March 2016 by SMCMA

S a n M at e o C o u n t y

March 2016

Physician

IN S ID E

S A N M AT E O C O U N T Y M E D I C A L A S S O C I AT I O N

Volume 5 Issue 3

Group walking seems to boost overall health

Five tips to prevent or mitigate physician burnout

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S a n M at e o C o u n t y

Physician Editorial Committee

March 2016 - Volume 5, Issue 3

Russ Granich, MD, Chair; Judy Chang, MD; Uli Chettipally, MD; Sharon Clark, MD; Carri Allen Jones, MD; Edward Morhauser, MD; Gurpreet Padam, MD

Columns

Sue U. Malone, Executive Director Shannon Goecke, Managing Editor

SMCMA Leadership Michael Norris, MD, President; Russ Granich, MD, President-Elect; Alexander Ding, MD, SecretaryTreasurer; Vincent Mason, MD, Immediate Past President Alex Lakowsky, MD; Richard Moore, MD; Michael O’Holleran, MD; Joshua Parker, MD; Suzanne Pertsch, MD; Xiushui (Mike) Ren, MD; Sara Whitehead, MD; Douglas Zuckermann, MD; Dirk Baumann, MD, AMA Alternate Delegate; Scott A. Morrow, MD, Health Officer, County of San Mateo;

Editorial/Advertising Inquiries San Mateo County Physician is published ten times per year by the San Mateo County Medical Association. Opinions expressed by authors are their own and not necessarily those of the SMCMA. San Mateo County Physician reserves the right to edit contributions for clarity and length, as well as to reject any material submitted. Acceptance and publication of advertising does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised. For more information, contact the managing editor at (650) 312-1663 or sgoecke@smcma.org.

President’s Message: Burnout: An epidemic.............................................. 5 Michael Norris, MD

Executive Report: SMCMA members, help us serve you better................ 7 Sue U. Malone

Feature Articles Group walking seems to boost overall health. . ....................................... 8 Henry A. Solomon, MD, and Dorothy Caputo, RN

Five steps to prevent or mitigate physician burnout. . .......................... 10 Samanta Meltzer-Brody, MD, MPH

Of Interest SMCMA welcomes new members..........................................................13 Membership updates, classified ads, index of advertisers. . ................14

On the cover: Russian Ridge Open Space Preserve, by Flickr user Calwhiz (https://www.flickr.com/photos/calwhiz). Reprinted with permission under Flickr Creative Commons license. Russian Ridge will be one of the sites of the SMCMA’s 2016 Walk with a Doc program. See page 6 for more information.

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4 SAN MATEO COUNTY PHYSICIAN | MARCH 2016

President’s Message

Burnout: An epidemic Several articles about physician burnout recently caught my eye. A survey conducted by the Mayo Clinic and the AMA involving 7,000 respondents revealed that 54 percent experienced at least one symptom of burnout. The same surveyors compared this result with their study done three years earlier, when 46 percent of physicians had demonstrated a burnout symptom. Another study, published by Medscape in 2015, noted a physician self-reported burnout rate of 46 percent. There appears to be an epidemic spreading among American doctors, yet no one is talking about it. The reasons for the silence are ingrained in the physician’s DNA, hardened during residency, when we were praised for being “strong” and criticized for being “weak.” How many of us learned quickly to never complain about lack of sleep, or the absence of life outside the hospital? “If you’re only on call every other night, you’re missing half the good cases,” one might say. Or, “If the program wanted you to have a spouse, they would have issued you one.” We were the Marines of medicine, and like the postwar cases of PTSD, we are now suffering, potentially leading to poor decision making, poor patient outcomes, family turmoil and substance abuse.

Michael Norris, MD President

What is burnout? The AMA has developed a list of seven symptoms: 1. 2. 3. 4. 5. 6. 7.

You have a high tolerance to stress. Your practice is exceptionally chaotic. You don’t agree with your boss’ values or leadership. You’re the “emotional buffer” for patients. Your job constantly interferes with family events. You lack control over your work schedule and free time. You don’t take care of yourself.

The passing of the torch...

According to an often-quoted assessment tool, the Maslach Burnout Inventory, burnout may present as: 1. Emotional exhaustion: feelings of being emotionally overextended, depleted, and exhausted by one’s work. 2. Depersonalization: Negative or inappropriate attitudes toward patients and coworkers, irritability, and loss of idealism. 3. Reduced personal accomplishment: lessoned productivity, decreased morale, social withdrawal, and an inability to cope. The front page headline of the March issue of Plastic Surgery News reads “Breaking the silenceShining a light on surgeon burnout is vital to doctor’s health, patient safety.” So, how do we go about “shining a light” and “breaking the silence”? It begins with conversation, caring and compassion for our fellow docs. We have been in the closet about this problem and need to discuss it openly and honestly. SMCMA once had a Physician’s Wellness committee, charged with helping “doctors with problems.” This committee is no longer in place, but we need to reestablish a forum for communication of our mutual issues, without fear of being seen as “weak.” Kaiser-Permanents has taken the lead in offering their physicians an assist. I am interested in opening up a dialogue on this problem. I would like to hear from members with their individual thoughts on this epidemic. I can be reached via my personal secure e-mail at mnor0213@att.net. My cell phone is 415-608-5776. Maybe you are one of the minority not yet afflicted with the burnout virus. Or, you may be like the chairman of a surgery department at a Midwest medical school, who, after looking at the list of the seven symptoms, concluded that he had all seven. Best wishes. ■

How many of us learned quickly to never complain about lack of sleep, or the absence of a life outside the hospital? “If you’re only on call every other night, you’re missing half the good cases,” one might say. Or, “If the program wanted you to have a spouse, they would have issued you one.”

MARCH 2016 | SAN MATEO COUNTY PHYSICIAN 5

San Mateo County Medical Association Community Service Foundation

WALK with a DOC 2016 Walk with a Doc is a free program of the SMCMA Community Service Foundation in which community members enjoy a walk with local physicians while discussing healthy living and health-related issues along the way. Our 2016 program will feature 26 walks at 13 picturesque locations throughout San Mateo County. Walks take place on Saturday morning, at 10:00 a.m., from April 2 through October 15, 2016, excluding holiday weekends. The programâ&#x20AC;&#x2122;s success relies heavily on the participation of our physicians. You can help by attending one or more walks as a physician volunteer and/or advertising Walk with a Doc to your patients. Dates and locations are posted at smcma.org/walkwithadoc.

2016 Walks by DATE April 2: San Mateo - East SF Bay Trail at Seal Point Park

June 25: S San Francisco SF Bay Trail from Oyster Point Park

April 9: Foster City SF Bay Trail @ Shorebird Park

July 9: Burlingame Anza Lagoon

April 16: Belmont/San Carlos Crystal Springs Trail

First loop complete! Now weâ&#x20AC;&#x2122;ll circle back through the same parks:

April 23: Redwood Shores SF Bay Trail from Sandpiper School

July 16: San Mateo - East

April 30: Menlo Park SF Bay Trail from Bedwell Bayfront Park

July 23: Foster City

May 7: East Palo Alto Ravenswood Open Space Preserve

August 6: Redwood Shores

May 14: La Honda/Redwood City Russian Ridge Open Space Preserve

August 20: East Palo Alto

May 21: Woodside El Corte de Madera Open Space Preserve

September 10: Woodside

June 4: San Mateo - West Sawyer Camp Trail @ Crystal Springs

September 24: San Bruno

June 11: San Bruno San Andreas Trail @ Skyline Blvd.

October 8: S San Francisco

July 30: Belmont August 13: Menlo Park August 27: La Honda/RWC September 17: San Mateo - West October 1: Pacifica October 15: Burlingame

June 18: Pacifica Rockaway Beach Trail

2016 Walks by LOCATION Belmont/San Carlos Crystal Springs Trail April 16 and July 30 Burlingame Anza Lagoon July 9 and October 15 East Palo Alto Ravenwsood Open Space Preserve May 7 and August 20 Foster City SF Bay Trail @ Shorebird Park April 9 and July 23 La Honda/Redwood City Russian Ridge Open Space Preserve May 14 and September 10 Menlo Park SF Bay Trail at Bedwell Bayfront Park April 30 and August 13 Pacifica Rockaway Beach Trail June 18 and October 1

Redwood Shores SF Bay Trail from Sandpiper School April 23 and August 6 San Bruno San Andreas Trail at Skyline Blvd June 11 and September 24 San Mateo - East SF Bay Trail at Oyster Point April 2 and July 23 San Mateo - West Sawyer Camp Trail at Crystal Springs Blvd June 4 and September 17 S San Francisco SF Bay Trail from Oyster Point Park June 25 and October 8 Woodside El Corte de Madera Open Space Preserve May 21 and August 27

Learn more and sign up at www.smcma.org/walkwithadoc or call us at (650) 312-1623. Many thanks to our Walk with a Doc program sponsors:

6 SAN MATEO COUNTY PHYSICIAN | MARCH 2016

Executive Report

Sue U. Malone Executive Director

SMCMA members, help us serve you better On Saturday, April 30, 2016, members of SMCMA leadership and staff will assemble for a day-long planning retreat to set our strategic direction, identify priorities and set goals, and establish roles and responsibilities. Such retreats give participants the opportunity to assemble in a relaxed setting that fosters creative thinking and collaboration. Retreats can also help strengthen leaders’ commitment to a shared mission and generate enthusiasm to help achieve goals. The retreat will be facilitated by a professional consultant with extensive experience working with nonprofit associations. But the first step in this process is to collect input from our stakeholders—SMCMA members. We want to know what members think the SMCMA is doing well, and where it can do better. That information will inform the discussions and decisions that will take place during the April 30 retreat. Toward that end, the SMCMA will be sending its members, via email link, a brief membership survey during the first week of April. The survey should take no more than five to ten minutes to complete, and respondents will be entered to win a Visa gift card. Hard copy surveys will also be available to those who request one. Check your email for the survey link, and be sure to weigh in before close of business on Monday, April 18, 2016. If you did not receive the email, want to request a hard copy survey be sent to you, or need any other assistance, please contact the association. You can also send your feedback directly to smcma@smcma.org, and it will be shared with leadership.

Members, please take a moment to share your thoughts, and help SMCMA serve you better.

Please take a moment to share your thoughts and help us serve you better. ■

MARCH 2016 | SAN MATEO COUNTY PHYSICIAN 7

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GROUP WALKING SEEMS TO BOOST OVERALL HEALTH Participating in a walking group may dramatically improve overall health with little to no adverse effect, researchers reported. A systemic review and meta-analysis of 42 studies found participants of group walking showed significant reduction in mean differences for systolic blood pressure, resting heart rate, body fat, body mass index (BMI), and total cholesterol, according to Sarah Hanson, a PhD candidate, and Andy Jones, PhD, of Norwich Medical School. “Walking groups are effective and safe with good adherence and wide ranging health benefits,” they wrote online in the British Journal of Sports Medicine. “They could be a promising intervention as an adjunct to other healthcare, or as a proactive health-promoting activity.” The study looked at 5,145 citations in seven electronic databases, clinical trial registers, grey literature, and reference lists in English language up to November 2013 and identified 42 studies. The eligibility criteria included adults participating in group walking outdoors with outcome directly attributable to the walking intervention. A total of 1,843 participants walked in outdoor walking groups with at least 1,488 hours of provision and a total of 74,023 hours of participant walking time. Participants involved in this study were from 14 different countries and had a wide range of long-term conditions, including arthritis, dementia, diabetes, fibromyalgia, obesity/overweight, mental health issues, and Parkinson’s disease. The levels of walking were varied in duration and intensity, ranging from 168 to 8,580 minutes of walking over a period of three weeks to one year, with intensity ranging from selfselected and low to brisk walking and high-intensity intervals. Mean adherence, where stated, was 75%. The meta-analysis showed statistically significant reductions in mean difference for: Systolic blood pressure: -3.72 mm Hg (95% CI minus 5.28-minus 2.17) Diastolic blood pressure: -3.14 mm Hg (95% CI minus 4.15-minus 2.13) Resting heart rate: -2.88 bpm (95% CI minus 4.13-minus 1.64) Body fat: -1.31% (95% CI minus 2.10-minus 0.52) BMI: -0.71 kg/m2 (95% CI minus 1.19-minus 0.23) Total cholesterol: -0.11 mmol/L (95 CI minus 0.22-minus 0.01) Moreover, the analysis identified significant mean increases in VO2max of 2.66 mL/kg/min (95% CI 1.67-3.65) and SF36 (physical functioning) score 6.02 (95% CI 0.51-11.53).

However, the authors pointed out that “the evidence was less clear for other outcomes such as waist circumference, fasting glucose, SF-36 (mental health), and serum lipids such as high-density lipids.” For adverse effects, one study described a fall with a brief absence from the walking program, while another reported a calf injury. In one study in participants with Parkinson’s disease, one person experienced exercise-induced hypotension after intense uphill walking in hot weather; four fell on roots and wet ground. Otherwise, the authors stated that there were no injuries, or there was no reference to adverse effects. The research had some limitations, specifically the analysis of studies in English only. Also, there was no information on walking dose in many of the studies so the authors could not perform an analysis of dose-responses. Still, the results further demonstrated the dramatic impact walking groups can have on overall health, the authors stated, and are in line with previous research. A 2013 meta-analysis found that interventions to promote walking in groups boosted physical activity. Looking specifically at blood pressure, a population surveybased study demonstrated that a reduction of 2 mm Hg in diastolic blood pressure could lower coronary heart risk by 6% and stroke and trans-ischemic attacks by 15%. A more recent study noted that a reduction of 2 mm Hg in systolic blood pressure could reduce stroke mortality by 10% and mortality from vascular causes in a middle-age population by 7%. That study also suggested a persistent reduction in average blood pressure could decrease large numbers of premature deaths and stroke. Hanson and Jones suggested that outdoor walking groups could be an example of such a practicable method. ■ by Henry A. Solomon, MD, FACP, FACC Clinical Associate Professor, Weill Cornell Medical College, and Dorothy Caputo, MA, BSN, RN, Nurse Planner. http://www.medpagetoday.com/ Endocrinology/GeneralEndocrinology/49614 MARCH 2016 | SAN MATEO COUNTY PHYSICIAN 9

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10 SAN MATEO COUNTY PHYSICIAN | MARCH 2016

FIVE TIPS TO PREVENT OR MITIGATE PHYSICIAN BURNOUT Physicians experiencing emotional exhaustion, depersonalization, and a reduced sense of accomplishment or loss of meaning in their work may be suffering from burnout. The symptoms need to be taken seriously, because burnout can lead to the erosion of professional behavior at work and increase relationship difficulties at home. Burnout is also associated with decreased empathy and compassion and, potentially, worse patient outcomes. Given the multitude of stressors that face physicians in the complicated and often fractured health care system, doctors need to find a way to take care of themselves and watch for signs and symptoms of burnout. The bottom line is that you can’t take care of others if you don’t take care of yourself. Physicians will often put their own care last on their long to-do list and this causes unpleasant consequences.

Tip 1: Engage in regular exercise and/or other restorative activities Each person has his/her own personal preference for what is restorative. Physical exercise has a large evidence base for decreasing stress and improving emotional well-being. It is critical to find time for regular exercise and to make this a top priority. Identifying an exercise partner (or buddy) to help you stick with your self-care can be a great way to aid compliance and make exercise more fun. Other people find yoga, mindfulness-based stress reduction, massage therapy, or acupuncture to be quite helpful in stress management. All of these have proven track records of increasing wellness and can make a significant difference in how you feel.

Tip 2: Spend time with friends and family Emotional connections and support from others are critical aspects of self-care. Make sure to spend time with loved ones or friends. When doctors start to feel burned out, they become exhausted and begin to withdraw from others. This leads to a vicious cycle of feeling more socially isolated while continuing to withdraw from other people who often want to be of help. Figure out ways to connect with family and friends on a regular basis. Schedule time with others so that connecting is not left up to chance.

Tip 3: Identify the things you can and can’t control at work

on your list that you can control and the things that are completely out of your control. If at all possible, don’t invest your time and energy in the things you can’t control, as doing so leads to feelings of helpfulness and psychological impotence.

Tip 4: Monitor your inner emotional energy barometer and know when you are running on empty We all have days when we feel fatigued and lack energy, concentration or motivation. It is important to check in on your personal barometer and assess how you are feeling. Try to pick a regular time each week to check in with yourself. Use a scale from 1 - 10 (1 = no energy and 10 = high energy). If you notice you are feeling consistently down and exhausted, this is a signal that you need to refuel. Try to take a few days off or make a serious effort to increase participation in restorative activities.

Tip 5: Look for warning signs of burnout--get professional help when needed Doctors don’t like to admit when they are having difficulty. Asking for psychological help is stigmatized. However, ignoring warning signs of burnout leads to much worse outcomes including depression, substance abuse/dependence and other impaired relationships. Take note if you are drinking more alcohol than usual and using it as a way of coping. Pay attention if you begin to feel increasingly irritable and are having more interpersonal conflict with colleagues at work and/or at home. Increased mood lability, tearfulness, changes in appetite and/or sleep are all warning signs of burnout. Ask for help.

About the author Samantha Meltzer-Brody, MD, MPH, is associate professor of psychiatry and director of the Perinatal Psychiatry Program, UNC Center for Women’s Mood Disorders. In 2012, she became one of two School of Medicine faculty members to be named a Sanders Clinician Scholar. Funded by Charles A. Sanders, MD, former chair of the UNC Health Care Board of Directors, Sanders Scholars develop educational efforts to enhance supportive direct personal contact to the daily care of patients.

The list of frustrations in the current health care system is quite long. Try to systemically and thoughtfully determine the things

MARCH 2016 | SAN MATEO COUNTY PHYSICIAN 11

MIEC Belongs to Our Policyholders!

Toni Brayer, MD Board of Governors

Philosophy is Important In 2016 MIEC will be the only MPLI carrier distributing dividends in California. It’s time to join the company whose philosophy puts policyholder-owners first. MIEC has never lost sight of its original mission, always putting policyholders (doctors like you) first. For 40 years, MIEC has been steadfast in our protection of California physicians with conscientious Underwriting, excellent Claims management and hands-on Loss Prevention services; we’ve partnered with policyholders to keep premiums low. Added value: n No profit motive and low overhead n Dividends for a TEN year average savings of 31.4%*

For more information or to apply: n www.miec.com n Call 800.227.4527 n Email questions to underwriting@miec.com * On premiums at $1/3 million limits. Future dividends cannot be guaranteed.

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MIEC Owned by the policyholders we protect.

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SMCMA welcomes new members

Norman Banks, MD *Physical Medicine San Carlos

David Hiroshima, MD *Family Medicine San Carlos

Tiffany Ly, MD *Internal Medicine Menlo Park

Cindy Tang, MD * Family Medicine San Mateo

Alex Wu, MD Urology SSF

Jennifer Boldrick, MD *Dermatology San Carlos

Brandon Jones *Family Medicine Menlo Park

Alan Pinyavat, MD *Internal Medicine Menlo Park

Greg Tarasoff, MD *Psychiatry SSF

John Wung, MD Family Medicine San Mateo

Sarah Cheyette, MD *Child Neurology San Carlos

Carri Jones *Physical Medicine Daly City/Redwood City

Gordon Sakamoto, MD Neurological Surgery San Carlos

Grace Tay, MD *General Surgery Redwood City

Regina Yee, MD *Pediatrics San Mateo

Enoch Choi, MD *Family Medicine San Carlos

Nicole Ketterman, MD *Pediatrics San Carlos, MD

Deborah Shin, MD *Obstetrics/Gynecology SSF

Darshmi Vira, MD *Otolaryngology SSF

Kathleen Forcier, MD *Pediatrics, San Carlos

Jeffrey Kwan, MD *Gastroenterology San Crlos

Rosendo So-Rosillo, MD *Oncology Redwood City MARCH 2016 | SAN MATEO COUNTY PHYSICIAN 13

S an M ateo MEDICAL c

a ss o c i a t i o n

Value of Membership S an M ateo c

“

MEDICAL a ss o c i a t i o n

I am a member of the SMCMA because I have always believed that doctors need to stand together. SMCMA is the most important organization I belong to—it does far more for me as an individual doc than any specialty society.

“

MICHAEL NORRIS, MD Plastic Surgery - Burlingame SMCMA President

Why PHYSICIANS PRACTICING IN SAN MATEO COUNTY need to be SMCMA/CMA members: 1. Speaking with a unified voice, physicians are a formidable presence in the political process. Organized medicine in the “one voice” that legislators want to hear from on health care issues.

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2. SMCMA and CMA worked tirelessly to protect MICRA (the Medical Injury Compensation Reform Act), spearheading a successful campaign to defeat legislation in the 2014 that would have gutted MICRA and sent malpractice insurance rates skyrocketing. 3. Free small practice resources, including regulation compliance, contract analysis and billing, can help keep your practice strong and successful.

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In Memoriam Alfred Chamberlain, MD March 19, 2016

REGISTRY

PLACEMENT

FIRM

Physicians

Nurse Practitioners Physician Assistants

Robert Telfer, MD December 27, 2015

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The CMA/SMCMA’s exclusive new Workers’ Compensation program can help your practice save money! Savings

CMA members qualify for an additional 5% discount* on top of Preferred Insurance’s already competitive rates. Preferred’s rates are set for long term consistency, and are managed by focusing on safety and injury prevention, fraud prevention and the control of medical costs for your practice by getting employees back to work as soon as practical.

Service Mercer’s team of insurance advisors is knowledgeable about the needs of physicians and is available to walk you through the application process. Preferred’s claims examiners are experts in helping members with an employee injury or illness claim. Plus Preferred’s payroll management and flexible payment plans help you manage your premiums in the way that works best for you and your practice’s cash-flow needs.

Safety In addition to mandatory CalOSHA information and videos on workplace safety, Preferred’s team of Risk Advisors are available for consultations when you need them. They also have a strong fraud prevention policy and as a California-based carrier, they know exactly what it takes to do business successfully in this State.

Stability Preferred Insurance prides itself on its stability, which includes maintaining some of the best and most consistent pricing available for CMA members. And because of its Medical Provider Network of credentialed medical professionals, claim costs can be closely monitored and managed while providing quality care to injured employees.

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