-year-old runner, until he realized he didn’t know the man’s entire story. After carefully reviewing the patient’s medical records, Baer ordered tests that revealed a severe anemia that had triggered a heart attack. “I’ll never forget that patient, because he taught me to tell stories with depth and detail and to look for twists and turns that can reveal stunning answers,” Baer said.

“The key to caring well for patients is to learn their stories.

I’ve found the best doctors to be excellent storytellers,” Baer said.

“They empathize with patients, they listen carefully, and they have a knack for asking good questions that can reveal the oftenhidden cause of a patient’s problems.” (1) Baer added that the best clinicians also recite their patient’s stories to other members of the health care team in a manner that captures their interest and makes them excited to participate in the care of that patient.

From the patient’s perspective, it’s essential to be able to effectively communicate one’s symptoms and medical history, to share the important clues that will enable your doctor to make the correct diagnosis and recommend the proper treatment plan. Maya Angelou once said, “There is no agony like bearing an untold story inside of you.” Doctors are often critiqued for not listening to their patients, which can be at times understandable, as patients may become tangential during the precious time during clinic visits. For patients with complex or rare conditions in particular, telling your story efficiently in an intriguing manner can improve your care if you can attract the interest of the doctor 18 19

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to research your case afterward or to confer with other specialists to make the elusive diagnosis.

A secret weapon in national efforts to improve patient safety was revealed in an article in the Journal of Patient Safety in 2010.

Lead author and actor Dennis Quaid highlighted the potential of “story power as an untapped vehicle to inform, equip, and challenge leaders to drive change that can save lives, save money, and build value in communities”. (2) He defined “story power” as the ability to change or reinforce the behavior of others by telling a story, as a call to action that harnesses the power of full engagement. Characterizing the battle in patient safety between fear and hope, Quaid highlighted the story of Josie King, an 18-month-old infant who died at one of America’s most famous hospitals because of missed orders to start oral fluids, followed by a medication error. A ten-minute videotape of her mother, Sorrel King, recounting the tragic story has now been used in more than 2,000 hospitals through the Josie King Patient Safety Initiative, which aims to transform the delivery of health care worldwide. (3) Neal Baer has also repeatedly witnessed the difference storytelling can make to transform health care at a national level. A survey of ER viewers found that 53 percent learned about important health issues from the show, and one in seven went to a health care provider after something they’d seen in a story from an episode. (1) This power of storytelling to promote a better understanding of safety concerns is repeated in the near-death experience of newborn twins Zoe Grace and Thomas Boone Quaid (the children of Dennis Quaid), who received 1,000 times the intended dosage of the blood thinner heparin, leading to a two-day battle between life and death. The larger tragedy is that the same medication error occurred eleven months earlier at a different hospital, killing other children, and has also happened since, all due to the look-alike packaging of two different concentrations of heparin. Quaid has been inspired to share this story publicly to become a champion for quality and safety in care, and he recently partnered with Captain Sully Sullenberger to advocate for an independent health care entity modeled after the National Transportation Safety Board to oversee patient safety efforts nationally. Captain Sullenberger’s appropriately titled new book on leadership, Making a Difference: Stories of Vision and Courage from America’s Leaders, harnesses the power of storytelling to enlighten the reader by recounting the inspiring personal tales of leaders across industries. The recurring theme of his book recalls a quote by Harvard psychologist Howard Gardner: “Stories are the single most powerful weapon in a leader’s arsenal.”

The impact of the Supreme Court decision in June upholding the Affordable Care Act has been felt worldwide, and the political

Continued on page 20 . . . www.sfms.org

Patient Education

Chronic disease Education for the Long-Term Patient Descartes Li, MD Patient behaviors play a critical role in many chronic diseases. In order to examine this role, take the

case of bipolar disorder. Appropriate educational interventions in bipolar disorder can be lifesaving and are applicable to many other chronic diseases (e.g., diabetes mellitus, asthma, epilepsy, congestive heart failure, etc.).

The Problem

Individuals with chronic illnesses are frequently not able to participate in formal, evidence-based programs for a variety of logistical, psychological, or financial reasons. They may have conflicting work or family obligations. Or their insurance won’t cover it. Or the educational program simply doesn’t exist in their community. So while it’s ideal to refer to a bipolar program or a psychotherapist who is adept in these psychotherapies, individuals with chronic conditions are often in the situation where they are receiving an ad hoc kind of patient education program from their doctor. Given this common situation, it really helps for the doctor to have some understanding of the evidence-based programs that are already developed.

For many chronic diseases, there are formal programs with a structured curriculum, usually provided by a non-MD educator, sometimes with the assistance of a physician. These formal instructional programs often have strong evidence of efficacy and are published and described in peer-reviewed journals. For bipolar disorder, there are four well-studied, effective, psychosocial treatments: cognitive-behavioral therapy, interpersonal and social rhythms therapy, family-focused therapy, and psychoeducational group psychotherapy (for a review, see Miklowitz 2008). They are all intended as adjuncts to medications for bipolar disorder. Overall, compared with pharmacotherapy alone, and compared with clinical management controls, these adjunctive psychotherapies are associated with a 30 to 40 percent reduction in relapse rates over twelve to thirty months. It seems pretty obvious that the patient who understands and accepts bipolar disorder is more likely to stay on beneficial medications, avoid extreme lifestyles, and realistically prepare for potential relapses. From there, a person with bipolar disorder can stay out of the hospital, stay out of mania or depression, and move forward in fulfilling their life goals.

The Basic Principles

Although there are four different psychosocial treatments for bipolar disorder, they do share a few common elements: treatment adherence, lifestyle regulation, early symptom detection/early intervention, and engaged significant others. These elements also seem applicable to other chronic disorders. www.sfms.org

Treatment Adherence: Am I Ill? First and foremost, patients have to accept that they have an illness. Particularly with chronic illness, accepting the illness is a process. The patient has to understand what the disorder is, how it is diagnosed, and what causes the problem.

Many patients will stop the treatment just to see if they are still ill (Conrad 1985). Part of the problem is that when treatment is working, the patient doesn’t notice anything. Also, the medical consequences often occur long after the patient stopped the treatment. For example, after going off of mood stabilizers, patients with bipolar disorder may not experience a relapse for several months or even years. Therefore, an essential part of treatment adherence is to help the patient see that treatment can impact overall health.

Clinical Pearl: Patients frequently ask questions along the lines of: “Do I still have bipolar disorder? Do I really need to be on medications for the rest of my life?” A doctor might say something like, “I’ve often thought that I myself would need to be hospitalized at least twice to convince me that I needed to be on meds indefinitely. At some point you may be tempted to go off your meds, and when that time comes, I hope you’ll come to me and we can talk about it. That way, if you go off your meds and you start experiencing symptoms, maybe we can prevent anything really bad from happening.”

Lifestyle Changes: Sleep Matters

Patient lifestyle choices often have dramatic effect on the course of chronic illnesses like bipolar disorder or diabetes mellitus. For example, once the patient stops drinking a bottle of wine a night, mood swings (or blood sugars) can stabilize remarkably. Going to bed regularly can have a significant effect on appetite, concentration, and blood pressure. Getting enough sleep was significantly predictive of patients maintaining weight loss (Elder 2011). Patients also need a vision of what it takes to live a healthy life. There are many books and blogs these days about healthy lifestyles that go along with specific disorders. It pays to be familiar with at least a few of these (see below for some resources for bipolar disorder).

Clinical Pearl: Regularize sleep and activities. If nothing else, getting up at the same time every morning can be helpful.

Early Symptom Detection and Early Intervention

There is often a brief window of opportunity in which early intervention may prevent a hospitalization or other negative sequelae. Key principles of this theme include developing plans when the patient feels well rather than during a

Continued on the following page . . .

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Chronic Disease Continued from previous page . . . crisis. Particularly in bipolar disorder, crises are often times when the patient lacks judgment for appropriate planning and thinking. Therefore, patients should identify other “agents of the plan” (relatives, friends, and clinicians). When the patient is relatively well, clinicians can help the patient examine prior illness episodes, paying special attention to early symptoms (moods, thoughts, and behaviors), the role of medication nonadherence, and other stressors related to onset. In bipolar disorder, having a small supply of antipsychotic medication available for as-needed usage can forestall a hospitalization.

Clinical Pearl: Even when the patient is feeling fine, it helps to plan for the future.

Engaging the Significant Others

Significant others are often critical contributors to improving patient behaviors. The opposite is also true. Prescribing a low-sodium diet is much more effective if the person who prepares the meals agrees with the treatment plan. Similarly, a significant other is usually a lot more influential than the physician in getting the patient to go to bed on a regular basis.

Family members can also be a source of clinical information about the patient’s adherence to medications, other lifestyle changes, and comorbidities (e.g., alcohol abuse) that may be influencing patient outcomes.

Clinical Pearl: Invite family members to some visits.

Summary

A formal psychoeducational program has advantages but may not be available for many of our patients. There are basic principles that are useful in the treatment of bipolar disorder, and they are common to many other chronic illnesses. Therefore, basic principles that underlie all patient education are reviewed. These basic principles include emphasis on medication/treatment adherence, lifestyle regularity, early intervention, and engaging social supports.

Basic Principles of Effective Patient Education • Emphasis on medication/treatment adherence • Increased lifestyle regularity • Early symptom detection and early intervention • Increased social supports and decreased conflicts: involve significant others

Resources for Bipolar Disorder

National Organizations and Websites Depression and Bipolar Support Alliance, (800) 8263632, www.dbsalliance.org National Alliance for the Mentally Ill (NAMI), (800) 950NAMI www.nami.org

Books

Miklowitz D. The Bipolar Disorder Survival Guide: What You and Your Family Need to Know. New York: Guilford Press.

2002.

Jamison KR. An Unquiet Mind. New York: Knopf. 1995.

20 San 21 SanFrancisco FranciscoMedicine Medicine July/August July/August2012 2012

Dr. Descartes Li is the director of the UCSF Bipolar Program and co-director of the UCSF Electroconvulsive Therapy Service.

His work involves teaching both UCSF psychiatry residents as well as UCSF medical students. He has been in clinical practice since 1997 and also speaks Mandarin Chinese. He gives numerous talks and presentations in both academic and community settings. His areas of interest include bipolar disorder, electroconvulsive therapy, cultural psychiatry, and suicide. He is a dedicated teacher and public speaker.

References Miklowitz DJ. Adjunctive psychotherapy for bipolar disorder: State of the evidence. Am J Psychiatry. 2008; 165(11):1408-19.

Conrad P. The Meaning of medications: Another look at compliance. Soc Sci Med. 1985; 20(1):29-37.

Elder CR, Gullion CM, Funk KL et al. Impact of sleep, screen time, depression, and stress on weight change in the intensive weight loss phase of the LIFE study. Int J Obesity.

2012; 36(1):86-92.

Tell a Story Continued from page 18 . . . war over health care reform has erupted once again. As the debate moves forward, patients and doctors across America should enlighten the discussion on Capitol Hill with the hopes, failures, and triumphs of their personal stories. A key difference this time around is the story of the amazing recovery of Congresswoman Gabrielle Giffords, which has wrought a positive change in perception in Congress about the heroism and courage of America’s emergency workforce. In Washington, two of the most important forces to move Congress to enact new laws are the power of the law and the power of storytelling, as the gateway to television and media. Scholar Harold Goddard once said, “The destiny of the world is determined less by the battles that are lost and won than by the stories it loves and believes in.” An individual may choose to harness the power of storytelling to become a better doctor, patient, health care advocate, or health policy leader, and the time has clearly arrived to emphasize the principles of fairness, equality, and justice to strengthen health care reform in America.

John Maa, MD, is an assistant professor at UCSF, Division of General Surgery; director of the UCSF Surgical Hospitalist Program; and a member of the University of California Office of the President Tobacco-Related Disease Research Program (TRDRP), Scientific Advisory Committee. He is also a member of the SFMS board of directors.

References 1. Yollin P. UCSF News website. January 24, 2012. Accessible at http://www.ucsf.edu/news/2012/01/11324/physicians-emphasize-importance-story-telling-advance-patient-care.

2. Quaid D, Thao J, Denham CR. Story power: The secret weapon. J Patient Saf. 2010 Mar; 6(1):5-14.

3. The Josie King Foundation. Additional information at http://www.josieking.org/. www.sfms.org

Patient Education

ONLINE PATIENT EDUCATION FamilyDoctor.org Tools Facilitate Communication Angelike Gaunt As health information becomes increasingly accessible on the Web, patients actively go online to seek answers to the maladies that afflict them.

According to a survey by the Pew Research Center’s Internet & American Life Project published in 2011, 80 percent of Internet users look for health information online1—and this can be good news for everyone.

Patients feel more confident when they have more knowledge about their health conditions. For example, a survey by Wolters Kluwer Health showed that 67 percent of survey participants believe that health websites have made them betterinformed patients.2 Online health information and tools can also become strong allies to physicians and other health care professionals encouraging patients to be more engaged in the management of their health. The same survey by Wolters Kluwer Health indicated that 48 percent of the respondents go online to look for health information before going to a doctor’s appointment.2 A patient who comes to his or her doctor’s office prepared with questions may help make the time spent with the doctor more efficient.

Facilitating communication between physicians and patients is one of the goals of FamilyDoctor.org, the American Academy of Family Physician’s patient education website.

For example, the “Questions to Ask Your Doctor” section on FamilyDoctor.org provides users with a list of specific questions to ask about a certain condition or disease during their next doctor’s visit.

Robert Kelly, MD, a practicing family physician in Fairview, Ohio, and medical editor of FamilyDoctor.org, agrees that greater access to information online fosters better communication between patients and physicians and increases patient engagement. According to Kelly, physicians can help their patients by becoming familiar with high-quality resources on the Web. “This will allow the physician to direct patients to these sites to complement, and potentially refute, information they may have gotten from less reliable sources.”

In addition to reliable, unbiased information, physicians should consider their patients’ health literacy level when referring them to a resource online. According to the U.S. Department of Health and Human Services, limited health literacy skills are associated with poor health outcomes, and approximately nine out of ten American adults lack the skills to effectively manage their health and prevent diseases.3 In order to help translate complex information into easyto-understand language for patients, all of the content on FamilyDoctor.org is available in English and Spanish and is written at a sixth- to eighth-grade reading level. Information on the site is also available in audio format through a textwww.sfms.org

to-audio tool, which allows visually impaired users and those with poor health literacy skills to listen to the information in English and in Spanish.

According to the 2011 Pew survey data, information about symptoms and treatment of specific conditions continues to be a popular topic of interest among Web users looking for health content.1 In fact, a FamilyDoctor.org tool that allows users to search for health information by symptom is one of the most accessed pieces of content on the site, with about 600,000 visits each month. Site visitors also have the option of searching for information by age, in a list of conditions that are more likely in certain age ranges, or by the name of the ailment.

The newest addition to FamilyDoctor.org is a more comprehensive section of content for caregivers. According to the Family Caregiver Alliance, more than 43 million Americans currently provide care for someone age 50 or older.4 And as a greater proportion of the American population continues to age, the number of adults assuming the role of caregiver for an older relative is also likely to increase. The Institute of Medicine estimates that adults aged 65 years and older will comprise 20 percent of the U.S. population by 2030, from 12 percent in 2005.5 The new caregiver content on FamilyDoctor.org addresses topics such as caregiver stress and how to balance caregiving and work, as well as how to find appropriate housing options for seniors and how to care for older adults who have dementia. Information to help older adults and caregivers better manage their health care is also available, including a section about how to manage medications and how to deal with end-of-life issues.

Overall, physicians who engage in proactive conversations with their patients about trustworthy resources online have a good chance to continue to inform and educate their patients even when they are not in the office for their annual visits. Reliable health websites, like FamilyDoctor.org, can encourage patients to become more engaged in their health and help physicians support a true partnership with patients in the management of their health.

Angelike Gaunt is manager of content optimization at the American Academy of Family Physicians (AAFP), a nonprofit national medical association with more than 105,000 members.

Gaunt oversees the content strategy for all of the AAFP websites.

She is also managing editor of the AAFP award-winning patient education website FamilyDoctor.org. A full list of references is available online at www.sfms.org.

July/August 2012 San Francisco Medicine

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LIFE INSURANCE

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San Francisco Medicine July/August 2012

www.sfms.org

Patient Education

Wellness EDUCATION at sfgh Underserved Patients Find Resources at the Wellness Club Blue Walcer, MPH Luis Lopez came to the U.S. from El Salvador in 1980.

An electrician since the age of sixteen, Luis is also a skilled carpenter and plumber. In his youth, Luis enjoyed swimming, lifting weights, and practicing gymnastics.

Luis first came to San Francisco General Hospital twenty years ago when he was experiencing dizziness. He was later diagnosed with diabetes. In July 2011, he woke up with weakness and difficulty speaking, and he was unable to use his right arm and leg. At the time, he wasn’t aware that these were symptoms of a stroke. After a couple of days, he spoke with a nurse at SFGH, was ultimately admitted to the hospital, and was later transferred to Laguna Honda Hospital for rehabilitation.

In January, Luis spotted a flyer advertising the hospital’s Community Wellness Program. Since then, Luis has participated in a number of wellness classes, including Chair Stretch and Boogie, Bollywood, and the Walk It Out patient walking group.

He came to the Community Wellness Center because “there are so many people there who want to improve their health. They motivate me!” Luis’s participation in wellness classes has helped improve his mobility, flexibility, and strength. But the benefits he receives from the Community Wellness Program go well beyond the physical realm. As a social being with a sparkling personality, Luis appreciates the opportunities the wellness center provides him to share stories and tell jokes with wellness participants and staff. For Luis, engaging with others is as important to health and well-being as physical exercise. “The people here are so kind and friendly . . . that makes me feel trust and confidence in the environment. I feel like I’m in a special club! ” As Luis’s story illustrates, participating in a thoughtfully developed wellness program promotes a remarkably holistic vision of health. SFGH’s Community Wellness Program works to ensure that the benefits Luis receives from his participation in wellness activities are more readily available to medically underserved patients throughout the health care system. At SFGH, patient education groups with a wellness focus seek to improve the quality of life for medically underserved patients, their families, and their caregivers. The program’s research, much of it qualitative, has revealed that participating in these groups and classes can generate feelings of empowerment, energy, and support. Many of our medically underserved patients are socially, economically, or educationally disadvantaged and face cultural or linguistic barriers to care. These patients often have lower levels of health literacy and less access to other sources of information and support. As Luis’s story demonstrates, wellness-focused groups provide valuable support and companionship that serve to reinforce explicit self-care messages and to relieve some of the social isolation that many medically underserved patients experience.

Intensive outreach and incentivizing efforts have allowed www.sfms.org

SFGH’s ongoing chronic- and acute-disease management groups to enroll an increasing number of diverse, disadvantaged patients with diagnoses including cancer, HIV/AIDS, and diabetes.

The programs provide a substantial experience for medically underserved patients by empowering them through self-care education delivered in an atmosphere that incorporates meaningful social support.

SFGH’s Community Wellness Program is part of San Francisco’s public health care network, which provides care for uninsured and indigent patients. Although many education and support resources for patients with chronic and/or acute diseases exist in the Bay Area, many of our patients find these resources difficult to use due to cost, need for transportation, and lack of language and/or cultural accessibility. SFGH’s Community Wellness Program was initiated in 2011 to meet the wellness needs of patients and staff by providing holistic, culturally and linguistically appropriate wellness support at no cost.

In addition to offering a host of movement and nutrition classes, the Community Wellness Program provides patients with wellness support through disease-specific education groups. The programs’ cancer-focused wellness group (CARE), for example, includes sessions on on cancer-related and wellness topics, such as “What’s New in Cancer Treatment,” “Symptom Management,” “Eating Well, Healing Well,” and “Healing Moves.”

Sessions are led by guest speakers from the health professions (medicine, psychology, complementary and alternative medicine, palliative care, and nutrition) or by educators from other fields (dance and theater, massage and body work, social work, and bereavement).

Groups are facilitated by a professional health educator. The facilitator begins each session with a group-member check-in. At this time participants typically report personal news from the week or talk about their health. The guest speaker then presents his or her material. Each session ends with a check-out exercise during which participants focus on what they will take away from the day’s session, and they complete a brief evaluation.

All sessions are cofacilitated by local university students in the health professions (medicine, nursing, or public health). Cofacilitators are trained prior to each CARE series and their work during the series is closely monitored and supervised. Cofacilitators take qualitative field notes, assist with participants’ transportation needs, and provide other logistical support.

Prior to the start of each CARE session, cofacilitators are trained in how to take qualitative field notes. They use a structured form to ensure that comparable data is recorded for all sessions. The form includes close-ended fields to record the number and gender of participants, the session topic and guest

Continued on the following page . . .

July/August 2012 San Francisco Medicine

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Wellness Education at SFGH Continued from page 23 . . . speaker, and the session learning objectives. The form includes open-ended fields with the following prompts and questions: • What types of questions are participants asking?

• Comments other than questions—how else are people engaged? What are people talking about? Are they interacting with each other, with the speaker?

• What did we learn today? (Be specific.)

• Checkout: Were the objectives for the session accomplished? Was this session helpful?

• Additional comments/problems/issues/suggestions that arose today.

• Personal reflection: How did this session or the program overall affect you (the cofacilitator) in terms of your personal and/or professional development?

In addition to providing us with rich and textured qualitative data, the field notes also promote a service learning model in which health-profession students are encouraged to reflect upon the ways in which a specific group session or the program overall has affected them both personally and professionally.

In this way, we contribute to health-profession education that promotes compassion, sensitivity, and self-awareness.

Patient-centered education with a wellness focus serves as a model for health promotion and disease prevention in public hospital settings and beyond. This approach to peer education, integrated with wellness support, represents the future of health care. As we build robust partnerships with primary care providers and patients, our holistic approach will serve to improve health outcomes.

SFGH’s Community Wellness Center has developed a program that recognizes and responds to some of the challenges many of our patients face. Among hospital-based wellness programs nationally, the Community Wellness Program stands out because it serves hospital staff as well as SFGH’s low-income and indigent patients. The Com24 25

San Francisco Medicine July/August 2012

munity Wellness Center supports an array of patients and staff that are extremely diverse in terms of language, race and ethnicity, gender, and health status. Program staff conscientiously model kindness and compassion in interactions with everyone who walks through the door. The quality and style of interactions that occur in the hospital’s Community Wellness Center remain as significant as the content of the wellness education the program provides. The Community Wellness Program’s staff and participants want everyone we serve to feel that they’re respected and appreciated—as if they belong to a special wellness club.

Blue Walcer, MPH, wellness innovator at SFGH Community Wellness Center and founder and director of the CARE program, works to give patients a greater role in their health care and health care decisions. Her background includes work with adolescents, immigrants, injured workers, and victims of domestic violence.

www.sfms.org

Patient Education

Are patients Afraid to ask?

New Local Research on the Fear of Being “Difficult” Steve Heilig, MPH In 1980, an article titled “Arrogance” by eminent gastroenterologist Franz Ingelfinger, MD, appeared in the

New England Journal of Medicine. Ingelfinger, then editor of the journal, recounted his struggles making treatment decisions for his own cancer until he turned the choices over to his physicians.

He concluded that “authoritarianism, paternalism, and dominance” were often an unavoidable part of the good physician’s role. His piece, published posthumously, elicited much comment, and thirty years later it remains a classic article, with the uncommon—and unpopular—stance of defending paternalism.

In June of this year, a New York Times article titled “The Trouble with Doctor Knows Best” by columnist Pauline Chen, MD, reported on new surveys of San Francisco Bay Area patients about the increasingly popular concept of patient-centered medical decision making, in teamwork with physicians. Chen reported, “The findings fly in the face of previous optimistic assumptions about shared decision making that were based mostly on studies that examined physicians’ intent, but not patient perceptions.”

The lead researcher for these papers is Dominick Frosch, PhD, of the Palo Alto Medical Clinic. Here, in excerpts from an interview, he summarizes his team’s work to date as food for thought for anyone interested.

“We did this study as the role of patients is changing, with more discussion than ever about patient involvement in clinical decisions, especially with what we call preference-sensitive care—those areas where there are multiple options but the evidence fails to identify a clear superior choice. So there’s been a lot of focus on developing decision support for patients—informational websites, seminars, booklets and such, for example for options in early breast cancer. A lot of this presumes that providing information is sufficient, but we actually know quite little about how patients perceive and communicate about this information with their physicians. So we were trying to get an in-depth understanding of how patients perceive communicating with their physicians about medical decisions. We built on the initial focus groups to do a quantitative survey, with 1,340 participants. The results of that are forthcoming in the Archives of Internal Medicine and largely confirm what we found in the qualitative study.

“The results showed that patients very much want to collaborate with their physicians, but that their ability to do so depended upon their physician’s attitude and demeanor, and patients often have a sense of needing to adopt a role of a ‘good’ patient. They also felt that if they were to question the advice or recommendation of a physician, that implied they were questioning their expertise and challenging their authority, which they worried could foster resentment and possibly lead to receiving lower-quality care in the future. They worried if they were assertive or questioning they might be labeled as ‘difficult.’ So they adopted deferential positions and avoided asking too many queswww.sfms.org

tions or disagreeing with recommendations. Many also reported they felt disrespected or unheard, and that their physicians acted in an authoritarian rather than authoritative manner, rather than offering their expertise and inviting the patient the chance to participate in making choices.

“We now live in a reality where patients have ready access to medical information and are going to inform themselves and expect their health care providers to engage with that. The Internet is not going away. This is a challenge for both sides. It’s certainly frustrating when patients bring in a lot of information that has no scientific credibility and demand things that don’t make sense; on the other hand, more informed patients may do other things that are much better for themselves. It cuts both ways.

“There’s little evidence that engaging patients in the decision process really requires much more time. But it is clear that we need some payment reform—we should be adequately reimbursing for counseling time. The priorities of policy makers and payers need to reflect not just rhetorically that patient-centered care is important, but through real measures that have an impact.

More efficient ways of communication with patients can help too.

“When I’ve talked about these issues with colleagues, invariably I hear personal stories of similar experiences. The response to the New York Times story on this study quickly produced over 600 public comments, the vast majority of which seem to validate our findings.

“Ultimately it is in health care providers’ interest to change things, as I do believe we’ve got plenty of evidence to suggest that outcomes of care will be better if we have true partnerships— especially in chronic disease management, which we know is a very large burden of the health care problem we face in the United States. I’m trained as a psychologist and know that behavior change is very hard. Most physicians know this too, but many persist in using ineffective approaches to try to change patients’ behavior, by admonishing, ordering, telling them what to do. It doesn’t often work that way—you have to help people convince themselves that they want to do something.”

Again, food for thought—but please don’t kill the messenger(s).

Steve Heilig, MPH, is assistant executive director for public health and education at the SFMS.

References Frosch DL, May SG, Rendle KA, Tietbohl C, Elwyn G. Authoritarian physicians and patients’ fear of being labeled ‘difficult’ among key obstacles to shared decision making. Health Aff. 2012.

31(5):1030-8.

Pauline Chen, MD. Afraid to speak up at the doctor’s office. well.blogs.nytimes.com. May 31, 2012.

July/August 2012 San Francisco Medicine

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The Black Plague was a major pestilence in the 14th century.

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Communication Failures more then 50,000 patients each year in the 21st century. *

eVigils.com eVigils™ is a private, closed-loop, and secure “collaborative texting” service which improves on standard texting, e-mail, and paging to prevent common communications errors.

eVigils™ means never again wasting time trying to reach and hear from team members, never again wading through e-mails looking for what you need.

eVigils™ is compliant with HIPAA and the Joint Commission ruling on texting. * Institute of Medicine. “To err is human: building a safer health system.” Washington, DC: National Academy Press; 2000

© MITEM Corporation, 2012

Artwork copyright © 2012 Dan Harding

Patient Education

physician as role model Research Shows Healthy Physicians Make Better Role Models Carolyne Krupa Whether doctors avoid smoking, eat right, exercise, or maintain a proper weight can influence how

they talk with patients about making lifestyle choices.

A physician’s health influences how comfortable he or she is offering healthy advice to patients—and that could motivate patients to adopt positive lifestyle changes, according to new research.

“Practicing what we preach is important,” said Jo Marie Reilly, MD, a family physician and associate professor at the Keck School of Medicine at the University of Southern California. “Physicians are just more aware and better able to counsel patients if they take care of themselves.”

A survey of 1,000 primary care physicians found that those who exercised at least once a week or didn’t smoke were about twice as likely to recommend five lifestyle changes to patients with hypertension. Those changes: eat a healthy diet, reduce salt intake, attain or maintain a healthy weight, limit alcohol use, and exercise regularly.

The survey, presented March 14 at an American Heart Association meeting, found that 4 percent of the doctors smoked at least once a week, 27 percent exercised at least five days a week, and 39 percent ate the recommended five servings of fruits and vegetables a week.

Doctors who lead healthy lifestyles demonstrate that they believe in the importance of preventive health, said Ralph Sacco, MD, AHA immediate past president and chairman of neurology at the University of Miami Miller School of Medicine. A quarter of doctors exercise at least five days a week.

“Physicians who are healthier themselves are more apt to counsel patients about healthy lifestyle and diet,” Miller said. “They are more educated, more personally invested in personal health, and therefore are better health advocates for their patients.”

The research follows a study in the January 19 issue of Obesity that looked at how a physician’s body mass index influences whether doctors talk with overweight patients about losing weight. In the survey of 498 physicians, researchers found that 30 percent of doctors with a healthy BMI spoke with patients about losing weight, compared with 18 percent of overweight or obese physicians.

A study in the fall 2010 issue of Preventive Cardiology showed that doctors who exercised regularly and maintained a healthy weight were most comfortable talking with patients about making healthy lifestyle choices.

Helping to Fight Obesity

More than one-third of U.S. adults and about 17 percent of children and adolescents are obese, defined as having a www.sfms.org

body mass index of 30 or higher, says the Centers for Disease Control and Prevention. Those high obesity rates contribute to more cases of chronic conditions such as diabetes, heart disease, and hypertension.

Physicians will play an increasingly key role in combating chronic conditions as the health care system focuses more on prevention in coming years, said Department of Health and Human Services Secretary Kathleen Sebelius. She made the remark in a March 9 speech at the American Medical Student Association’s annual convention in Houston.

“There is a growing body of evidence that people’s behaviors outside the health care system—what we eat, how much we exercise, whether we smoke or not—affect our health just as much, if not more, than the treatments and medicines we get when we visit a doctor,” Sebelius said.

Even if physicians aren’t physically fit themselves, they can help patients by talking about their personal struggles with weight or other health issues, said Dr. Reilly, who has written about how physician health influences patients.

Doctors can encourage others in their office to adopt healthy behaviors and avoid negative influences, such as having snack machines full of junk food in the break room. Most important, physicians need to make sure they take time to talk with patients about making healthy choices, she said.

“It’s really important that we take that time at each visit to counsel patients about how their health habits influence their lives, and that we look at that as important as any medication,” Dr. Reilly said.

Reprinted with permission from http://www.ama-assn.org.

NEW CME at UCSF Cannabis in Medicine: A Primer for Health Care Professionals October 24, 2012 • UCSF Laurel Heights Auditorium Chaired by Donald Abrams, MD, the session will include a brief overview on cannabinoids, the types of cannabinoids currently available, and the endocannabinoid system. This will be followed by a clinically focused section on the pulmonary effects of smoked cannabis and on different conditions for which cannabinoids are therapeutically relevant. The session will close with an open-forum discussion. The objective is to present a balanced and expert overview of the clinical use of cannabinoids to an engaged audience of health care practitioners in a mainstream hospital-clinical setting. https://www.cme.ucsf. edu/cme/CourseDetail.aspx?coursenumber=MMJ13001A July/August 2012 San Francisco Medicine

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HOSPITAL NEWS KAISER

Veteran’s

CPMC

Robert Mithun, MD

Diana Nicoll, MD, PhD, MPA

Michael Rokeach, MD

Our focus at Kaiser Permanente is on the total health of our patients. One of the best strategies to keeping people well and out of clinics and hospitals is giving them tools to stay healthy in the first place. Central to this strategy is Kaiser Permanente’s ability, through technology, to empower patients with educational information that helps to ensure maximum health.

To that end, our health education programs cover all aspects of well being—physical, intellectual, and emotional. We strive to keep patient education in the medical care setting up to date with the latest information and to make it accessible online to all our patients. Patients who access health education materials to manage chronic and other types of conditions have the choice of online as well as in-person options.

Kaiser Permanente offers online health education programs, newsletters, and patient education tools for children, adults, and seniors.

Online tools allow patients to take a proactive role in managing their health and to become a partner with their health care provider. Kaiser Permanente patients have the ability to access screening information, immunizations, and test results online without having to wait for their providers to notify them when they are due for certain tests and when the results are available.

Physician homepages at the Kaiser Permanente website kp.org/mydoctor (My Doctor Online) offer an array of online tools and health calculators for patients to track their weight, body mass index, and calories. Patients can search the online health encyclopedia to research the latest information on chronic conditions and use the interactive programs, videos, and podcasts, which include information on back care, diabetes, nutrition, stress management, fall prevention, urinary incontinence, exercise, and other topics of interest.

Kaiser Permanente continually uses new technology, such as mobile phone apps and personal, interactive programs, to help patients stay healthy at home, at work, and en route. Patient education programs are current and evidencebased, enabling patients to receive health information in a format that best suits their needs.

For the second year in a row, our military has lost more troops to suicide than to combat. Clearly a better understanding of combat-related risk factors for suicide is critical.

San Francisco VA Medical Center researchers recently conducted a study, the first of its kind, to examine the association of killing in war and suicidal thoughts among war veterans. Coauthors are Shira Maguen, PhD; Thomas Metzler, MA; Jeane Bosch, MPH; Charles Marmar, MD; Sara Knight, PhD; and Thomas Neylan, MD. The study was published electronically in the Journal of Depression and Anxiety in April.

The authors used a cross-sectional, retrospective, nationally representative sample of Vietnam veterans from the National Vietnam Veterans Readjustment Study. They found that, compared with people having no history of military service, veterans are at an increased risk for suicide.

The study also showed a correlation between experiences of killing during combat and future risk of suicide. Veterans who had many killing experiences had twice the odds of suicidal thoughts compared to those with few or no killing experiences, even after adjusting for demographic variables, posttraumatic stress (PTSD), depression, substance use disorders, and combat exposure. PTSD, depression, and substance use disorders were each associated with higher odds of suicidal thoughts. Actual suicide attempts were most strongly associated with PTSD. “The VA has a lot of very good mental health programs, including suicide prevention,” said lead author Maguen. “Our goal is to make those programs even stronger. We want clinicians and suicide prevention coordinators to be aware that, in analyzing a veteran’s risk of suicide, this is an additional factor that they may or may not be aware of.”

Since killing experiences have not been included in past routine suicide risk assessments, this indicates the current need for their inclusion in suicide risk assessments of war veterans.

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San Francisco Medicine July/August 2012

On Tuesday, May 1, the San Francisco Municipal Transportation Agency’s Board of Directors voted unanimously to recommend approval of CPMC’s Development Agreement with the City. The agreement includes $20M in new funding for transit construction and operations. The SFMTA board also recommended approval of all our proposed street improvements around the St. Luke’s Van Ness and Geary campuses and passed all of these issues on to the Board of Supervisors for final review and consideration. In the coming months, we will present our project to the Board of Supervisors for a final approval, which will then allow us to begin construction.

Congratulations to Craig Vercruysse, who has been named chief operations officer at CPMC. Craig has a long history of service with CPMC and Sutter Health, beginning in 2001 when he joined CPMC as a leader on the IT team. Since then he has held positions of increasing responsibility, including serving as the chief information officer of CPMC and the West Bay. As chief process officer and deployment leader of QDS, he has helped use leading-edge management practices to make quality, safety, and efficiency improvements necessary for our continued organizational success.

CPMC is pleased to announce the completion of its annual community benefit audit. CPMC provides more charity care than any other private hospital in San Francisco and, working with community partners, provides both programs and financial support to increase needy San Francisco residents’ access to high-quality, affordable health care.

In 2011, CPMC’s total community benefit expense was $151 million, which included $19 million for traditional charity care (a $4 million increase from 2010); $72 million for the unpaid costs of Medi-Cal; and $52 million in benefits for the broader community, which includes education and research, cash and inkind donations, and non-billed services. www.sfms.org

Letter to the CMA Saint Francis Patricia Galamba, MD

Saint Francis Memorial Hospital, along with community partners Self Help for the Elderly and Curry Senior Center, is hosting Healthier Living Workshops to teach chronic disease self-management. Chronic diseases are the leading cost of health care today. So it is vital to find ways to assist patients with these diseases in staying healthy and out of the hospital.

These peer-led, 2.5-hour classes are taught in a six-week series. Class participants are recruits from among hospital patients and visitors, physician practices, volunteer programs, and the general community. The chronic diseases that are most commonly seen are arthritis, diabetes, hypertension, pulmonary problems, chronic pain, and weight issues. After class completion, the program follows participants monthly for six months to monitor their hospitalizations rates. The classes are held at Saint Francis and at Self Help for the Elderly and Curry Senior Center sites. Self Help for the Elderly has significant interest in healthy living activities and programs. Curry Senior Center regularly hosts health education programs that provide important socialization and community building for seniors living in the Tenderloin. The certified trainers at the three sites support each other’s programs and help with language needs of the patients. We have several trainers certified to teach in Chinese. This licensed program is modeled after the very successful five-year study that was completed by Kate Lorig, RN, Dr.PH at Stanford University School of Medicine in 1996. Her work continues at the Stanford Patient Education Research Center. Our program participants have overwhelmingly enjoyed the weekly sessions and are appreciative of the camaraderie of the group. Saint Francis Memorial Hospital has provided grant funding to both the Curry Senior Center and Self Help for the Elderly to support their efforts.

Lorig KR, Sobel DS, Stewart AL, Brown Jr BW, González VM, Laurent DD, Holman HR. Evidence suggesting that chronic disease self-management program can improve health status while reducing utilization and costs: A randomized trial. Medical Care. 1999; 37(1):5-14. www.sfms.org

May 30, 2012 To: Dr. James Hay, President of the California Medical Association Dr. David Aizuss, Vice-Chair, Board of Trustees

I am writing as a member of the California Medical Association (CMA) to request that you ask Dr. Marcy Zwelling to discontinue reference to her previous affiliation with the Los Angeles County Medical Association (LACMA) in advertisements against Proposition 29.

While I agree that Dr. Zwelling is entitled to her opinion, I believe that when she is speaking publicly or adding her signature to materials in the California Voter Information Pamphlet, the ethical action is for her to clarify to the general public that she is speaking as an individual, not on behalf of either the CMA or LACMA. This is particularly relevant as the opinion she is expressing is in opposition to an official position reached unanimously by the CMA Board of Trustees. I am concerned that Dr. Zwelling is generating confusion with California’s voters and has created the appearance of being misleading.

I would also like to suggest that a change to CMA membership bylaws be introduced to require an individual to request authorization to list their CMA affiliation in their credentials if they take a position in opposition to an official CMA endorsement, and thereby make our organization aware of the disagreement in advance of a public disclosure. Thank you for your leadership and responsiveness to the concerns of CMA members across the State, and for your unanimous endorsement of Proposition 29.

Sincerely, John Maa, MD Board of Directors, San Francisco Medical Society CC: Dr. James Madera, CEO of the American Medical Association

Tracy Zweig Associates INC.

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July/August 2012 San Francisco Medicine

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IN MEMORIAM Jean Haddad, MD Dr. Haddad passed away unexpectedly in Morocco on June 4.

Dr. Haddad, 80, was on holiday with his wife Sandy.

Dr. Haddad served Saint Francis Memorial Hospital for over four decades before retiring and shepherding his son Tom Haddad into his gastroenterology practice. A Cornell undergraduate, Dr. Haddad graduated from George Washington University School of Medicine in 1959. He then completed an internship at Walter Reed General Hospital, residency at Letterman General Hospital, and a gastroenterology fellowship at Veterans Hospital in San Francisco.

He was board certified in internal medicine and gastroenterology.

Dr. Haddad was a longtime member and past-president of the San Francisco Medical Society and also served two terms as chief of staff at Saint Francis.

Dr. Haddad led a very active professional life, but he always found time to enjoy with family and friends. Many of his weekends were spent at his Sonoma retreat and vineyard, where he dabbled in wine making and enjoyed the company of his family. In the last few years, Dr. Haddad particularly enjoyed working as a docent at the Academy of Sciences in the Golden Gate Park. He also loved photography, practiced Pilates, and enjoyed playing golf. In his retirement he traveled extensively, enjoying trips to Russia, Mexico, the Galapagos Islands, Sweden, Norway, France, Italy, Germany, and Guadalupe.

Matt Dickstein

Business Attorney Representing Medical Practices Since 1994 * Medical Corporations * Stark & Kickback / Regulatory Compliance * Employment & Contractor Agreements * Breakaway Physician Competition * Buying & Selling a Practice * Hospital – Group Contracts * Leases for Medical Offices * Multi-Discipline Practices Idea of the Month: Speak when you are angry and you will make the best speech you will ever regret.

– Ambrose Bierce 39488 Stevenson Pl. #100 Fremont, CA 94539 510-796-9144 mattdickstein@hotmail.com mattdickstein.com 30

San Francisco Medicine July/August 2012

California Pre-Existing Condition Insurance Plan (PCIP) Do you have uninsured patients?

It is a well-known fact that California has one of the highest rates of uninsured residents in the country. This is an ongoing challenge for providers. We need to educate the public about PCIP and to enroll eligible people into the program, thus decreasing the number of uninsured Californians. This is where you can help, by passing along information on PCIP to your patients who can benefit from the program.

For patients who cannot obtain insurance due to preexisting conditions, California’s Pre-Existing Condition Insurance Plan (PCIP), part of the Affordable Care Act, might be the answer to improving their health status. Individuals who have been denied coverage because of preexisting health conditions and have been uninsured for at least six (6) months are potentially eligible for PCIP.

Benefits

The program benefits include inpatient and outpatient services, doctor visits, pharmacy benefits, behavioral health, preventive care, physical therapy, case and disease management, laboratory and imaging services, physical therapy, and more.

Costs

By law, premiums for PCIP can be no more than 100 percent of those charged to persons without preexisting conditions on the individual insurance market. Since PCIP does not rate up for any factors beyond age and area of residence, premiums may be lower than those on the open market. In other words, PCIP is a good buy for your patients.

Eligibility

Other eligibility requirements include that subscribers be U.S. citizens, nationals, or lawfully present California residents who can prove their preexisting conditions. Proof can be verified through a denial letter from an insurance carrier, health plan, or a letter from a licensed provider confirming the preexisting condition. This is something specific that you or a licensed provider on your staff can do to assist your patients in their PCIP enrollment.

Enrollment into PCIP is a straightforward process involving a four-page application. Application and customer service is provided through a call center at (877) 428-5060 and at www.pcip. ca.gov. Assistance is also available from insurance agents/brokers and certified application assistants.

Marketing Materials

If you would like to display PCIP materials (available in both English and Spanish) or have additional questions, contact PCIP’s outreach coordinator at (916) 673-4692 or at mooreawarrenharms@maximus.com. www.sfms.org

A former employee sued me for wrongful termination.

What do I do now?

You are not alone. Employment-related lawsuits are more common. What many physicians don’t realize is that help is literally a phone call away. SFMS members have access to a unique blend of risk management services and insurance specifically designed to assist physician groups in addressing these important employment issues. Among the features of the sponsored Employment Practices Liability program are: • A Helpline staffed by experienced employment defense attorneys. Any manager, officer or principal of

your practice has access to the Helpline for obtaining advice on handling workplace issues, including internal sexual harassment complaints, discipline and employee terminations.

• If a member seeks Helpline advice on an employee termination which later results in a claim, there is

a 50% reduction of the member’s EPLI deductible for that claim.

• Free, comprehensive criminal background checks for newly hired and promoted managers/supervisors.

• EEO compliance training for managers/supervisors. An internet-based training program, compliant with

California law, provides supervisors with sexual harassment training.

• A low, minimum premium of $2,500 annually.

• Wage and Hour Defense Coverage.

For more information on these important benefits, and the special SFMS First-Time Buyers program, please contact Marsh at 800-842-3761 or email us at CMACounty.Insurance@marsh.com.

Sponsored by:

59808 (6/12) ©Seabury & Smith, Inc. 2012 • 777 S. Figueroa St., Los Angeles, CA 90017 • www.CountyCMAMemberInsurance.com • CMACounty.Insurance@marsh.com

d/b/a in CA Seabury & Smith Insurance Program Management • CA Ins. Lic. #SL0633005 • AR Ins. Lic. #245544 • 800-842-3761

We Celebrate Excellence – Corey S. Maas, MD, FACS CAP Member and founder of “Books for Botox®” community outreach program, benefitting the libraries of local underfunded public schools

800-252-7706 www.CAPphysicians.com San Diego orange LoS angeLeS PaLo aLTo SacramenTo

For over 30 years, the Cooperative of American Physicians, Inc. (CAP) has provided California’s finest physicians, like San Francisco facial plastic surgeon Corey Maas, MD, with superior medical professional liability protection through its Mutual Protection Trust (MPT).

Physician owned and physician governed, CAP rewards excellence with remarkably low rates on medical professional liability coverage – up to 40 percent less than our competitors.

CAP members also enjoy a number of other valuable benefits, including comprehensive risk management programs, best-in-class legal defense, and a 24-hour CAP Cares physician hotline. And MPT is the nation’s only physician-owned medical professional liability provider rated A+ (Superior) by A.M. Best.

We invite you to join the more than 11,000 preferred California physicians already enjoying the benefits of CAP membership.

Superior Physicians. Superior Protection.