November 2018

SAN FRANCISCO MARIN 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 A R I N M E D I CA L S O C I E T Y

PEDIATRICS

AND ADOLESCENT MEDICINE: IN CLINIC, COMMUNITY, CLASSROOM, S AND BEYOND FMM ct !

S f o e l MD, dent-E , n i a Bret A Pres r e t M Pe ed C t Elec

Volume 91, Number 8 | November 2018

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SAN FRANCISCO MARIN MEDICINE

IN THIS ISSUE

November 2018 Volume 91, Number 8

PEDIATRICS AND ADOLESCENT MEDICINE FEATURE ARTICLES

MONTHLY COLUMNS

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Membership Matters

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President’s Message: 2018 Legislative Review—with an Eye to 2019 John Maa, MD

SNAD: Fixing San Francisco’s Missing Special Needs Anesthesia Dentistry Ben Meisel, MD

10 Prescribing Nature

Tracey Hessel, MD

12 The Un-Well Child Check

Mark Ghaly, MD, MPH

14 The Migrant Children Crisis Is Not Over

Heyman Oo, MD, MPH

16 Pediatric Priorities: The American Academy of Pediatrics Agenda for Health

John I. Takayama, MD

21 Creating a Healthy Relationship with Technology

Shannon Udovic-Constant, MD 23 Stepping Out of the Walls of the Clinic: Integrating Health and Education

Ryan Padrez, MD 26 School of Hard Knocks: Concussion Care in Marin County

Jeanne-Marie Sinnott, DO

30 Improving Public Health Equity for Children and Famililes

Curtis Chan, MD, MPH, Anda Kuo, MD, and

Tomás J. Aragón, MD, DrPH

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Anniversary

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Guest Editorial: Advocating for Children Kimberly Newell Green, MD

32 Community News: Kaiser Permanente

Maria Ansari, MD 32 Upcoming Events 32 Advertiser Index

OF INTEREST 4 SFMMS’ Peter Bretan, Jr., MD, Elected CMA President-Elect

PEDIATRIC SPOTLIGHTS: 18 Pediatrics and Drug/Device Development

Emin Maltepe, MD, PhD 24 The Latest Challenges and Rewards

Tracey DeAmicis McMahan, MD

SAN FRANCISCO

MARIN MEDICAL SOCIETY

Editorial and Advertising Offices: San Francisco Marin Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133 Phone: (415) 561-0850 Web: www.sfmms.org

MEMBERSHIP MATTERS CELEBRATING 150 YEARS OF SFMMS HISTORY—FIGHTING FOR PUBLIC HEALTH AS AN ADVOCATE OF PUBLIC HEALTH, SFMMS

was a loud voice for cracking down on tobacco promotion and use, and supported the early 1990s ban on smoking in restaurants and other businesses. SFMMS also advocated for stronger protections from secondhand smoke, higher taxes on tobacco products to provide additional funding to Medi-Cal, and the removal of tobacco products from pharmacies. SFMMS supported a recent ban on flavored tobacco products and will continue to stand up against big tobacco.

SFMMS has long been on record combatting overconsumption and marketing of sugar and soda, especially to young people, and supported the landmark local tax on sugar-sweetened beverages that recently passed in San Francisco. The medical society has

supported efforts to improve vaccination rates in children and adolescents. Other public health initiatives for which SFMMS has contributed to national policy and published resources include domestic violence guidelines, antibiotic resistance, and gun safety, particularly focused on ending censorship and allowing physicians to discuss gun safety with their patients.

SFMMS is very proud to count the physicians of the San Francisco Department of Public Health and Marin Department of Health and Human Services among our members, and as leaders of the medical society. Protecting the public health of the community remains a top priority for SFMMS and our members.

SFMMS CONGRATULATES PETER BRETAN, JR., MD, ON BEING NAMED CMA PRESIDENT-ELECT SFMMS congratulates its own, Peter N. Bretan, Jr., MD, on being elected by the California Medical Association (CMA) House of Delegates as the new president-elect. He will be the first Filipino-American physician to serve as CMA president.

Dr. Bretan is a urologist and kidney transplant surgeon practicDr. Bretan (center) with campaign team Drs. ing in Marin, Sonoma and Santa Cruz Lawrence Cheung (left) and John Maa. counties. He has served as a CMA trustee and delegate, and is a three-time president of the Marin Medical Society. He is the current President of the California Urological Association and serves as an adjunct clinical professor at Touro University, where he has taught classes in healthcare policy for the past 15 years. Dr. Bretan is the founder and CEO of Life Plant International, a charitable organization that promotes disaster preparedness, organ donation and early disease screening worldwide. He has also provided care around the world on medical missions. Dr. Bretan will serve on the CMA’s Executive Committee for the next year as president-elect, and he will be installed as the CMA president in October 2019. Read Dr. Bretan’s statement on page 4, and more at

Members of the SFMMS Delegation to the CMA House of Delegates, with CMA CEO Dustin Corcoran.

http://bit.ly/2q1XYDa.

SFMMS Welcomes Dr. Patrice Harris as AMA President-Elect

SFMMS members attending the reception included (from left): Dr. Rob Margolin, Dr. Lawrence Cheung, Mary Lou Licwinko (SFMMS Executive Director/CEO), Dr. John Maa (SFMMS President), Dr. Patrice Harris (AMA President-Elect), Dr. Grace Kwok, Dr. Michael Kwok, and Dr. Michael Schrader.

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SFMMS co-sponsored a reception for American Medical Association (AMA) President-Elect, Patrice Harris, MD, along with the UCSF Department of Psychiatry. Dr. Harris, a child psychiatrist and the first African-American woman president-elect of the AMA, spoke about her healthcare priorities during her term as AMA president, as well as factors contributing to physician burnout and how the profession can better address physician well-being.

SAN FRANCISCO MARIN MEDICINE NOVEMBER 2018 WWW.SFMMS.ORG

SFMMS Sponsors Assemblymember Ting and Lieutenant Governor Candidate Kounalakis

From left: SFMMS President Dr. John Maa, Assemblymember Phil Ting, and SFMMS Executive Director/CEO Mary Lou Licwinko.

From left: Dr. James Constant, Dr. Shannon Udovic-Constant, Mary Lou Licwinko, Eleni Kounalakis, and Dr. John Maa.

SFMMS was a proud sponsor at a recent campaign fundraiser for Assemblymember Phil Ting.

Assemblymember Ting has partnered with SFMMS on several initiatives focused on improving public health and healthcare accessibility, and we look forward to our continued relationship with him.

A recent fundraiser held for Lieutenant Governor candidate Eleni Kounalakis was sponsored

by SFMMS’ Shannon Udovic-Constant, MD, and CMA’s Tanya Spirtos, MD. Many SFMMS physician members were in attendance to hear the candidate speak knowledgeably and passionately about education, housing and healthcare.

Marin County Teen Vaping Forum Held

SFMMS Board Member and Marin County Public Health Officer Matt Willis, MD, MPH, presented at a recent countywide workshop on youth vaping to parents, youth, and community members. The workshop included a panel of experts who provided up-to-date information on the teen vaping epidemic, and discussed the risks associated with adolescent use, as well as prevention strategies. View the workshop at http://bit.ly/2CWkoOH.

Join Us for the 2019 SFMMS Annual Gala

The 2019 SFMMS Annual Gala will be held on Friday, January 25, 2019, at Cavallo Point in Sausalito. President-Elect, Kimberly Newell Green, MD, will be installed as the 2019 SFMMS President. Watch for your invitation to arrive in the mail. Purchase tickets at www.sfmms.org/events.aspx. Sponsorship opportunities are available—contact Erin Henke at ehenke@sfmms.org or (415) 561-0850 x268.

WWW.SFMMS.ORG

November 2018 Volume 91, Number 8

Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Guest Editor Kimberly Newell Green, MD Production Linda McLaughlin EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Michel Accad, MD Stephen Askin, MD Toni Brayer, MD Chunbo Cai, MD Linda Hawes Clever, MD Anne Cummings, MD Irina deFischer, MD Erica Goode, MD, MPH Shieva Khayam-Bashi, MD Arthur Lyons, MD John Maa, MD David Pating, MD SFMMS OFFICERS President John Maa, MD President-Elect Kimberly L. Newell Green, MD Secretary Benjamin Franc, MD, MS, MBA Treasurer Brian Grady, MD Immediate Past President Man-Kit Leung, MD SFMMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Erin Henke Membership Coordinator Ruben Pambid Executive Assistant/Office Manager Ian Knox SFMMS BOARD OF DIRECTORS Charles E. Binkley, MD Peter N. Bretan, Jr., MD Alice Hm Chen, MD Anne Cummings, MD Nida F. Degesys, MD Robert A. Harvey, MD Naveen Kumar, MD Michael K. Kwok, MD Raymond Liu, MD Jason R. Nau, MD Dawn D. Ogawa, MD Stephanie Oltmann, MD Heyman Oo, MD Rayshad Oshtory, MD David R. Pating, MD William T. Prey, MD Justin P. Quock, MD Michael Scahill, MD, MBA Monique D. Schaulis, MD Michael C. Schrader, MD, PhD, FACP Dennis Song, MD Jeffrey L. Stevenson, MD Winnie Tong, MD Eric C. Wang, MD Matthew D. Willis, MD Joseph W. Woo, MD

NOVEMBER 2018

SAN FRANCISCO MARIN MEDICINE

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SFMMS’

PETER BRETAN, JR., MD, ELECTED CMA PRESIDENT-ELECT

SAN FRANCISCO

MARIN MEDICAL SOCIETY

JOIN OR RENEW TODAY When you join the San Francisco Marin Medical Society, you join more than 2,000 members in San Francisco and Marin who are actively protecting the practice of medicine and defending public health. Working together with you, SFMMS unites physicians to champion healthcare initiatives and innovation, advocate for patients, and serve our local medical community, including physicians of all specialties and practice modes.

We cannot do this alone.

Join SFMMS/CMA Today to Receive 15 Months of Membership for the Price of 12 Starting October 1, 2018, new members who join paying full 2019 dues, will receive the remaining months of 2018 membership for free. Join today to start receiving your benefits. Visit www. sfmms.org/membership for more information about SFMMS membership and benefits, or to join online.

At the CMA’s annual meeting in October, urologist and kidney

transplant surgeon, Peter N. Bretan, Jr., MD, was elected the association’s new President-Elect. He will be the first Filipino-American physician to serve as CMA President. Dr. Bretan practices in Marin, Sonoma and Santa Cruz counties.

In a heartfelt acceptance talk, Dr. Bretan said, “I am truly humbled and honored, and thank this CMA House of Delegates for your votes, and for taking the time to be here for our annual meeting on behalf of our profession and patients. I will seek to unify the intelligence, experience, and energy in this room to move our profession forward in these challenging times.

“For me, this is the fulfillment of a 50-year dream, first of becoming a surgeon, and then of saving and helping even more lives by working towards better health policies as CMA President.

“I have tremendous shoes to fill in following such leaders as Drs. Ted Mazer, Ruth Haskins, and now David Aizuss. I look forward to working closely with AMA Chair Dr. Jack Resnick of UCSF. And I congratulate Drs. Strebig and Blumenfeld for running class-act campaigns, raising the bar for future elections and actually bettering me as a person. And especially, I am profoundly grateful to all my colleagues from my Districts 8 and 10, particularly my campaign managers Drs. Lawrence Cheung and John Maa. “I pledge to embrace empathy and diversity to enable every physician to succeed and thrive in serving their patients and our communities. That is what this is all about, and again, I thank you for entrusting me with this responsibility—from the bottom of my heart.”

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Renew Your Commitment to Medicine; Renew Your SFMMS Membership Today Make sure you continue to receive the benefits of SFMMS and CMA membership by renewing today. Full dues-paying members enjoy a 5% Early Bird Discount* if your renewal is received by December 15, 2018. Renewing is easy: 1. Mail/fax your completed renewal form when you receive it in the mail; or 2. Renew online at www.sfmms.org with a credit card. *5% Early Bird Discount applies to 2018 full duespaying members only who are renewing at the same level for 2019; renewal form and payment must be received by December 15, 2018.

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Anniversary

SAN FRANCISCO MARIN MEDICINE NOVEMBER 2018 WWW.SFMMS.ORG

PRESIDENT’S MESSAGE John Maa, MD

2018 LEGISLATIVE REVIEW — WITH AN EYE TO 2019 As we look to 2019, the important topics of universal health-

care, pharmaceutical pricing, single payor, and many others loom large in the landscape. In February of 2019, the deadline to submit new ideas to the Legislature for consideration as new bills will arrive, and a worthwhile goal is for SFMMS to develop new legislation with our local State Elected Officials. Hopefully in September of 2019 SFMMS leaders will be photographed alongside the new California Governor during a Capitol signing ceremony when a superb SFMMS-sponsored bill is signed into law.

To be successful in this ambition, it will be essential to reflect upon the valuable lessons learned from 2018.

In September, Governor Brown took action on the last of the 1,217 bills that were placed on his desk this year by the Legislature. The Governor signed 1,016 of the bills and vetoed 201. Interestingly, during his second Administration, legislators never attempted to override a Governor’s veto, even for bills that passed with bipartisan and unanimous support through both the Assembly or Senate. In contrast, during his first Administration in the 1970s, the Legislature successfully overturned several through a veto override.

The Governor’s actions on bills that SFMMS prioritized for the two-year advocacy cycle of 2017–2018 were evenly split. In 2017, SFMMS opposed SB 905 to extend alcohol service hours to 4 am in SF, and supported AB 186 to create safe injection sites in SF. The Governor vetoed both bills. In 2018, SFMMS endorsed SB 1192 to make milk and water the default beverages for kids’ meals in California, consistent with our advocacy against the health hazards of sugary drinks. SFMMS endorsed SB 221 to ban gun and ammunition shows at the Cow Palace, as an extension of our firearm safety efforts. The Governor signed SB 1192, but vetoed SB 221, resulting in a split for SFMMS advocacy actions in 2018. A tobacco control bill (that SFMMS did not take a position upon) by Assemblyman Mark Levine to ban smoking in parks and on beaches was vetoed for a third time. The Governor did sign SB 1045 by Senator Scott Wiener (and supported by Mayor London Breed) to create a conservatorship program for those with serious mental illness and substance use disorders who are seen repeatedly in SF emergency rooms. While SFMMS did not take a position on this controversial bill, we will study the topic carefully to inform future discussion.

As the legislative session is now complete, the final remaining outcome that SFMMS awaits as of this writing is the fate of the Proposition 8 dialysis-pricing ballot measure on November 6.

WWW.SFMMS.ORG

SFMMS has endorsed “No on Prop. 8,” and almost every leading California newspaper has also recommended that voters reject Proposition 8. Marin Public Health Officer Dr. Matt Willis has also championed a Marin flavored-tobacco products ban modeled after the San Francisco law upheld via Proposition E in June, and a final decision will be forthcoming soon.

In his veto message for SB 221, the Governor highlighted what may prove to be the future answer for the intent of both SB 221 and AB 186. The Governor indicated that these types of local public policy efforts should originate within local jurisdictions rather than statewide action in Sacramento. SFMMS should therefore strive to work with our local elected officials to move core concepts forward through local City Halls. Another valuable pearl came through the outcome of the slate of 15 firearm safety bills. Governor Brown signed 10, and vetoed five. Over the years, he has been balanced, and weighed the spectrum of bills on a specific topic as a package, vetoing the more radical, and signing more incremental changes into law. A successful strategy has been to place a number of related bills on his desk, knowing some (but not all) will get through. We’ll see if the new Governor acts in a similar manner.

A likely priority for 2019 will be a statewide sugary drinks tax championed by Assemblyman Richard Bloom. In 2014, then UCSF medical student Tom Gaither submitted the novel concept of a soda warning label to a CMA idea contest forum, which was selected by Senator Bill Monning for a new bill. This later inspired the San Francisco soda warning label championed by Senator Scott Wiener that was signed into law by Mayor Ed Lee. A final lesson learned in politics has been that bills like this focused on protecting children are easier to garner support.

Perhaps another bright idea contest sponsored by SFMMS could lead to new legislation in Sacramento to curb the health hazards of sugary drinks, or the vaping epidemic that we are witnessing among middle and high school students in San Francisco and Marin, and we welcome your thoughts.

Dr. John Maa attended UC Berkeley and Harvard Medical School, completing his surgery residency at UCSF, and also completed a fellowship at the UCSF Institute of Health Policy Studies and has been President of the Northern California chapter of the American College of Surgeons. He is the Chief of the Division of General and Acute Care Surgery at Marin General Hospital and on the medical staff of Dignity-St. Francis Hospital.

NOVEMBER 2018

SAN FRANCISCO MARIN MEDICINE

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GUEST EDITORIAL Kimberly Newell Green, MD

ADVOCATING FOR CHILDREN: Ensuring a Strong Future for Our City, Our Nation, and Our World CHILDREN ARE OUR FUTURE. It may sound obvious, but

it’s also true. They are the future workers, future caregivers, future creators and procreators, and future sources of wisdom in our world. As physicians we all should know the importance of children’s health. But raising healthy children who grow into healthy and productive adults is much broader than traditional definitions of health.

To thrive, children require positive inputs in arenas ranging from food and nutrition to education, family economics, and health services. Conversely, toxic inputs and stresses affect the architecture of the developing brain and negatively influence physical, mental and economic outcomes well into adulthood.

We know it intuitively, and research demonstrates more and more, that without a good beginning, future success is at risk.

This beginning is so vital that we all—as physicians and citizens, have a role in helping to support the children who are our future.

How to be involved? It is my hope that the examples set forth in this issue will ignite and inspire us all to find our voices in advocating for children and child health, and thus, for a brighter future.

To get a sense of the range of opportunities to support healthy children and a healthy future, let’s first look at the American Academy of Pediatrics’ 2016 “Blueprint for Children,” a message to our federal administration. In order to support a healthy foundation for our country, the AAP advocates that government should strive to better children’s lives by promoting healthy children, supporting secure families, building strong communities, and ensuring that the United States is a leading nation for children.

What does this mean? It means that we must ensure that children have access to affordable high quality healthcare, including behavioral and mental health services, in a family-centered medical home. We must work to support healthy families in which our children can grow and thrive, by reforming the workplace and improving childcare quality and availability, providing job and housing security, ensuring access to affordable nutritious foods, and implementing positive parenting skills training. We must promote strong communities that are free of violence and environmental hazards. We must promote high-quality early childhood education programs, and strong maternal and child health programs. We must respond effectively when disasters and public health emergencies occur. And we must be a global leader for children by addressing climate change, reforming our immigration systems, developing innovative new therapies for children’s diseases and promoting research into the state-of-theart methods to help children grow into healthy adults.

In this issue of San Francisco Marin Medicine, we have highlighted the work of some of our powerful local advocates for children.

WWW.SFMMS.ORG

Dr. Ben Meisel tells a compelling story about how gaps in dental care in the young adult population create unnecessary pain, stress, and massive costs.

Dr. Tracey Hessel demonstrates an important model of the medical community collaborating with county services to link patients and families to the healing powers of nature. Mark Ghaly, MD, describes the complex work of caring for a family overwhelmed by a variety of toxic stresses.

Dr. Jon Takayama, President of the American Academy of Pediatrics California Chapter 1, has highlighted for us the vital work that this organization has done to advocate for children.

Dr. Heyman Oo writes about the profoundly disturbing impacts of recent immigration policies on families, telling tales of child separation and highlighting approaches being used to reform these broken policies. Dr. Emin Maltepe reveals exciting work in building structures to help support and promote pediatric drug development.

Dr. Shannon Udovic-Constant discusses her efforts to understand the impact of a rapidly developing media environment on teens, and to translate that knowledge into actionable advice. Dr. Ryan Padrez embodies an innovative and exciting approach to broadening our connection to the whole child and family.

Jeanne-Marie Sinnott, DO, describes work of a partnership of physician, community and government leaders in Marin County to develop a system that will ensure that school, sports, and medical providers can work together to prevent and treat concussion. Curtis Chan, MD, reviews the frameworks with which San Francisco thinks about child health priorities. And Tracey McMahan, MD, describes the vital work of staying up to date as a primary care physician.

As a pediatrician, mother, and citizen of this city and world, I am grateful to be able to celebrate and promote this important work. I urge you all to follow their examples and find your own arena in which to work to promote the health of our children with equal tenacity and spirit. By partnering with the many vital organizations and individuals already doing this important work, we can extend our voice, our reach and our power and ensure a healthy future for our children and families, and by extension for all of us.

Kimberly Newell Green, MD, is President-Elect of SFMMS and a pediatrician in San Francisco and Assistant Clinical Professor at UCSF. She is the former Chief of Healthcare Innovation and Chief of Physician Health and Wellness at Kaiser Permanente San Francisco. She is working to transform healthcare by leading and supporting innovations in digital technology while keeping humanity at the center of health and healing.

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Pediatrics and Adolescent Medicine

SNAD—FIXING SAN FRANCISCO’S MISSING SPECIAL NEEDS ANESTHESIA DENTISTRY Ben Meisel, MD

Note: The ideas expressed in this article are my own and do not necessarily represent those of my employer.

In an effort to be crass and mix metaphors, one might

say: The [deadly] route to a child’s heart [a child with surgically corrected congenital heart disease] is through his/her poor dentition.

It is common knowledge that dental caries or dental abscesses can communicate with vulnerable tissues in a myriad of horrific and avoidable ways—pathologic oral bacteria can cause conditions like osteomyelitis (in people with abnormal bone integrity), endocarditis (in people with abnormal cardiac tissue), pneumonia (in people with sickle cell disease), sepsis (in people with immunodeficiency), etc.

Based on the above, the medical community agrees that maintaining dental health is especially critical for children and youth with special healthcare needs. In fact, access to dental care is a protected right for all U.S. children from birth to 21 years through Medicaid’s Early and Periodic Screening Diagnostic and Treatment (EPSDT) program. EPSDT dental service guidelines state: “At a minimum, dental services include relief of pain and infections, restoration of teeth, and maintenance of dental health. Dental services may not be limited to emergency services. Each state is required to develop a dental periodicity schedule in consultation with recognized dental organizations involved in child health.”

That’s why it shocked me to find out that in San Francisco, 17–21 year-olds whose special medical or behavioral health needs demand their dental care be done under general anesthesia must wait as long as five years for an appointment. It seems to me that, when considering the medical complications likely to occur in this particularly high-risk group of people, these are the youth that the medical community might want to see getting preventive dental care twice a year . . . not once every five years!!!

So, how has this happened in San Francisco? The answer is both complicated and simple.

The complicated answer is that (1) Denti-Cal does not want to encourage general anesthesia dental care in people who don’t actually need that level of care; (2) special needs dental care often takes longer, involves more time-consuming calculus removal, and requires special needs dental training; (3) DentiCal reimbursement for procedures done under general anesthesia does not fully cover the costs of the care; (4) submission 8

to Denti-Cal of “proof” of care provided has been onerous and difficult, often requiring hiring extra personnel; (5) operating room time is reserved in hospitals for urgent procedures and those that enable premium reimbursement; (6) when every California county struggles with providing access to special needs anesthesia dental care, then vulnerable families flock to state-mandated medical centers (like UCSF) when a Denti-Cal program is offered. This overwhelms the clinic’s capacity and keeps San Francisco clients from gaining access.

The simple answer is: money.

Why me? Why should I, Medical Director of CCS San Francisco, be writing about access to dental care?

After witnessing several cases of patients with complex medical needs (e.g., movement disorders like dystonia, unstable airway patients on home ventilators, severely immunocompromised transplant patients needing careful monitoring during dental care, etc.) suffering from dental complications or having their medical conditions worsened by lack of access to dental care, it was time for someone to attempt to do something. I looked around unsuccessfully for someone to lead this charge . . . then finally gave up and took a look in the ol’ mirror. So, since 2017, I have been working with San Francisco’s dental leaders to elucidate the problem in order to, ultimately, begin addressing this unintentional healthcare travesty.

Osteomyelitis, endocarditis, severe dental pain . . . these are expensive problems that often require extended hospitalizations in a person who already is medically or behaviorally complex.

A real example—who must remain anonymous: A young man, over 17 years old, who had seven hospitalizations in a single 12-month period. Two of these UCSF hospitalizations included dental pain as a primary complaint. He was assessed for his dental pain during these UCSF hospitalizations, but without a “hospital dentistry” program where he could receive dental care under general anesthesia, the issue was not resolvable. Because of this young man’s medical complexity, each of those two hospitalizations cost over $200,000. Eliminating both of these hospitalizations would have paid for more than 160 special needs anesthesia dental visits—enough visits to enable all 140–160 of San Francisco’s special needs 17–21-yearold Denti-Cal youth to receive a preventive general anesthesia dental care visit.

When we solve this problem we will be improving care, decreasing suffering and saving money.

SAN FRANCISCO MARIN MEDICINE NOVEMBER 2018 WWW.SFMMS.ORG

The Current State of Denti-Cal Special Needs Anesthesia Dentistry in San Francisco We have two world-class dental training programs in San Francisco, UCSF School of Dentistry and University of the Pacific School of Dentistry (UOP). Currently, in a collaborative program between the General Practice Dental Residency and its AEGD program, UOP has 1.5 days of operating room time at CPMC that enables it to take care of urgent or emergent dental care cases under general anesthesia. For preventive care there is a wait list of at least two years.

In 2015, after years of losing money (UCSF reports it was losing $500,000–$600,000 yearly—partly due to the Dental School not billing at all because of the onerous Denti-Cal billing process and low reimbursement rates), UCSF discontinued its hospital dentistry service. Before it was closed, the hospital dentistry program guaranteed the UCSF School of Dentistry valuable operating room time.

Since the closure of the adult hospital dentistry program, Benioff UCSF Children’s Hospital has continued to provide general anesthesia dentistry to patients up until they are 17 years old; however, the dentists who provide this service are pediatric dentists and do not feel it is safe or appropriate for them to be providing dental services to adults. Without a UCSF hospital dentistry program, only emergent cases are being addressed, primarily by the Oral Maxillofacial Surgery Department, whose capacity is quite limited. Thus, when patients 17 years old and older are referred for preventive special needs anesthesia dental care—the wait for care is three to five years.

Hope on the Horizon?

Thanks to a coalition of organizations that include UCSF, University of the Pacific, San Francisco General Hospital, Golden Gate Regional Center, California Dental Association, San Francisco CCS, San Francisco Maternal Child Adolescent Health, and others . . . there is a growing, hope-laden effort to correct this unintentional care gap in San Francisco.

Ultimately, a lasting change to Denti-Cal reimbursement for cases involving patients with complex special healthcare needs is needed. In the meantime, a matrix of organizations are coming together as part of the San Francisco Special Needs Anesthesia Dentistry Workgroup (SNAD) in order to find a solution to the remaining barriers. Some hopeful gains so far include:

• The Golden Gate Regional Center (whose funding is pro-

vided by the Department of Developmental Services as a result of California’s Lanterman Developmental Disability Services Act) is considering ways that it can supplement general anesthesia dental care for San Francisco Golden Gate Regional Center clients as part of “Specialized Therapeutic Services”: Prop. V—the Soda Tax—Nov. 2017—It would be poetic justice for some of this money to be used toward SNAD care.

Denti-Cal funding changes: Prop. 56—the Tobacco Tax—has funded a 40% increase in Denti-Cal procedure reimbursements.

There is a new $100 payment available four times per year for extra time required in the care of Denti-Cal patients with special needs.

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These changes have been powerful, but they are tied to funding that is likely to diminish in the future; and thus they are Band-Aid solutions rather than one sustainable system improvement designed to guarantee long-term dental-care access for our most medically vulnerable youth.

Barriers that Remain

Lack of operating room time dedicated to dentists—a willingness of medical centers to provide operating room or day procedure room time to special needs anesthesia dentistry.

California Children’s Services youth who need SNAD have medical complexity that requires anesthesia provided by a physician anesthesiologist rather than a dental anesthesiologist.

Reimbursement for anesthesia by physicians occurs through Medi-Cal rather than Denti-Cal. While Denti-Cal has increased its reimbursement rate for dental anesthesiologists, Medi-Cal has not done the same for physician anesthesiologists. A future increase in the Medi-Cal reimbursement for physician anesthesiologists providing general anesthesia during dental procedures is needed before hospitals are willing to set aside operating room time for the dental cases of medically complex youth.

Lack of reimbursement for desensitization visits—where children with developmental/behavioral conditions or tactile sensitivities (e.g., common with people who have autism) need a few visits to become receptive to a dental hygienist and dentist before allowing them to get near the mouth.

Lack of dental school training programs with a comprehensive special needs dentistry training curriculum. When dental schools don’t offer special needs anesthesia dentistry training fewer dentists come out of school feeling able to provide care for this most vulnerable population (with or without anesthesia).

While lack of access to special needs anesthesia dental care remains for people 17 and older in San Francisco, I am hoping articles like this will move us forward toward a lasting, sustainable solution. Until that time, our most vulnerable patients are suffering. Join us in this effort. We can do better.

Ben Meisel, MD, is Medical Director for the City and County of San Francisco’s California Children’s Services program and Volunteer Clinical Professor of Pediatrics at UCSF. He is founder and chair of the San Francisco Special Needs Anesthesia Dentistry Workgroup and the San Francisco Child to Adult (C2A) Transition Workgroup. His personal vision and professional passion is “Building Play Into Health” for Children and Youth with Special Healthcare Needs. He is former Medical Director of The Painted Turtle, California’s SeriousFun Children’s Network Camp for children with complex medical conditions and is a celebrated children’s music composer with awardwinning recordings as Dr. Ben & Company and KiD’n Together. “Dr. Ben” completed his pediatric residency at UCSF, where he is still remembered as the “Singing Rainbow Scrubs Doctor” for his purposeful use of music and game play to promote healing through collaborative engagement of patients, families and peers.

NOVEMBER 2018

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Pediatrics and Adolescent Medicine

PRESCRIBING NATURE

Tracey Hessel, MD

Everybody needs beauty as well as bread, places to play in and pray in, where nature may heal and give strength to body and soul.

— John Muir

It’s a beautiful day, sunny

with a breeze coming off the Bay. We watch as an older sister uses a giant wand to blow bubbles and her siblings and a handful of other small children laugh and run in circles trying to catch them. One of our colleagues is walking with some of the adults and more adventurous older children in our group. There are school-age children kicking around a soccer ball. When the walkers return, we gather together, sharing a healthy snack.

These are pretty typical activities for a day at the park. But they feel momentous and important as a physician getting to step out of the medical office setting and share these experiences with our patients.

Inspired by the Park Prescription movement that is starting to happen across the country, our clinics started working several years ago with the Marin County parks, the San Rafael city parks and Marin County Health and Human Services to develop a program to promote physical activity and time outdoors in our local parks.

The primary team from our clinic involved in developing the program includes a family practice physician, a pediatrician and a health educator. When we first started to envision a Park Rx program, we immediately thought of the several visits a day spent trying to support families of overweight children and our adult patients with diabetes and hypertension trying to adopt healthy lifestyle changes. The parks and their programming represented a resource to offer patients who are faced with a lack of affordable physical activity opportunities in the community.

We were excited about the promising documented health benefits that were seen by our colleagues at the Marin City Health and Wellness Center, who worked with the Marin County Parks and Health and Human Services staff to develop structured physical activity classes in the park next to their clinic site.

They were able to document improvements in blood pressure and Body Mass Index as well as subjective reports of actually feeling better from the patients who participated in the program after a two-month pilot.

With financial support from the county parks, we kicked 10

off our efforts with a big park event to introduce our patients and staff. We designed a day of free activities and a healthy lunch.

Staff and patients alike participated in ranger-led activities, such as Art in the Park, physical activities including zumba, yoga and youth soccer provided by the City of San Rafael, and demonstrations by community organizations including Wildcare, One Tam and the Marin County Free Library. We estimated that we would have 30–100 participants. We were thrilled to have to send repeatedly for more lunch food when our numbers topped 500. That activity reinforced our impression that there was a real interest in an opportunity to be outdoors.

As we worked to build on that initial excitement to develop a sustainable, ongoing program, we encountered more challenges. We have four clinic sites and a large and geographically dispersed population. So, while patients expressed interest in attending free physical activity groups, finding the times, activities and locations that could work for more than a small group of patients was difficult. We decided to focus on finding a variety of affordable activities in the community and provide a “prescription” for our patients to attend the one that best fit their schedule and interests. We found that, while the intent seemed to be there, there were other barriers that prevented patients from following through—most often cited were time, competing obligations, lack of familiarity with the location, discomfort with exploring a hike or joining a group on their own.

In fits and starts, we’ve landed on a format that seems to work for at least a subset of our patients—MCC in the Parks.

Our staff organizes periodic outings to local parks. We found that providing transportation and having our clinic staff attend the outings has been critical for patient participation, in many cases more because they know someone familiar will be with them as they explore something new, than because of an actual lack of access to a car. On these outings, we try to offer something for everyone—we model simple, affordable outdoor activities: flying a kite, tossing a frisbee, creating a hopscotch pattern with chalk, or going on a scavenger hunt to explore the nature around

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us. A subset of our adults and more intrepid kids often take a walk. Some family members sit in the shade with their infants.

And that’s OK too.

We have started to change our focus from a desire to engage all of our patients in structured physical activity to trying to help connect our patients to the resources—natural and organized— offered by our local parks to engage in the way that makes the most sense for them.

As has been demonstrated by others looking at the benefits of prescribing nature, we are seeing the profound positive impact of being outdoors, beyond the well-documented physical and emotional benefits of exercise. We all know intuitively that we feel better when we spend time outdoors, disconnecting from technology and our busy lives.

Now, there’s a growing body of research that supports that.

Dr. Nooshin Razani recently published a study that demonstrated that participation in park outings resulted in reduced stress in the parents of children from their clinics at UCSF Benioff Children’s Hospital Oakland.¹ Spending time in nature not only results in increased physical activity and the physiologic benefits associated with exercise, but it’s also associated with decreased symptoms of anxiety, rumination and negative affect.² In terms of mood, a study done by the University of Essex found that 9 of 10 patients with depression reported feeling higher self-esteem after a walk in a green setting. Almost threequarters reported feeling less depressed.³ We’ve expanded our target population from children with overweight and adults with hypertension and diabetes to include anyone with stress, trouble sleeping, anxiety, depression, a desire to spend quality time with their families or connect with other community . . . basically everyone. We’re convinced of the myriad benefits of prescribing nature. We’re now looking at how to better reach more of our population—those who may be interested but unable to participate in our current offerings.

Our current park outing model requires a significant amount of staff time spent on planning and program development, building and maintaining community partnerships and participating in the actual events. Our eventual hope is to find ways to more effectively connect our patients directly with the many WWW.SFMMS.ORG

park offerings and free programs provided by the parks and by other community partners to expand the reach of the program to include our patients who might better engage in different activities or opportunities that are offered at times or locations that are more convenient for them. We are working with our County partners to develop some structure or technology that will allow us to provide incentive and encouragement without necessarily always accompanying them.

In the meantime, we’ll continue to provide the bridge to the beauty around us and enjoy this special time engaging with our patients outside the clinic walls, experiencing the healing effects of time in nature.

Tracey Hessel, MD, is the Lead Pediatrician at the Marin Community Clinics, a federally qualified health center in Marin County. In addition to her clinical work as a primary care pediatrician, she is involved in developing new programs and ensuring quality within the pediatric department and working with outside agencies to strengthen the safety net for underserved children in Marin County. She completed her medical school and pediatric residency training at UCSF and is currently participating in the UCSF Champion Provider Fellowship program.

References 1. Razani N, et al, “Effect of park prescriptions with and without group visits to parks on stress reduction in lowincome parents: SHINE randomized trial,” PLOS ONE 13(2): e0192921, https://journals.plos.org/plosone/ article?id=10.1371/journal.pone.0192921 (2018).

2. Bratman G, et al, “The benefits of nature experience: Improved affect and cognition,” Landscape and Urban Planning,138,41-50, www.sciencedirect.com/science/article/ pii/S0169204615000286 (2015).

3. Peacock J, et al, “Ecotherapy: the green agenda for mental health,” MIND, www.mind.org.uk/media/211255/Ecotherapy_The_green_agenda_for_mental_health.pdf (2007).

NOVEMBER 2018

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Pediatrics and Adolescent Medicine

THE UN-WELL CHILD CHECK Mark Ghaly, MD, MPH

“I can’t control them. It’s getting too hard. Can you do anything? No one helps me.”

For most pediatricians, these words are unsettling coming

from a patient’s caregiver. They underscore one of the key challenges of our profession: helping young children, disproportionately of color, who have no obvious chronic or serious health condition early in life but who, because of their social and structural environment, enter adulthood (if they’re lucky to live) with few options for good health or future opportunity.

When Tonya uttered these words in my exam room during a routine well child check in 2006, her twin boys, my patients, had just turned 8. The mother’s desperation became more and more apparent as the twins sat slumped in adult-sized chairs in my health clinic in the Bayview Hunters Point community of Southeast San Francisco. Tonya and I reviewed all the things that were being done: Individualized Education Plans (IEPs) for each boy at school (which took over a year to get in place), therapy appointments, consideration for ADHD medications, and efforts to get them into organized sports and choir.

I offered once again to go to their school and meet with Principal Jackson or their teachers. “What more will that do? Another plan to avoid kicking them out of school? They don’t get anything out of school anyhow.”

Eventually, Tonya, the twins and I got through the visit.

Like most physically healthy kids, the twins laughed their way through the abdominal exam, enjoyed having their reflexes checked, and were ultimately distracted by the threat of receiving vaccines. The visit did end. But besides these signs of normalcy, the ominous signs of decline for Tonya and her boys felt more intense and more certain than ever.

Like millions of “at risk” families living in urban America, trauma, poor social conditions and structural violence invaded the lives of Tonya and her boys. And despite countless attempts by the school, the health system, the social services system, the child welfare system and others, statistics predicted that Tonya’s family would follow an all-too-familiar course.

Tonya’s boys experienced urban poverty and its accompanying chronic stress, setting the stage for stunted child development, poor school performance, low high school and college graduation rates and a lower chance of being consistently employed in early adulthood.1,2 With community violence a daily spectacle for the twins, their risk of future violent behavior and delinquency rose alongside increased risks of depression, anxiety and post-traumatic stress.³ The fact that Tonya and the boys were periodically homeless made surviving even more daunting.

Tonya frequently made me feel the full weight of her poverty.

Making it through the day, and night, was her full-time job.

Last spring, 12 years after meeting Tonya and her twin boys, this fate became even more certain. My brother, a psychiatrist in San Francisco’s jail, called me and said: “It happened. I saw 12

Tonya’s son today at County.” My brother had years before met Tonya while she was in jail for a misdemeanor, and she easily made the family connection between us. She loved that he was her doctor, and she began outpatient care with him in a Tenderloin mental health clinic, while I was doctor to her kids.

The decade-plus between our well child visit and my brother’s call was not kind to Tonya: her mental illness, always apparent, had worsened as her boys fell in and out of foster care, group homes, her home, and juvenile detention. Tonya herself had tried outpatient mental health services and multiple medications but had difficulty staying sober and relapsed time and time again.

Jail was her most frequent bed with the streets of the Tenderloin a close second. The toll of these trials on her boys was as tragic as it was predictable.

One in 28 children in the U.S. have a parent who is incarcerated.⁴ And, as in Tonya’s case, children feel the full weight of this burden. Due to lost income and the cost of attorneys and court proceedings, nearly two-thirds of families can’t meet their basic needs when a family member becomes incarcerated.⁵ Without their mother, the twins lost any semblance of stability, cycled faster and faster through various systems of care, and continued to face hardship.

Children in the dependency system are at increased risk for adverse outcomes including homelessness and incarceration. In King County, Washington, over a third of foster children become homeless within one year of aging out of the foster care system.⁶ And in Los Angeles, half of those exiting foster care who had juvenile justice system involvement are homeless within six months.⁷ Within two years of leaving foster care, approximately 25% of transitional-age young adults are involved in the justice system.⁸ Juvenile justice involvement increases the chances of incarceration later in life and reduces the probability of graduating from high school.⁹ Although youth arrests are down across California, those who are arrested are more likely to be poor and a person of color. Diverting youth away from the juvenile justice system through evidence-based, data-driven diversion programming, reduces the likelihood of re-arrest by a factor of 2.5. These programs need health partners—the impact of chronic illness, mental health and substance use are for many at-risk youth a prominent driver of their offenses and public safety risk. This is particularly true for youth whose parents have been incarcerated.

In Los Angeles County, where I work now, elected leaders have made tremendous investments in social programs that address access to health services for children in foster care, have implemented justice system diversion programs, and have tackled the issue of homelessness and homelessness prevention

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by advancing a ¼-cent sales tax that voters supported to address the county’s crisis—Los Angeles County Measure H. These efforts do not just include planning processes or policy declarations. They go deep into programmatic implementation. They involve building housing, improving housing conditions for the most vulnerable, implementing large-scale case management programs, funding training for law enforcement personnel on health and behavioral health conditions, hiring leaders to improve healthcare in jails and probation facilities, and expanding staff capacity in designated foster care clinics, to name a handful. In Los Angeles, social challenges have been re-examined through a health and health equity framework. Advancing this framework has allowed health leaders the opportunity to work well beyond hospital and clinic walls to impact outcomes where they matter most for vulnerable and overlooked populations—their communities and homes.

A few years ago, a student asked me why I became a pediatrician while I seemed so concerned with adult issues. I responded that pediatrics is the ultimate in adult preventative medicine.

If an important feature of a pediatrician’s job is to help ensure kids enter adulthood healthy and ready to thrive, then we must not just become policy and program advocates, but we must use our healthcare teams to relentlessly seek the services and opportunities that promote a prosperous adulthood. Pediatricians are well-poised to play a role in improving the life trajectories of their patients and their patients’ families. But only if they ask the right questions and mobilize the right resources to help. A growing movement in social pediatrics promises to train the next generation of pediatricians to better target and address the social and behavioral factors that determine 60% of one’s health. Trainees develop skills in advocacy, health policy, social justice and community health. Failure to acknowledge this path at scale will continue to limit the full contribution that medicine can make on important societal, community, and individual patient issues.

For many children living in America’s poorest urban communities, the pediatrics they need is different. A patient problem list seems incomplete if it fails to consider a child’s access to safe schools, a regular and trusted guardian, safe transportation and meaningful extracurricular activities, to name a few.

Pediatricians in low-income urban communities might even consider turning the well-child visit upside down since the social and structural factors that are routinely left for the end of a visit are exactly what have the greatest impact on health for some children. Given that all kids and all communities are not the same, the well-child check should differ accordingly.

Every couple of months, my brother mentions Tonya. He’s often fulfilling his promise to her to pass on her news and ask me her constant question: why I moved from the Bay to LA. While Tonya thankfully lives, the bright spots are fewer than the dark ones. Her twins continue to cycle through the justice system. It is only a matter of time before the twins will have children of their own. For those children, our future pediatric patients, my hope is for a provider able to take action, and to recognize that even though the physical exam may likely be normal, the social exam will reveal a staggering degree of unwellness that we, as physicians, can and should address.

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Mark Ghaly is Deputy Director for Community Health for the LA County Dept of Health Services. Prior to his current position, Dr. Ghaly was the medical director at Southeast Health Center in the Bayview Hunters Point community. Dr. Ghaly attended Brown University and received his MD and his MPH in health policy from Harvard University. He completed his residency in pediatrics at UCSF.

References 1. “Escaping Poverty Predictors of Persistently Poor Children’s Economic Success,” Urban Institute, www.urban.org/sites/default/ files/publication/90321/escaping-poverty.pdf (May 2017), accessed Oct. 5, 2018.

2. http://pediatrics.aappublications.org/content/early/2016/03/07/ peds.2016-0339.

3. www.child-encyclopedia.com/activite-physique/according-experts/effects-community-violence-child-development.

4. https://nrccfi.camden.rutgers.edu/files/nrccfi-fact-sheet-2014.pdf.

5. https://forwardtogether.app.box.com/s/1vtvbd8pa8ubtpg7ne9pe d14primxkaz.

6. www.kingcounty.gov/~/media/depts/community-human-services/housing/documents/one-table/One_Table_PPT.ashx?la=en.

7. www.latimes.com/opinion/readersreact/la-ol-le-homelessnessfoster-care-20180302-story.html.

8. https://jlc.org/news/what-foster-care-prison-pipeline.

9. https://voxeu.org/article/what-long-term-impact-incarceratingjuveniles.

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Pediatrics and Adolescent Medicine

THE MIGRANT CHILDREN CRISIS IS NOT OVER

Heyman Oo, MD, MPH

On April 6, 2018, Attorney General Jeff Sessions announced a “zero-tolerance” policy regarding the immigration crisis at the U.S. southern border, but it was not until May 7, 2018, that he delivered remarks in San Diego that would spark an eight-week national outcry.¹ In an attempt to deter illegal border crossings, the U.S. Department of Justice and U.S. Customs and Border Patrol (CBP) took what was formerly a quiet, obscure, case-bycase procedural decision—i.e., the separation of family units in CBP custody—and universally expanded the policy to separate all asylum-seeking parents from their children. In less than two months, almost 3,000 children were separated from their caregivers at border processing facilities, sometimes under false pretenses of “taking them for a bath.”² These children, including over 100 children under the “tender” age of five, were transported without their caregivers’ permission or knowledge to detention centers and shelters all over the country.

We have all seen the photos of children in cages. We have heard the stories of toddlers as young as three years old representing themselves in immigration court hearings without their parent present.³ Many of us physicians felt particular outrage at the reports of children being forcibly given psychotropic medications without consent in order to “calm them”⁴ after they were exhibiting clear behavior changes related to their governmentinflicted trauma. As healers and as health experts, we knew how this trauma would have long-lasting detrimental effects on the health of these children for months and possible years to come.

So we showed up and we spoke out—pediatricians, psychiatrists, family medicine providers, and many others. We attended rallies, wrote letters, contacted Congress, went on local and national television demanding not only compassion for these families for compassion’s sake, but also educating the public about the science of trauma in childhood and its persistent, negative effects on health. Finally, and perhaps in part because of our collective efforts, on July 22, a U.S. District judge in San Diego signed an injunction on the family separation policy⁵ and required the government to reunite all separated children with their caregivers within one month. It was a solid victory. Now, many months later, after hundreds of news articles, journal pieces and opinion blogs, what more is there to say?

To start, as of mid-September, over 500 children still have not been reunited with their caregivers for reasons not entirely clear or transparent. These children are scattered all over this country, some perhaps placed with distant family members or family friends; some may be in shelters for unaccompanied minors (a false designation given when our government forcibly separated them from their parents making them newly unaccompanied) and some, no doubt, placed with strangers in 14

our already-overburdened foster care system. The American Civil Liberties Union and other organizations continue to work tirelessly to obtain the names and locations of these children in reunification efforts. However, this humanitarian mess of our government’s creation is far from over.

On the contrary, the Department of Homeland Security (DHS) is proposing to Congress ways to hold minors in detention for longer periods of time, maybe even indefinitely. They aim to overrule or circumvent the Flores settlement of 1997, which requires the government to hold minor migrants in the “least restrictive setting possible” and usually for less than a month.⁶ Recent reports show that the number of immigrant children currently in government detention has already reached historically high numbers,⁷ and these numbers will only continue to rise if the Flores settlement is completely overturned.

We know that there is no “safe” detention environment, no dose or set period of time that is without consequence for detained children. Moreover, government-funded detention facilities and shelters have a long history of widespread physical, sexual and medical abuses. Most recently, these abuses were documented in 30,000 pages of evidence submitted for a lawsuit filed by the ACLU⁸ and in a whistleblower report filed by two physicians serving as health experts for the DHS Office of Civil Rights and Civil Liberties.⁹ As medical providers, we serve as advocates for our patients and their families. When it comes to children, who are by definition disenfranchised and more vulnerable, our responsibility as pediatricians is that much greater. Until every one of these remaining children is reunited with their families, we as physician advocates need to keep writing, keep calling and keep speaking out.

We need to urge our public officials to uphold the Flores settlement and require that the government honor and recognize

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the universal truth that innocent children do not belong in jail.

We cannot let the public forget that detention is harmful for children’s health, not only in the immediate period, but with serious implications for the rest of their lives. We need to continue to demand that children currently in DHS detention facilities are regularly evaluated and routinely cared for by licensed medical providers in good standing with their professional organizations. Lastly, we need to demand that these children who have already suffered the trauma of family separation are given an opportunity upon release and reunification to receive the proper physical and mental healthcare they will most definitely need.

They should not only recover from this trauma, but, as children, they should have the chance to thrive.

Heyman Oo, MD, MPH, is a primary care pediatrician in Marin County and an Associate Physician/Clinical Instructor for the General Pediatrics Department at Zuckerberg San Francisco General and UCSF Benioff Children’s Hospital. She earned her MPH in healthcare policy and administration from Harvard TH Chan School of Public Health and is currently leading a pilot project with the Center for Youth Wellness at Marin Community Clinics, screening for Adverse Childhood Experiences (ACEs) in a pediatric primary care setting.

References 1. www.justice.gov/opa/speech/attorney-general-sessionsdelivers-remarks-discussing-immigration-enforcementactions 2. www.independent.co.uk/news/world/americas/us-borderpatrol-immigrants-family-separation-ice-childrenseparation-a8394326.html 3. www.nbcnews.com/health/health-news/defendants-diapers-immigrant-toddlers-appear-court-alone-n887356 4. www.reuters.com/article/us-usa-immigration-medication/ u-s-centers-force-migrant-children-to-take-drugs-lawsuitidUSKBN1JH076 5. www.latimes.com/local/lanow/la-me-judge-immigration20180626-story.html 6. www.washingtonpost.com/world/national-security/ trump-administration-to-circumvent-court-limits-ondetention-of-child-migrants/2018/09/06/181d376cb1bd-11e8-a810-4d6b627c3d5d_story.html?utm_term=. bbb2ba018140 7. www.nytimes.com/2018/09/12/us/migrant-childrendetention.html 8. www.aclu.org/news/aclu-obtains-documents-showingwidespread-abuse-child-immigrants-us-custody 9. www.nytimes.com/2018/07/18/us/migrant-childrenfamily-detention-doctors.html

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NOVEMBER 2018

SAN FRANCISCO MARIN MEDICINE

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Pediatrics and Adolescent Medicine

PEDIATRIC PRIORITIES:

THE AMERICAN ACADEMY OF PEDIATRICS AGENDA FOR HEALTH John I. Takayama, MD The American Academy of Pediatrics California (AAPCA)

of resources to help pediatricians better prepare themselves, PEDIATRIC PRIORITIES: Chapter 1 is a dynamic professional organization of nearly 2,000 their patients and their practices for disasters (please see webTHE AMERICAN ACADEMY OF PEDIATRICS pediatricians in Northern California whose mission is to advosite linkAGENDA below). FOR HEALTH I. Takayama, MD optimal cate on behalf of all childrenJohn so that they can achieve health. Our chapter is one of 58 such chapters that make up the Mental Healthcare The American Academy of Pediatrics California (AAPCA)) Chapter 1 is a dynamic national American Academy of Pediatrics (Figure 1). Members A different type of crisis that can be devastating to families professional organization of nearly 2,000 pediatricians in Northern California whose mission is hail from a large geographictoarea with King, Tulare and Inyo is the rising incidence anxiety advocate on behalf of all children so that they can achieve optimal health.of Our chapterand is onedepression among adocounties to the south, Oregon to the north and Nevada to the lescents.

One way that we focus chapter efforts is by developof 58 such chapters that make up the national American Academy of Pediatrics (Figure 1).

Members hail from a large geographic area with ing King,aTulare and Inyo to the south, east. Some pediatricians provide primary care, others practice strategic plancounties and surveying chapter members. Last year, the Oregon north and Nevada border the east.

Some includes pediatricians provide hospital or subspecialty medicine; someborder work to in the group practices ourtoboard, which elected representatives from each of primary care, others practice hospital or subspecialty medicine; some work in group practices including FQHCs, others in staff model HMOs, and yet others in our regions, agreed overwhelmingly to address mental healthincluding FQHC’s, others in staff model HMO’s and yet others in academic medical centers and academic medical centers and public health departments. care for children and youth.

We conducted a member survey public health departments. that identified access Figure1.1.Organizational Organization Structure for for thethe American Academy of Pediatrics (AAP) (AAP) Figure Structure American Academy of Pediatrics Disaster Response to appropriate mental and Preparedness healthcare as a problem Most of our work for a majority of famiAAP (NaMonal) this past year has been lies. Barriers included 68,000 members in response to disasters, not enough mental both natural and manhealth providers with made. When the federal training in children’s AAP California government decided to mental health services, (District IX) end DACA (the Deferred inadequate reimburse5,000 members Action for Childhood ment for mental health Arrivals) protection, services, and difficulties AAPCA AAPCA AAPCA AAPCA we immediately pubfaced by patients and Chapter 1 Chapter 2 Chapter 3 Chapter 4 licized our disappointfamilies in navigating Northern California Los Angeles San Diego Orange County ment with the decision the referral process for as well as our support mental health services. for the 200,000 young In response to immigrants in California brought to the U.S. as children. In Octosurvey findings, our chapter assembled an ad hoc committee to Preparedness ber, Raul Gutierrez, Co-ChairDisaster of our Response Advocacyand Committee, and explore ways to support pediatricians in providing immediate Jyothi Marbin, chapter member and Director of the PLUS (Pedicare and in referring children and youth to mental health proMost of our work this past year has been in response to disasters, both natural and atric Leaders Advancing Health Equity) residency program at fessionals.

We(the forged relationships man-made. When the federal government decided to end DACA Deferred Action for with partners such as NAMI UCSF, convened “Supporting the Health of Immigrant Families,” a (National Alliance on Mental Health) Childhood Arrivals) protection, we immediately publicized our disappointment with the and the California Children’s decision well as our support forimmithe 200,000 young California solutions. brought to the conference in Oakland to learn aboutas the trauma faced by Trustimmigrants to exploreinpotential In late September during our U.S. as children.

In October, Raul Gutierrez, of our Advocacy Committee, and Jyothi grant children and their families, and the skills and resources to Co-Chair annual board retreat, Diane Dooley and Janice Kim, Co-Chairs of Marbin, chapter member and Director of the PLUS (Pediatric Leaders Advancing Health Equity) include, protect and help. the ad hoc committee, presented their findings and recommendaWildfires swept through Northern California last fall, cultions. One of the identified challenges is the administrative divide minating in a massive fire that destroyed thousands of homes between healthcare and mental healthcare; many healthcare and other structures in Santa Rosa. Many families were forced plans have “carved out” mental healthcare and have contracted to evacuate immediately and, upon return, found damage and with separate organizations to provide mental healthcare. For the destruction. We invited David Schonfeld, Director of the National publicly insured, the systems and processes can vary by county; Center for School Crisis and Bereavement, to facilitate a discusand there are 48 counties in Northern California. sion in Santa Rosa about how pediatricians and other professionWhen tackling access to mental healthcare, an enormous als could assist families through their shock and grief. We learned issue, breaking it down into smaller categories makes sense. The about psychological first aid and the important ways to ask and ad hoc committee did just that and created potential objectives to listen. Since then, with grant support from the national AAP, and plans (Table 1). The first category, for example, focuses on we have identified local experts and assembled a compendium supporting the pediatrician. Most pediatricians already screen 16

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Table 1. Opportunities to Improve Mental Healthcare for Children and Youth

Enhance Primary Care Capacity for Mental/Behavioral Healthcare

Improve Connections between Providers and Services

Advocate for Improved Systems of Care

Use website and other communication methods to distribute available resources

Collaborate with local and regional organizations and agencies with similar goals

Work with AAP California to support legislation to improve systems of care

Include trainings to integrate preventive mental healthcare into pediatric practice

Connect with insurance systems to identify models of communication/ consultation

Collect “cases” from primary care describing barriers to mental health services

for anxiety and depression using tools such as the PHQ9 and CRAFFT. We have begun to collect and offer key resources (please see website link below) so that initial mental healthcare can begin in primary care. We are currently planning a series of case-based discussions during the Spring Meeting in 2019 to ensure that pediatricians can enhance their skills, methods and approaches (i.e., include trauma-informed care).

Education for Pediatricians

With advances in research and technology, our ability to address diseases and conditions keeps advancing. In order to assist pediatricians in staying up to date, we sponsor conferences twice per year, in the spring and winter. The spring meetings tend to focus on specific themes and skills. In 2017, our chapter collaborated with the Alameda County Public Health Department to present “Learning the School Alphabet: IDEA, SST, IEP.” The purpose was to help pediatricians be more effective educational advocates and understand ways that children struggling in school can get help. Facilitated small group discussions featuring cases were used to discuss student educational needs, rights and practical solutions.

The 3rd Annual Pediatric Puzzles, our winter conference, will be held on Saturday, December 1, at the UCSF Mission Bay Conference Center. Planned by our chapter’s Education Committee, led by Co-Chairs Yasmin Carim and Mika Hiramatsu, this year’s topics include: Adverse Childhood Experiences, Headaches, Sleep Strategies, Adolescent GYN, Shoulder Injuries, Latent TB, Syphilis and Influenza. An interactive response system will be used so participants can relay what they have learned and speakers can elaborate when and where needed.

Some types of training require other forms of more ubiquitous dissemination and adoption. The recent “Black Lives Matter” and “Me Too” movements have reminded all of us about the exclusion and inequities that continue to pervade today’s society and the critical roles they play in affecting the health and well-being of our children and families. The national AAP has created a provisional Section on Minority Health, Equity and Inclusion; and implicit bias trainings are being rolled out nationally as well as locally. Rhea Boyd, board member, led us through such a training at our recent leadership retreat. We encourage pediatricians not only to address interpersonal biases but also those that exist in larger systems of education and care.

Pediatrician and Practice Resources

Practice guidelines and related reports are developed through an evidence-based iterative process through the national WWW.SFMMS.ORG

committees, sections and councils. At the chapter level, we attempt to help translate some recommendations so that they can be adopted by individual practices. One of our recent efforts was to use Quality Improvement methods to help practices achieve tangible improvements. In 2017, with grant support from national AAP, we carried out an HPV immunization QI project in which we assisted 10 pediatric practices adopt QI methods to increasing the rates of HPV immunization of adolescents at their 11- and 12-year child health supervision visits.

Collaborating with pediatricians in practice has helped us identify a major issue that pediatricians face personally on a daily basis. Pediatricians are becoming “burned out.” Some of the factors include the increasing prevalence of patient and family concerns, such as those related to mental health, that cannot be easily addressed by providing medication, information or reassurance; the advent of the electronic medical records system, which has created a new category of “after visit” orders and documentation activities; and the constant distractions posed by our being connected to devices. As a start, mindfulness activities have been included in educational activities for pediatricians. More is needed to maintain the health and well-being of pediatricians so that they can continue to provide high-quality care for children.

Child Advocacy

Children cannot speak for themselves both literally, sometimes, and in society. As pediatricians, we have the privilege to belong to a special group of adults (that includes parents, child care providers and teachers) who are ideal advocates; we see children routinely and we know about many of their needs.

Opportunities for advocacy arise constantly, sometimes through emails from the national or statewide AAP offices and at other times from more local events that arise unexpectedly. Here, I want to highlight two recent local advocacy efforts by individual pediatricians.

Aaron Nayfack, our State Government Affairs Representative, heard about a city plan in late 2017 to consider a permit for opening a new gun store in San Carlos. Given that our national policy statement clearly states that “the absence of guns from children’s homes and communities is the most reliable and effective measure to prevent firearm-related injuries to children and adolescents,” we were able to write a letter of support for citizens opposed to such an opening. Aaron, representing our chapter, delivered the letter to a crowded city meeting. With most people speaking in favor of a moratorium, the city council voted to pass a one-year moratorium.

Claire Gibson, resident in pediatrics at UCSF, learned about NOVEMBER 2018

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Pediatrics and Adolescent Medicine a proposal in Fresno this summer to consider a small increase in the sales tax to fund refurbishment and expansion of local parks. Fresno ranks 94th out of 100 major U.S. cities in terms of park access, acreage and investment. Given the many benefits of open spaces for children, our chapter was able to support this city measure. The caveat, a lesson for all of us, was that we had to consider seriously the regressive nature of the taxation.

Jolie Limon, member of our Chapter Board representing Fresno, signed the letter and Claire’s grandmother, a retired pediatrician, delivered the letter. The Fresno City Council voted 7-0 to place this measure on the November ballot and many local institutions have followed the AAP in endorsing the measure.

Collaboration with Organizations

We can achieve our mission to attain the optimal physical, mental and social health and well-being for all children, adolescents and young adults, only by working together with other like-minded organizations. This summer, AAP California Chapter leaders met with First 5 state and local representatives to strategize on ways to assure routine developmental and behavioral screening and referral; and to improve school readiness for all children in California.

We look forward to collaboration with other organizations including the SFMMS on issues and themes discussed above.

Upcoming Conferences

Exploring Nature and Health: The latest science and strategies to integrate nature into patient care. Saturday, Oct. 27, 2018; 8:30 a.m. – 5:00 p.m., Benioff Children’s Hospital (5700 Martin Luther King Jr. Way, Oakland); www.bitly.com/ucsf-nature2018.

3rd Annual Pediatric Puzzles: An interactive case-based conference. Saturday, Dec. 1, 2018; 8 a.m. – 5 p.m., Mission Bay Conference Center, UCSF (1675 Owens St., San Francisco); www.aapca1.org/

event/pediatric-puzzles-interactive-case-based-conference-0.

Dr. John Takayama is a pediatrician who provides primary care at UCSF Benioff Children’s Hospital. He is particularly interested in health promotion, patientphysician communication, child advocacy and community collaboration, and the care of children with special health care needs. Takayama earned a medical degree at New York University School of Medicine and completed a residency and chief residency in pediatrics at the Yale-New Haven Hospital. He also earned a master’s degree in public health and completed a fellowship in clinical research at the University of Washington.

References and Resources • Psychological First Aid: www.nctsn.org/treatments-andpractices/psychological-first-aid-and-skills-forpsychological-recovery/about-pfa • Disaster Preparedness: www.aapca1.org/disasterpreparedness • Mental Health: www.aapca1.org/mental-health • AAP Section on Minority Health, Equity and Inclusion: www.aap.org/en-us/about-the-aap/Sections/Section-onMinority-Health-Equity-and-Inclusion/Pages/PSOMHEI. aspx

PEDIATRICS AND DRUG/DEVICE DEVELOPMENT THE BIGGEST STORY IN PEDIATRICS over the past five years is that the pace of pediatric therapeutics development continues to lag dramatically behind adult drug development efforts. The reasons for this are generally well known. The main obstacle is economic. High risk, high development costs, and low return on investment for manufacturers discourage spending on pediatric research. Exacerbating this problem, preclinical drug development does not pay necessary attention to the unique physiology of pediatric patients, their dramatically differing drug metabolism profiles, and their effects on drug pharmacokinetics and pharmacodynamics.

Additionally, ethical concerns have historically discouraged drug trials in children due to concerns this may expose this vulnerable population to undue risk. In 2008, only an estimated 50% to 60% of prescription drugs that were being used to treat children had actually been studied in the pediatric population.

The likelihood that a medicine had actually been studied in neonates—children less than a month old—was close to zero.

Despite increases in pediatric clinical trial numbers, the rate of trial success hovers at around only 50%. This is for drugs already approved in adults.

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Emin Maltepe, MD, PhD To improve these odds, we at UCSF have launched the Initiative for Pediatric Drug and Device Development (iPD3) in partnership with the University of Maryland, Baltimore. A collaboration between pediatric specialists, clinical pharmacologists, preclinical disease modeling experts, and a longstanding relationship with regulatory agencies, iPD3 aims to become a one-stop-shop for any biotech, pharmaceutical manufacturer or other entity interested in developing drugs or devices specifically for pediatric indications.

Supported by funding from the NIH, Bill and Melinda Gates Foundation and industry partners, iPD3 aims to level the playing field with respect to pediatric therapeutics development. Find out more at www.ipd3.org.

Emin Maltepe, MD, PhD, is Associate Professor of Pediatrics, UCSF, and Director, Product Development, iPD3.

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Pediatrics and Adolescent Medicine

CREATING A HEALTHY RELATIONSHIP WITH TECHNOLOGY

Shannon Udovic-Constant, MD

In our world everything seems to be going faster. Pico Iyer, who wrote The Art of Stillness, says we are “living at the speed of light and not the speed of life.”

There are many benefits associated with technology and social media. Yet we want to find the balance of the doing with the being.

I have started to realize that if I set up parameters for myself around technology, I then free up the time that I need to create the space to be more mindful and present with my family, in my work and in my free time. As a pediatrician and a mom, I have many conversations with youth and their parents about how to set limits with technology.

There are two particular issues for screen time and young people. The first is that the prefrontal cortex, the part of the brain responsible for planning, impulse control and decisionmaking, is the last area of the brain to myelinate, so it is still developing into our 20s, and is more likely damaged by stimulating things.

The other issue is that screen time releases dopamine in the reward center of the brain and a developing brain is more susceptible to its effects. Dr. Delaney Ruston, physician/mom and director of the film, “Screenagers,” states that “research shows that those who play a lot of video games—about three hours a day—have MRI brain scans that reveal patterns similar to those of people addicted to drugs.”

Dr. Robert Lustig, a pediatric endocrinologist at UCSF, further elaborates on the dopamine effects from screen time. In his book The Hacking of the American Mind, he educates his readers about the difference between pleasure caused by dopamine and happiness caused by serotonin. In general, he writes that pleasure is short-lived, visceral (feel it inside yourself), is achievable with substances, typically experienced alone, and can have addiction as an endpoint. On the other hand, happiness that is caused by serotonin is long-lived, ethereal (notice it above yourself), is giving, is not achievable through substances, is usually achieved in social groups, and does not have addiction as an end point. Dopamine hits occur with technology when we pass a level on candy crush, someone “likes” our Instagram photo, or shares our Tweet. The danger is that it can start to take more and more to get the same feeling because the receptors can start to down-regulate. Dr. Lustig warns that your “phone is a slot machine in your pocket.”

In response to these concerns, there are efforts underway to raise awareness through education to hopefully counter the downside of technology, especially for young people. Dr. Ruston’s “Screenagers” is being shown in schools and communities across the nation to guide parents and educators to better understand the issues and help youth create guidelines for their technology use. Please go to her website for information about upcoming screenings of the movie or how to arrange a screening in your WWW.SFMMS.ORG

community (www.screenagersmovie.com/find-a-screening).

In addition, The Center for Humane Technology has been created with the mission of “realigning technology with humanity’s best interests.” This group was started by some Silicon Valley technology leaders because of the concern about companies using manipulative psychology in the development of their products in order to compete for our attention with the ultimate goal of making money. In response, the organization is developing a code of ethics to meet criteria for humane technology.

Its website states: • Snapchat turns conversations into streaks, redefining how our children measure friendship.

• Instagram glorifies the picture-perfect life, eroding our self worth.

• Facebook segregates us into echo chambers, fragmenting our communities.

• YouTube autoplays the next video within seconds, even if it eats into our sleep.

I encourage you to view the TED talk by co-founder of Center for Humane Tech, Tristan Harris, entitled “How a Handful of Companies Control Billions of Minds Every Day.” On its website at http://humanetech.com/take-control there are tips to help us take control of our phones that include: • Turn off all notifications except from people.

• Go grayscale to decrease the brain’s shiny rewards to result in checking your phone less.

• Try keeping your home screen set to tools only to decrease mindless checking of other things.

• Then launch other apps by typing which is more purposeful.

• Charge your device outside the bedroom.

• Go cold turkey—remove social media from your phone.

• Send audio notes or call instead of texting—avoids misinterpretation.

• Texting shortcut: use quick reactions (icon for thumbs up, etc.).

• Download apps and extensions that help you live without distraction. Some examples include Flux (cuts blue light from your screen to aid sleep), Freedom (blocks specific websites or apps for set periods of time), Moment (see how much time you spend on your phone), Facebook Newsfeed Eradicator (removes FB newsfeed and blurs the sidebars and notifications), Distraction-Free YouTube (removes recommended videos from the side bar of YouTube to stop you from getting sucked in), etc.

Below are some things to consider implementing for yourself and having some shared decision-making with the young people in your life about creating structure around screen time for everyone: NOVEMBER 2018

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Pediatrics and Adolescent Medicine Be mindful when purchasing a new device (tablet, smartphone or gaming system) for your child. Ask yourself ahead of time if the age of your child is right for the device, what is the purpose of the device, and what rules do you want to have around its use.

Teach and model how to create social connection—no screens during mealtime, if having a conversation then put your phone down. Also try to allocate time, at least half an hour, to really be present with the people who are important in your life (mealtime or play a game together).

Remind everyone that it is OK to be uncomfortable or feel awkward in social situations. Help everyone to get comfortable with this so that the phone isn’t being used to avoid that feeling.

Teach about multitasking—we all think we are so good at it yet the research over and over again proves that we are not. This is important with work and also homework. A best practice is to remove the technology temptation for focused periods while doing homework or other work and then take a “tech break” to check in with your social media or relax by playing a game on your phone.

Parents need to set limits—create an acceptable technology curfew where all screens need to leave the bedroom and go to their charging station at a certain time each night. This should be between 30 and 60 minutes before lights out/bedtime.

Monitor time spent using screens—Apple’s Screen Time can be used to set overall limits or limits on specific apps. Another app is Moment, which can give usage reports/set limits (see resource below, Screenagers Parenting Apps).

Sign up for the Screenagers Tech Talk Tuesdays to receive a concise conversation starter to use with your family about social media, video game use, tech tips, latest research and more (www.screenagersmovie.com/tech-talk-tuesdays).

Create a screen time agreement or contract for all members of your family to agree to (www.screenagersmovie.com/ contracts).

Social media—there are benefits to it and then there can be harm. The downside is social comparison and the resulting impact to one’s self-esteem. The research shows that this is heightened for girls because most of the female social media posts are pictures of themselves so if the “likes” don’t come then it is a direct hit to their self-esteem. A protection against this is to encourage posts that are more artsy and not directly about themselves. The benefits of social media include improved family relationships through connection on social media, community engagement by being aware of activities around them, better connection with peers from all over the world, and increased creativity by using technology tools.

Technology is here to stay. We want to continue to strive for the balance of doing with being. Our goal should be to direct our attention to where we want it to go and not have it be manipulated through psychological means to keep us focused on things that don’t bring us joy. We do this by being mindful of our (and our children’s) use of technology. When we move away from our screens—only then can we be truly present to notice and connect with those around us and have our attention tending to those things that are most precious.

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Shannon Udovic-Constant, MD, is a former SFMMS President, pediatrician at Kaiser San Francisco, and trustee of the California Medical Association.

RESOURCES: • American Academy of Pediatrics’ HealthyChildren.org (www.healthychildren.org/english/family-life/media/Pages/ default.aspx): Offers lots of American Academy of Pediatrics health articles for parents on kids’ use of tech and screens.

• Center on Media and Child Health (http://cmch.tv/ parents): Offers research-based health guidance for parents on tech/screen time.

• Commonsense Media (www.commonsensemedia.org): Nonprofit organization helping parents make smart media choices with ratings and reviews for movies/games/apps/TV shows/books including recommended ages.

• Screen-Free Week (www.screenfree.org/basics): Offers resources for parents on the effects of screen time.

• Center for Humane Technology (http://humanetech.com): Former tech insiders and CEOs working to promote humane design standards, policy and business practices for technology.

• Screenagers (www.screenagersmovie.com/parenting-apps): A website promoting the movie. Also offers parenting apps including Screentime Management apps.

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STEPPING OUT OF THE WALLS OF THE CLINIC: INTEGRATING HEALTH AND EDUCATION Ryan Padrez, MD

As with many patients at a community safety net clinic, my 24-month-old patient screened positive for speech delay on the Ages and Stages Questionnaire (ASQ). Other aspects of development appeared to be on track, but the boy had only two real words, putting his speech well behind for his age. I explained my concerns to the mother and assessed her readiness to engage with outside developmental supports.

I made a referral to audiology to rule out hearing loss, a referral to Early Start for speech services; and I passed out books to encourage more reading at home. I asked the family to make a follow-up appointment with me in two months to ensure the child was getting appropriate support. But now this Spanishspeaking mother needed to navigate a complex web of services in order to get her son on track.

These systems are complex for anyone, but they are particularly difficult for those with low English proficiency and other stressors at home. The child missed his follow-up appointment with me two months later, the cell phone was disconnected, and when he returned for his 3-year-old visit he was even further delayed. During the year between our appointments I also learned the family lost their housing and that the mother had separated from the child’s father due to domestic violence.

With unaddressed speech delay and toxic stress in the home, I was deeply concerned about this child’s ability to be ready for kindergarten.

The evidence is clear that children who enter school “kindergarten ready” are more likely to achieve reading proficiency by end of third grade and ultimately succeed academically. “Kindergarten ready” means having age-appropriate skills across five domains: cognitive development, language development, physical development, self-help skills, and social emotional development. Children who enter school behind their peers are more likely to drop out of school, experience teen pregnancy or be incarcerated as juveniles.¹ To achieve kindergarten readiness, the health and education systems need to work together instead of staying in their current silos. Integration across systems is critical for addressing developmental needs and also the impacts of toxic stress and other social determinants of health that can profoundly compromise a child’s ability to be ready for kindergarten. I like the focus on kindergarten readiness because it is an outcome of how well our systems are doing. Unfortunately, California continues to have among the largest gaps in school readiness in the nation.² As a pediatrician working in the safety net system, I get limited and unpredictable time with my patients and families. When 46% of households with children in California report experiencing a significant traumatic experience in the home and close to 40% on my panel screens at risk for a developmental delay, the WWW.SFMMS.ORG

current annual 15-minute well-child visit for my young patients is not sufficient.³ There is much more we need to do if we want to achieve kindergarten readiness, overcome impacts of toxic stress, and ultimately close equity gaps in the health outcomes we desire for all kids.

We need to move away from a system of referrals and paper hand-outs for social and developmental services, to one with better integration, more precise screening and seamless coordination of family-centered services. The scenario of my 3-yearold with a speech delay who lives in a home with toxic stress is becoming all too prevalent, and pediatricians are yearning for new systems that can do better. Many of my colleagues working in primary care with vulnerable populations are burned out due to their inability to effect change for many of their patients.

Feeling the same frustrations, two years ago I stepped outside the walls of the clinic to work more closely with the education system as the Medical Director of a new school in East Palo Alto called The Primary School. Founded by my pediatric colleague and former co-resident, Dr. Priscilla Chan, I was drawn to the mission of the school: “to foster each child’s well-being as a foundation for academic and life success by drawing on the strengths of the child’s entire community including the family, educators, medical, and mental health providers.”

Fueled by the belief that the current definition of school is too limited to close the achievement gap for our nation’s most at-risk children, we are designing a new model of integrated primary education and primary healthcare that braids together education, health and family-support services. Our approach rests on three key premises: 1) we need to start much earlier than kindergarten; 2) we need to partner with parents; and 3) we need to take a whole child approach that integrates health and education services.

We are now in our third year as a program with 250 lowincome children enrolled from East Palo Alto. Our students span from 1 to 6 years old, with early childhood playgroup programming for infants and toddlers, full-day preschool for 3- and 4-year-old students, and kindergarten and first grade offered this year. Our programs care deeply about trauma-informed practices and building an environment that fosters resiliency for all of our students and families. We also seek to build a system around the needs of the child, rather than by siloed content area.

This means bringing multi-disciplinary teams together, including at times the voice of the pediatrician into the school.

In building the model, we are keeping a sharp focus on creating programs that are scalable and sustainable in a public system. We look for unique ways to utilize public funding and rely heavily on partners to ensure we are not duplicating services already offered in the community. This also includes our NOVEMBER 2018

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Pediatrics and Adolescent Medicine pediatric services. Rather than build out a new, independent school-based health clinic, we have elected to partner with our community’s existing pediatric medical homes. For most families this is a neighboring federally qualified health center, Ravenswood Family Health Center.

My two-year journey at The Primary School has been filled with incredible opportunities to learn from families and our staff about how to build a team-based approach that can better support students with health and developmental needs. It has also been filled with realizations that this work is challenging.

Some early lessons learned include: Systems do not make communication easy between education and healthcare. This includes overcoming barriers of HIPAA and FERPA consents as well as lack of interoperability of healthcare’s electronic health records.

When trying to build a team from so many different disciplines, it can be difficult to align on the best approach, or even ensure that everyone is speaking the same language.

New approaches are needed to overcome common health barriers to learning including developmental services, vision deficits, dental carries, asthma control, and addressing mental health, especially for those on Medicaid.

We still have a long way to go to achieve our goals at The Primary School. We make many mistakes but are also learning better ways to bring our mission to life for our students and families in East Palo Alto. In the future we hope our model can influence systems of care and help other communities transform their approach to health and education. In the short term, my

hope is that for patients like my 3-year-old with speech delay and toxic stress at home we have helped to build an approach that works better.

Ryan Padrez, MD, is the Medical Director at The Primary School and Assistant Clinical Professor of Pediatrics at Stanford University School of Medicine. While at The Primary School he continues to care for patients and teach pediatric residents and medical students at Gardner Packard Children’s Health Center. He completed his pediatric residency at UCSF and participated in UCSF’s Pediatric Leadership for the Underserved (PLUS) program. He is a former board member of the San Francisco Medical Society.

References 1

Fiscella K, Kitzman H, “Disparities in academic achievement and health: The intersection of child education and health policy,” Pediatrics 123, 1073–1080 (2009).

2. “Getting Down to Facts II: Current Conditions and Paths Forward in California Schools,” Stanford University and Policy Analysis for California Education (PACE), September 2018.

Accessed on Sept. 28, 2018, at: http://gettingdowntofacts.com/sites/default/files/2018-09/ GDTFII%20Summary%20Report.pdf.

3. Rodriguez D, et al, “Prevalence of adverse childhood experiences by county, California Behavioral Risk Factor Surveillance System 2008, 2009, 2011, and 2013,” Public Health Institute, Survey Research Group (2016).

THE LATEST CHALLENGES AND REWARDS Tracey DeAmicis McMahan, MD AS A GENERAL PEDIATRICIAN, I love that medicine con-

stantly evolves. I am privileged to see a lot of changes firsthand, from my youngest to my oldest patients. While doing nursery rounds, I have witnessed the practice of head cooling.

When an infant is born with symptoms of birth asphyxia, some qualify for a protocol that cools their entire body over 72 hours to preserve metabolism and brain function. The improved developmental outcomes are impressive.

In our infant patients, we now recommend probiotics for managing colic.

A few months older, thanks to the Israeli peanut studies, we now know that we can and probably should challenge infants as young as 6 months with small tastes of peanut and other allergic foods as a way to build up their immunity and make them less allergic.

In school age children, we routinely screen for guns in the home as we are painfully aware of the devastating effects of gun violence in schools.

Our children are growing up during stressful times, thus we screen for and see a lot of anxiety and depression. Fortunately, I have watched many patients improve with cognitive behavioral therapy.

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The HPV vaccine, originally marketed to young girls as the cervical cancer vaccine, has now been shown to prevent many other cancers so we routinely give it to boys, too.

In adolescent patients, we have seen more high-risk behaviors since the introduction of vaping and juuling and since the legalization of marijuana, which is heavily marketed to this population. These concentrated toxins are highly addictive and transform our adolescents’ developing brains, and we see the ill effects firsthand.

While we continue to try to battle what our children are exposed to on the internet and the time they spend on it, we are forced to do more of it. Because of electronic medical records, we try to have healthy doctor-patient relationships without a screen between us, but we stay late at work charting and answering emails. Being a doctor means staying abreast of all these changes, and I am grateful for my job each day.

Dr. McMahan is a general pediatrician at Golden Gate Pediatrics, with offices in San Francisco and Mill Valley.

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Pediatrics and Adolescent Medicine

SCHOOL OF HARD KNOCKS: CONCUSSION CARE IN MARIN COUNTY Jeanne-Marie Sinnott, DO

With youth sports growing in popularity and the scientific community learning more and more about the detrimental longterm health effects of repetitive head injury, concussion is in the spotlight.

According to the CDC, more than 800,000 children seek treatment for traumatic brain injury each year. Most concussions (90%) occur without loss of consciousness, and they can occur even without a direct blow to the head. Symptom onset can occur up to 3 days following the injury, and it’s not always a simple diagnosis. Patients with a history of migraine or mood disorders can paint a confusing clinical picture, and, when diagnosed with concussion, are likely to have persistent symptoms.

Children ages 12 and under can be expected to take up to 4 weeks to recover from a concussion, although the prognosis for children and adolescents varies widely and studies in this age group are lacking.

Research is ongoing on the long-term effects of repeated blows to the head in contact sports, and what role concussions play in the eventual development of conditions like dementia, depression and chronic traumatic encephalopathy (CTE).

While we don’t have proof that concussions lead to CTE, we do know that returning to play prematurely, not allowing for sufficient recovery, places children at risk for having another concussion, and even worse, at risk for the devastating “second impact syndrome” which, although very rare, is often fatal.

On January1, 2017, California Assembly Bill 2007 (AB 2007) took effect statewide. AB 2007 applies to youth sports organizations for athletes age 17 and under in a list of 27 sports from football and hockey to roller derby and parkour. Under AB 2007, “an athlete who is suspected of sustaining a concussion shall be immediately removed from the athletic activity for the remainder of the day, and shall not be permitted to return to any athletic activity until he or she is evaluated by a licensed healthcare provider . . . and receives written clearance to return to (play). If the licensed healthcare provider determines that the athlete sustained a concussion or other head injury, the athlete shall also complete a graduated return-to-play protocol of no less than seven days in duration.”

The bill requires schools to recognize signs and symptoms of concussion, whether they occurred in or outside of schoolsponsored activity, and whether they are confirmed/diagnosed by a licensed healthcare provider or not.

For the sports medicine community, this is nothing new.

The mantra “when in doubt, sit them out” dates back to the 1st international consensus statement issued by the Concussion in Sport Group in 2001, which also outlined a 6-step return to play protocol. But this legislation puts a lot more responsibility 26

on schools and coaches to have protocols in place that keep our kids safe and ensure proper follow-up.

In response to AB 2007 and the increased awareness of the incidence of youth concussions and their long-term consequences, there has been a call for countywide protocols standardizing concussion reporting and management. ConcussionSmart Marin was formed in 2017 and is a group of physicians, certified athletic trainers, and representatives from Marin County Office of Education, Health and Human Services, Marin County School Nurses, and the Schurig Center for Brain Injury Recovery. The group is working to educate the community and inform physicians, coaches, athletic trainers and parents about the latest research and guidelines on treating and preventing youth concussions.

ConcussionSmart Marin has collaborated with Marin County schools to develop protocols for keeping track of students with concussions and ensure they complete Return to Learn and Return to Play progressions under the guidance of their physician. On the physician end, we have been working to improve the coordination of care between emergency departments, primary care physicians and sports medicine specialists. At Kaiser San Rafael, a multi-specialty concussion committee has been formed to improve the workflow of concussion care across the appropriate specialties.

What’s New in Concussion Treatment?

Until recently, there were no evidence-based clinical guidelines for the treatment of concussion specific to the pediatric population, but that changed in September when the CDC issued its first guidelines on management of mild traumatic brain injury (mTBI) in children.

There are 19 guidelines, and they summarize the 5 “key practice-changing recommendations”: Do not routinely image pediatric patients to diagnose a mild traumatic brain injury. Reserve imaging for patients with red flag symptoms or in cases when you suspect a skull fracture or bleed. I tell patients that concussion is an injury to the function of the brain, but not the structure, and therefore doesn’t show up on imaging.

Use validated, age-appropriate symptom scales to diagnose a concussion. The most widely-used symptom scales are the SCAT5 (ages 13+) and SCAT5 Child (ages 5–12). Computerized neuro-cognitive evaluations such as ImPACT are useful in high school athletes, especially if a baseline (pre-season) score is available for comparison.

Assess for risk factors for prolonged recovery, including (Text continues on page 29)

SAN FRANCISCO MARIN MEDICINE NOVEMBER 2018 WWW.SFMMS.ORG

Concussion RETURNConcussion TO LEARN (RTL) Protocol Return to Learn (RTL) Protocol Instructions: • • • • •

Keep brain activity below the level that causes worsening of symptoms (e.g., headache, tiredness, irritability).

If symptoms worsen at any stage, stop activity and rest.

Seek further medical attention if your child continues with symptoms beyond 7 days.

If appropriate time is allowed to ensure adequate brain recovery before progressing mental activity, your child may have a better outcome (do not try to rush through these stages).

Please give this form to teachers/school administrators to help them understand your child’s recovery.

Stage

Brain Rest

Home Activity • Rest quietly, nap and sleep as much as needed • Avoid bright light if bothersome • Drink plenty of fluids and eat healthy foods every 3-4 hours • Avoid "screen time" (text, computer, cell phone, TV, video games)

School Activity

Physical Activity • Walking short distances to get around is okay • No strenuous exercise • No driving

• No school • No homework or take-home tests • Avoid reading and studying

Progress to the next stage when your child starts to improve, but may still have some symptoms

Restful Home Activity

• Set a regular bedtime/wake up schedule • Allow at least 8-10 hours of sleep and short naps if needed (less than 1 hour) • Drink lots of fluids and eat healthy foods every 3-4 hours • Limit "screen time" to less than 30 minutes total a day; use large font

• • • •

No school May begin easy tasks at home (drawing, baking, cooking) Soft music and ‘books on tape’ okay Once your child can complete 60-90 minutes of light mental activity without a worsening of symptoms they may go to the next step

• Progress physical activity, like untimed walking • No strenuous physical activity or contact sports • No driving

Progress to the next stage when your child starts to improve and has fewer symptoms

Return to School PARTIAL DAY

• Allow 8-10 hours of sleep per night • Limit napping to allow for full sleep at night • Drink lots of fluids and eat healthy foods every 3-4 hours • "Screen time" less than 1 hour a day • Limit social time outside of school

• Gradually return to school • Start with a few hours/half-day • Take breaks in the nurse’s office or a quiet room every 2 hours or as needed • Avoid loud areas (music, band, choir, shop class, locker room, cafeteria, loud hallway and gym) • Use brimmed hat/earplugs as needed. Sit in front of class • Use preprinted large font (18) class notes • Complete necessary assignments only • No tests or quizzes. Limit homework time • Multiple choice or verbal assignments better than long writing assignments • Tutoring or help as needed • Stop work if symptoms increase

• Progress physical activity and as instructed by physician • No strenuous physical activity or contact sports • No driving

Progress to the next stage when your child can complete the above activities without symptoms

Return to School FULL DAY

• Allow 8-10 hours of sleep per night • Avoid napping • Drink lots of fluids and eat healthy foods every 3-4 hours • "Screen time" and social activities outside of school as symptoms tolerate

• • • • • •

Progress to attending core classes for full days of school Add in electives when tolerated No more than 1 test or quiz per day Give extra time or untimed homework/tests Tutoring or help as needed Stop work if symptoms increase

• Progress physical activity and as instructed by physician • No strenuous physical activity or contact sports • Okay to drive

Progress to the next stage when your child has returned to full school and is able to complete all assignments/tests without symptoms Full Recovery

• Return to normal home and social activities

• Return to normal school schedule and course load

• Start CIF Return to Play Protocol

Source: CIF: http://www.cifstate.org/sports-medicine/concussions

** Guidelines adapted from Cincinnati Children’s Hospital Return to Learn Protocol

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• After Stage I, you cannot progress more than one stage per day (or longer if instructed by your physician).

• If symptoms return at any stage in the progression, IMMEDIATELY STOP any physical activity and follow up with your school’s AT, other identified concussion monitor, or your physician. In general, if you are symptom-free the next day, return to the previous stage where symptoms had not occurred.

Concussion RETURN TO PLAY (RTP) Protocol • Seek further medical attention if you cannot pass a stage after 3 attempts due to concussion symptoms, or if you feel uncomfortable at any time during the progression.

You must have written physician (MD/DO) clearance to begin and progress through the following Stages as outlined below, or as otherwise directed by your physician. Minimum of 6 days to pass Stages I and II. Date & Initials

Stage

Activity

Exercise Example

Objective of the Stage

Limited physical activity for at least 2 symptom-free days.

• Untimed walking okay • No activities requiring exertion (weight lifting, jogging, P.E. classes)

• Recovery and elimination of symptoms

II-A

Light aerobic activity

• 10-15 minutes (min) of brisk walking or stationary biking • Must be performed under direct supervision by designated individual

• Increase heart rate to no more than 50% of perceived maximum (max) exertion (e.g.,< 100 beats per min) • Monitor for symptom return

II-B

Moderate aerobic activity (Light resistance training)

• 20-30 min jogging or stationary biking • Body weight exercises (squats, planks, pushups), max 1 set of 10, no more than 10 min total

• Increase heart rate to 50-75% max exertion (e.g.,100-150 bpm) • Monitor for symptom return

II-C

Strenuous aerobic activity (Moderate resistance training)

• 30-45 min running or stationary biking • Weight lifting ≤ 50% of max weight

• Increase heart rate to > 75% max exertion • Monitor for symptom return

II-D

Non-contact training with sport-specific drills (No restrictions for weightlifting)

• Non-contact drills, sport-specific activities (cutting, jumping, sprinting) • No contact with people, padding or the floor/mat

• Add total body movement • Monitor for symptom return

I

Prior to beginning Stage III, please make sure that written physician (MD/DO) clearance for return to play, after successful completion of Stages I and II, has been given to your school’s concussion monitor.

III

Limited contact practice

• Controlled contact drills allowed (no scrimmaging)

Full contact practice Full unrestricted practice

• Return to normal training, with contact • Return to normal unrestricted training

• Increase acceleration, deceleration and rotational forces • Restore confidence, assess readiness for return to play • Monitor for symptom return

MANDATORY: You must complete at least ONE contact practice before return to competition, or if non-contact sport, ONE unrestricted practice (If contact sport, highly recommend that Stage III be divided into 2 contact practice days as outlined above) IV

Return to play (competition)

Source: CIF: www.cifstate.org/sports-medicine/concussions.

Student’s Name: ___________________________

• Normal game play (competitive event)

• Return to full sports activity without restrictions

Source: CIF: http://www.cifstate.org/sports-medicine/concussions

Date of Injury: _____________

Date of Concussion Diagnosis: ________________

CIFSTATE.ORG

Revised, 10/2017 CIF

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Anniversary

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(Continued from page 26)

history of concussions or other brain injury, severe symptom presentation immediately after the injury, and personal characteristics and family history. Children with history of previous concussion, learning difficulty, neuro or psychiatric conditions, lower socioeconomic status, and Hispanic race/ethnicity (compared with white) are likely to take longer to recover from concussion. Also, headaches persist longer in girls than in boys.

Provide patients and their parents/caregivers with instructions on returning to activity customized to their symptoms.

Returning to school and sport should be done gradually in a stepwise approach. Schools should allow for academic accommodations to allow students to participate in school without exacerbating their symptoms. The California Interscholastic Foundation (CIF) offers a school accommodation form on its website, which physicians can use to communicate with schools when treating a child with concussion.

Counsel patients and their parents/caregivers to return gradually to non-sports activities after no more than 2 to 3 days of rest. Historically, “rest” has been the cornerstone of treatment of concussion. But recent studies have shown that it is safe, and even beneficial, to return to light activity after an initial period (about 3 days) of physical and cognitive rest. Longer amounts of inactivity may worsen symptoms, and in patients with prolonged symptoms (>4 weeks), aerobic activity (below symptom exacerbation level) can speed recovery. I tell families that activities like walking the dog, as long as they don’t worsen symptoms, are OK in the initial period.

Jeanne-Marie Sinnott, DO, is with the Department of Family & Sports Medicine, Kaiser San Rafael.

Resources available for physicians: The CDC offers free online courses through its HEADS UP Initiative (www. cdc.gov/headsup). Online videos, PDFs and mobile apps are available geared to parents, athletes, coaches, and healthcare providers. Providers can earn CME by completing the online concussion training program.

The ConcussionSmart Marin website (www.Concussion SmartMarin.org) also offers a list of helpful tools and links to help physicians manage youth concussions and communicate effectively with schools and coaches regarding patients’ progress.

California Interscholastic Foundation (CIF): PDFs available to print, including Return to Play and Return to Learn protocols, school accommodation form, school letter templates, and symptom checklists—www.cifstate.org/sports-medicine/ concussions.

Advanced care for women with complex conditions.

Doctors at the new CPMC Mission Bernal campus specialize in complex care for women.

Our expertise includes maternal-fetal medicine, urogynecology, breast surgery and breast health. We work closely with referring doctors to manage and coordinate care for complex conditions.

To refer a patient call 888-630-6914 or email ssn@sutterhealth.org.

Sutter EHR messaging: P Sutter Specialty Network All other EHRs, Direct Address: sutter_specialty_network47810139@hisp.ehr.sutterhealth.org

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Pediatrics and Adolescent Medicine

IMPROVING PUBLIC HEALTH EQUITY FOR CHILDREN AND FAMILIES Curtis Chan, MD, MPH, Anda Kuo, MD, and Tomás J. Aragón, MD, DrPH PUBLIC HEALTH DEPARTMENTS, non-profit hospitals, and

governmental agencies conduct periodic “community assessments” to understand the health conditions of their patients and communities; which direct further planning and policy development. Healthcare providers are important informants to these “assessment” processes, because they care for many patients across communities likely to “represent the broad interests of the community,” and they understand the various healthcare systems.

Two important “community health assessments” conducted throughout the country are: • Community Health Needs Assessments (CHNA). By the Patient Protection and Affordable Care Act (ACA), tax-exempt hospitals are required to conduct a community health needs assessment (CHNA) every three years.

• Maternal & Child Health, Needs Assessment. The Title V (of the Social Security Act of 1935) Maternal and Child Health Service Block Grant requires that all states complete a comprehensive needs assessment every five years.

The 2014 Needs Assessment process identified 15 major health problems affecting mothers, children, and adolescents, along with annual data to measure outcomes. Stakeholders have further categorized these programs into four health impact areas (“Root Causes”): Social inequities that disproportionately impact the health of mothers and children:

1. Black maternal and infant health. Racism in its different forms (e.g., structural, institutionalized, personally mediated, internalized) cause worse outcomes for black women and infants, including maternal hypertension and obesity; and preterm birth and infant mortality.

2. Inadequate and unaffordable housing disproportionately affect the health of low-income families.

Toxic Stress and inequitable resources during early childhood cause a life course of health disparities: 3. Preterm Births. Babies were more likely to be born preterm or with low-birth weight among women with specific risk factors— poverty/Medi-Cal insured, Latina, Black, working, smoking, and obese.

4. Infant formula and breastfeeding. By two months old, 77% of infants of low-income families are fed infant formula, instead of exclusively breastfed as recommended.

5. Early childhood obesity. Nutrition and physical activity inequities are causing overweight (13%) and obesity (18%) among young children of low-income families in San Francisco.

6. Childhood dental decay. 34% of SFUSD kindergarteners have experienced dental caries.

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7. Child Abuse. 5.5% of SF children have experienced substantiated abuse or neglect.

8. Stress of special healthcare needs. Parents of children with special healthcare needs have increased stress because of health concerns, fragmented services, and lack of support.

9. Physical inactivity. Half of Latino (51%) and Black (48%) SFUSD 5th graders failed the Fitnessgram standards for aerobic capacity, twice the rates of White (26%) and Asians (23%).

Psychosocial health during preconception and perinatal periods: 10. Adolescent depression & suicidality. 26% of high school students (SFUSD) are feeling sad or hopeless.

11. Preconception and prenatal drug abuse. Women abusing drugs have poor health and social outcomes for themselves, but also poor pregnancy, birth, and infant outcomes.

12. Intimate partner violence during pregnancy. One in 10 women with Medi-Cal in SF experience intimate partner violence during pregnancy.

13. Perinatal depression. One in six mothers with Medi-Cal in SF suffer from postpartum depression, three times higher than those with private insurance (18.2% vs. 5.5%).

Equitable access to healthcare for young women: 14. Primary care utilization for young women. In San Francisco and other counties, women with Medi-Cal are significantly less likely to have regulary primary care and reproductive care compared to women with private insurance.

15. Prenatal care access. 30% of pregnant women with Medi-Cal missed first-trimester prenatal care, six times higher than those with private insurance (30% vs. 5%).

— SFDPH 5 Year Action Plan 2016–2020

Root Causes of Children’s Health Inequities: –1– Social inequities that impact the health of mothers and children; –2– Toxic stress & inequitable resources during early childhood; –3– Psychosocial health during preconception and perinatal periods; –4– Equitable access to healthcare for young women.

The San Francisco Department of Public Health emphasizes a life course approach to assessing community health status and public health practice. Dr. Paula Braveman summarizes this as “how early-life experiences can shape health across an entire lifetime and potentially across generations; it systematically directs attention to the role of context, including social and physical context along with biological factors, over time.

SAN FRANCISCO MARIN MEDICINE NOVEMBER 2018 WWW.SFMMS.ORG

Mechanism: Root Causes of Children’s Health Inequities Disease during childhood and life course

Inequitable Access to resources and services

Biological, Brain Development – mental health, adaptive behaviors –

Toxic Stress Poor Living and Working Conditions — SFDPH Model developed from survey and focus groups conducted by 2014 Community Needs Assessment

Skyrocketing income inequality and costs-of-living exacerbate the living and work condition inequities that cause toxic stress and many health disparities affecting young women, children, and families. Toxic stress affects biological disease processes directly, fractures mental health, and increases likelihood of harmful WWW.SFMMS.ORG

He alt hc are

This approach is particularly relevant to understanding and addressing health disparities, because social and physical contextual factors underlie socioeconomic and racial/ethnic disparities in health.”

Thus, the four health impact areas are linked together through a life course approach and other inter-generational models of understanding health inequities. Dr. Braveman provides a model and examples of how health professionals can not only provide “medical care” and educate on “personal behavior” in their daily job, but they can utilize their experience and knowledge to inform the policies that shape “living and working conditions” in the San Francisco Bay Area; and the overall “economic and social opportunities.”

In San Francisco, communities have emphasized “toxic stress” as the intermediary mechanism between “living and working conditions” and inequitable access to “opportunities and resources.”

Disease Treatment Efficiency

Preventive Services Quality

Social and Institutional Determinants of Childhood Health in SF

Access & Utilization Equity

De So ter cia mi l na nt s

— Dr. Paula Braveman, 2009

behaviors. Despite the additional burden of toxic stress in a very expensive city, low-income and under-represented communities have less access and fewer choices, including those for education, child and youth development, recreation, housing, and healthcare services.

Whereas much of the 200+ year history of the United States was fueled by colonialism, capitalism, and racism, the living and working conditions in San Francisco can also be shaped locally toward health equity. Our city’s “built environment” and “social environment” have been influenced by the cultural and social conditions that we’ve created. As described by our model with community partners below, equitable distribution of economic and educational opportunity across race and class is the major determinant of children’s health.

Built Environment Neighborhoods, roads, parks, workplaces, schools, homes

Social Environment

Education, employment, housing, community cohesion, social network

General Socioeconomic Conditions Economy, wealth distribution, racism

Model developed in collaboration with community representatives from Coleman Advocates for Children & Youth, UCSF in 2015.

Social Determinants of Children’s Health As health leaders are increasingly understanding their communities’ health problems and their root causes, health organizations and medical professional organizations in the San Francisco Bay Area have become committed to improving the social determinants of children’s health. Health providers have valuable perspectives on the living and working conditions that cause toxic stress and impact health.

Medical practice and public health are both based upon science and data, which are essential for advancing health equity and social progress. In the following issues, SFDPH will describe various approaches to addressing the social determinants of children’s health.

Developing partnerships with the medical society can significantly advance these approaches, including: primary prevention, legislative and institutional policy development, and collective action. Finding solutions for the 15 health problems will require access to healthcare, quality healthcare, and strong collaborations to address the social determinants of health.

Curtis Chan, MD, MPH, is Medical Director of Maternal, Child & Adolescent Health and Deputy Health Officer, San Francisco Department of Public Health. Anda Kuo, MD, is Professor of Pediatrics at UCSF and practices at the Children’s Health Center at Zuckerberg San Francisco General Hospital. Tomás J. Aragón, MD, DrPH, is Health Officer, City & County of San Francisco and Director, Population Health Division, SFDPH. NOVEMBER 2018

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UPCOMING EVENTS 2018 AMPAC Campaign School December 6–9, 2018 | AMA Office, Washington, D.C.

COMMUNITY NEWS

The 2018 AMPAC Campaign School is targeted to AMA members, their spouses, residents, medical students and medical society staff who want to become more involved in the campaign process. Visit http://www.ampaconline. org/political-education/ampac-campaign-school/ for more information.

KAISER PERMANENTE

SFMMS is pleased to be co-hosting a Holiday Mixer on December 11 at the South Beach Yacht Club with the Northern California Medical Group Management Association. This is a free event for SFMMS members and their guests, but registration is required. For more information or to RSVP, visit

Physicians often face challenges in treating adolescent

Holiday Mixer December 11, 2018, 5:30 pm to 8:30 pm | South Beach Yacht Club, San Francisco, CA

https://sfmms.pingg.com/sfmmsholidaymixer.

2019 SFMMS Annual Gala Friday, January 25, 2019 | Cavallo Point, Sausalito, CA

Purchase your tickets for the 2019 SFMMS Annual Gala! President-Elect, Kimberly Newell Green, MD, will be installed as the 2019 SFMMS President. Watch for your invitation to arrive in the mail. Tickets may be purchased online at www.sfmms.org/events.aspx. Sponsorship opportunities are available—contact Erin Henke at ehenke@sfmms.org or (415) 561-0850 x268.

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and teenage patients who may be reluctant to seek help for certain issues and conditions, or who may not be compliant with treatment protocols. For this reason, Kaiser Permanente San Francisco established a teen clinic more than 30 years ago to provide the services young patients need to stay healthy.

Serving patients between the ages of 9 and 18, the teen clinic is a general practice providing exams, immunizations, sports physicals, and general medical care. The clinic is staffed by pediatricians and led by Melissa Slivka, MD, who is fellowship certified in Adolescent Medicine at the University of California San Francisco.

Reproductive and sexual health are important areas of care for teens, and the clinic provides birth control, testing for pregnancy and sexually transmitted infections, and counseling for personal and family problems. Emergency contraceptives are available, as are long-acting reversible contraception methods such as IUDs and implants.

Our teen clinic respects its young patients’ privacy in making and scheduling appointments for sensitive issues and providing test results and treatment. Booking, charting, and billing can be coded for confidentiality in the electronic medical record.

We also screen all adolescent patients for drug and alcohol abuse, eating disorders, depression, anxiety, and suicidality. Our clinic makes referrals and works closely with psychiatrists and counselors. We stay up to date on the current issues facing teens, which include media and screen addiction and related stress, anxiety, and depression.

We also help adolescents manage ongoing health issues such as asthma, chronic migraine, and abdominal pain; learn how to manage their treatment effectively, and stay active in school and extracurricular activities. The teen clinic also works closely with schools in cases that require communication, coordination, and accommodation.

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