June 2017 by SMCMA

PLUS: THE MOONSHOT AND THE LOW-HANGING FRUIT

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JUNE 2017 - VOLUME 6, ISSUE 6

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Russ Granich, MD | President Alexander Ding, MD | President-Elect Sara Whitehead, MD | Secretary- Treasurer Michael Norris, MD | Immediate Past President Janet Chaikind, MD Uli Chettipally, MD Mamatha Chivukula, MD Paul Jemelian, MD Alex Lakowsky, MD Richard Moore, MD Joshua Parker, MD Xiushui (Mike) Ren, MD Brian Tang, MD Dirk Baumann, MD | AMA Alternate Delgate Scott A. Morrow, MD | Health Officer, County of San Mateo www.SMCMA.org facebook.com/smcma | twitter.com/SMCMedAssoc. EDITORIAL

San Mateo County Physician is published ten times per year by Physicians News Network (PNN) and the San Mateo County Medical Association. Opinions expressed by authors are their own and not necessarily those of PNN or 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.

On The Inside 2................President’s Letter THE SECOND AMENDMENT By Russ Granich, MD

4................A Tribute to Lisa Dyer, MD A WONDERFUL COLLEAGUE LOST TOO SOON By Sharon A. Clark, MD

6................Breaking the Stigma A PHYSICIAN’S PERSPECTIVE ON SELF-CARE AND RECOVERY By Adam B. Hill, MD

10..............Life Hacks By Gurpreet Kaur Padam, MD

12..............The Moonshot and the Low-Hanging Fruit By Chettipally, MD, MPH

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PRESIDENT’S MESSAGE

The Second Amendment BY RUSS GRANICH, MD

I really wanted to write something about healthcare on the national level, but things are changing so quickly, whatever I write will undoubtedly be out of date by the time it is read. However, there is something that keeps cropping up and does affect the health of our county residents, and that is gun violence. This is a hot topic, with people fervently on one side of gun control or the other. When do one person’s rights affect another person adversely? PHOTO BY SCOTT BUSCHMAN It all stems from the Second Amendment, which is often cited as “the right to bear arms.” Perhaps a look at the Second Amendment and its history might be of interest. The first 10 amendments to the Constitution, or the “They were Bill of Rights, were promoted by the anti-Federalists. They extremely wise; for were concerned that too much power in the hands of the federal government could end up restricting personal and lead to a monarchy. They were extremely example, the right rights wise; for example, the right to free speech and a free press has been a hallmark of our democracy and is part to free speech and a of a system of checks and balances to the government. Just look at all the dictatorships in the world; those rights free press has been are always denied and members of the press often end up in jail or worse. We can see in our country today a hallmark of our the importance of a free press, regardless of whether you like what they reveal or not. James Madison wrote democracy and is seven amendments and eventually they morphed into 12 amendments ratified by Congress. The states only 10, numbers 3-12; the first, now named part of a system of approved the Congressional Apportionment Amendment, is still technically before the states, and the second, affecting checks and balances the salary of members of Congress, became the 27th Amendment (202 years later, another interesting story). to the government.” The wording of the Second Amendment as ratified by the states is: A well regulated militia being necessary to the security of a free state, the right of the people to keep and bear arms shall not be infringed. In part, it is based on the English Bill of Rights when King James II tried to disarm the Protestants while arming Catholics and building his army. The pundits put forth a number of reasons for our deciding on the Second Amendment. These included the ability to form a militia; the right to defend oneself; the ability to repel invasions; the ability to squash revolts, in particular, slave revolts; and, of course, the ability to prevent the rise of tyranny. If we look at the Revolution, our army was essentially a militia, and if the settlers had not been armed, it never would have happened.

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When we delve further into the Constitution, we find that Article 1 gives the states the right to form a militia, but the federal government can use the militia as part of an army. Although I haven’t researched this in depth, I believe it is the first step to what eventually became the National Guard. The Federalists were against a federal army, and when the militia was needed, it was difficult to gather a sufficient number of men. This is part of the reason we had many setbacks in the War of 1812, including the sacking of Washington, D.C., and the burning of the White House. The first landmark case calling for an interpretation of the Second Amendment was in 1876, during the Reconstruction period, and concerned the Colfax Massacre, in Louisiana, where over 100 black freedmen, who were Republicans, were killed by a white militia, who were Democrats, in a dispute over the results of an election. (Everything else aside, what a Republican is and what a Democrat is today is very different.) Some of the white militiamen were convicted in what essentially was an infringement of civil rights regarding weapons. The Supreme Court handed down a decision that stated that the Second Amendment does not allow the federal government to prevent or allow individuals the right to bear arms, it only keeps Congress from interfering with states’ rights; in essence, it is up to the states to grant that right. In 1939, another case came shortly after the government started to tax automatic weapons and require their registration. The decision essentially stated that individuals do have the right to bear any non-military arms, that the Second Amendment allows states to have only weapons of war. This became the basis of Second Amendment proponents in their argument that the government cannot restrict gun access, namely, gun control. The issue of whether these rights are collective versus individual rights was a hot topic, and a couple of decisions, led by the late Justice Scalia, in the last decade have supported individual rights. The latest manifestation was House Joint Resolution 40, passed and signed into law by President Trump a few months ago. It repealed an Obama-era rule that required the Social Security Administration to notify the FBI of those beneficiaries who were deemed mentally ill and unable to manage their finances. This information would go into the FBI’s criminal background check system. The National Rifle Association felt the rule violated due process and lobbied for its reversal. Now 75,000 mentally ill people — ill enough to be on Social Security — can get guns. Now you are armed (pun intended) with more information for when you have learned discussions with your colleagues and friends. My grandson, who always wears short sleeves, even in winter (he lives in Boise!), thinks it should be “the right to bare arms.”

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A Tribute to Lisa Dyer, MD, A Wonderful Colleague Lost Too Soon By Sharon A. Clark, MD

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The medical community of MillsPeninsula Medical Center lost a vibrant part of our staff on March 25, 2017.1 This well-respected, hard-working obstetrician and gynecologist, a leader in the medical staff, had an outpouring of visitors at her wake on the following Tuesday evening. There were handmade cards of care to Lisa as a banner hanging from the ceiling, and photographs of her many special moments in life as well as objects with special meanings. Among them were the unique ones for ancient Andean healing techniques juxtaposed with modern medical tools. She was always questioning how to improve the healing process. I kept remembering the hopeless line from King Lear, Act V: “Why should a horse, a dog, a rat have life and thou no breath at all?” There are no answers for the injustice of death and its timing, especially for a mother with a son still in high school and one in college and for a wife with a devoted husband. On Wednesday afternoon, at Mercy Chapel in Burlingame, Marcus Corley, MD, a retired anesthesiologist and her close friend, gave a moving eulogy2 that captured a part of the complexity of Lisa and began to define our loss. No one can ever make sense of her being taken from us so early. She and I had started private practice at about the same time. Later I will never forget when I had my first son, and she rollerbladed up to my home to bring joy. We had both grown up in Southern California, the land of Walt Disney’s influence. One of my older sisters had drawn cartoons professionally. Once hearing this, Lisa perked up. Lisa smiled fully and impishly and, with a twinkle in her eyes, told me to look at some framed pictures in a nook. On her walls she had some acetate drawings3 of Snow White and the Seven Dwarfs in the woods with her friends the birds. All of these acetates had Snow White with her eyes closed!

Now Lisa’s vibrant, multihued brown eyes are closed forever. But I am convinced somehow she saw how the Labor and Delivery Nurses celebrated the occasion of her death, each holding a single white rose at the Chapel Service. Her spirit in some way sees how her family, friends, and colleagues express our loss and our remembrances of her gifts to us. Although we each have unique memories, we are united in this shared loss of a wonderfully talented and deeply caring person. Technically and intellectually we are lucky to have had this physician in our medical community. But it is Lisa’s warm spirit that continues to give a special meaning to our purpose and makes us all try to do a better job not only in our careers as physicians but also in our relationships to one another and to all forms of life. She taught us to be strong as we face challenges and to embrace the lasting beauty of Nature. Sharon Ann Clark, MD, FACS Certified by the American Board of Plastic Surgery San Mateo, CA sharonannclark@mac.com [1] Lisa Dyer, MD, Obituary www.legacy.com/obituaries/sfgate/obituary.aspx?pid=184716049 [2] Marcus Corley, MD, Eulogy, March 29, 2017. https://www.smcma.org/lisa%20dyer%20eulogy [3] Acetate drawings were a technique by hand with pen and ink before computer graphics.

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Breaking the Stigma A Physician’s Perspective on Self-Care and Recovery Adam B. Hill, MD

M Y N A M E I S A D A M . I am a human being, a husband, a father, a pediatric palliative care physician and an associate residency director. I have a history of depression and suicidal ideation and am a recovering alcoholic. Several years ago, I found myself sitting in a state park 45 minutes from my home, on a beautiful fall night under a canopy of ash trees, with a plan to never come home. For several months, I had been feeling abused, overworked, neglected and underappreciated. I felt I had lost my identity. I had slipped into a deep depression and relied on going home at night and having a handful of drinks just to fall asleep. Yet mine is a story of recovery: I am a survivor of an ongoing national epidemic of neglect of physicians’ mental health. In the past year, two of my colleagues died from suicide after struggling with mental health conditions. On my own recovery journey, I have often felt branded, tarnished and broken in a system that still embroiders a scarlet letter on the chest of anyone with a mental health condition. A system of hoops and barriers detours suffering people away from the help they desperately need—costing some of them their lives. Last year, I decided I could no longer sit by and watch friends and colleagues suffer in silence. I wanted to let my suffering colleagues know they are not alone. I delivered a grandrounds lecture to 200 people at my hospital, telling my own story of addiction, depression and recovery. The audience was quiet, respectful and compassionate and gave me a standing ovation. Afterward, hundreds of emails poured in from people sharing their own stories, struggles and triumphs. A floodgate of human connection opened up. I had been living in fear, ashamed of my own mental health history. When I embraced my own vulnerability, I found that many others also want to be heard—enough of us to start a cultural revolution. 6 S A N M AT E O C O U N T Y P H Y S I C I A N | J UN E 2017

My years of recovery taught me several important lessons. The first is about self-care and creating a plan to enable us to cope with our rigorous and stressful work. Personally, I use counseling, meditation and mindfulness activities, exercise, deep breathing, support groups and hot showers. I’ve worked hard to develop self-awareness—to know and acknowledge my own emotions and triggers—and I’ve set my own boundaries in both medicine and my personal life. I rearranged the hierarchy of my needs to reflect the fact that I’m a human being, a husband, a father and then a physician. I learned that I must take care of myself before I can care for anyone else. The second lesson is about stereotyping. Alcoholics are stereotyped as deadbeats or bums, but being humbled in your own life changes the way you treat other people. An alcoholic isn’t a bum under a bridge or an abusive spouse: I am the face of alcoholism. I have been in recovery meetings with people of every color, race and creed, from homeless people to executives. Mental health and substance-abuse conditions have no prejudice, and recovery shouldn’t either. When you live with such a condition, you’re made to feel afraid, ashamed, different and guilty. Those feelings remove us further from human connection and empathy. I’ve learned to be intolerant of stereotypes, to recognize that every person has a unique story. When we are privileged as professionals to hear another person’s story, we shouldn’t take it for granted.

The third lesson is about stigma. It’s ironic that mental health conditions are so stigmatized in the medical profession, given that physicians long fought to categorize them as medical diagnoses.

The third lesson is about stigma. It’s ironic that mental health conditions are so stigmatized in the medical profession, given that physicians long fought to categorize them as medical diagnoses. Why do medical institutions tolerate the fact that more than half their personnel have signs or symptoms of burnout? When mental health conditions come too close to us, we tend to look away—or to look with pity, exclusion or shame.

We may brand physicians who’ve had mental health conditions, while fostering environments that impede their ability to become and remain well. When, recently, I moved to a new state and disclosed my history of mental health treatment, the licensing board asked me to write a public letter discussing my treatment—an archaic practice of public shaming. Indeed, we are to be ashamed not only of the condition, but of seeking treatment for it, which our culture views as a sign of weakness. This attitude is pervasive and detrimental—it is killing our friends and colleagues. I’ve never heard a colleague say, “Dr. X wasn’t tough enough to fight off her cancer,” yet recently when a medical student died from suicide, I overheard someone say, “We were all worried she wasn’t strong enough to be a doctor.” We are all responsible for this shaming, and it’s up to us to stop it. The fourth lesson is about vulnerability. Seeing other people’s Facebook-perfect lives, we react by hiding away our truest selves. We forget that setbacks can breed creativity, innovation, discovery and resilience and that vulnerability opens us up to personal growth. Being honest with myself about

my own vulnerability has helped me develop self-compassion and understanding. And revealing my vulnerability to trusted colleagues, friends and family members has unlocked their compassion, understanding and human connection. Many physicians fear that showing vulnerability will lead to professional repercussions, judgment or reduced opportunities. My experience has been that the benefits of living authentically far outweigh the risks. When I introduced myself in an interview for a promotion by saying, “My name is Adam, I’m a recovering alcoholic with a history of depression, and let me tell you why that makes me an exceptional candidate,” I got the job. My openly discussing recovery also revealed the true identity of others. I quickly discovered the supportive people in my life. I can now seek work opportunities only in environments that support my personal and professional growth. The fifth lesson is about professionalism and patient safety. We work in a profession in which lives are at risk, and patient safety is critically important. But if we assume that the incidence of mental health conditions, substance abuse and suicidal ideation among physicians is similar to (or actually higher than) that in the general population, there are, nevertheless, many of us out there working successfully. The professionals who pose a risk to patient safety are those with active, untreated medical conditions who don’t seek help out of fear and shame. Physicians who are successfully engaged in a treatment program are actually the safest, thanks to their own self-care plans and support and accountability programs. Instead of stigmatizing physicians who have sought treatment, we need to break down the barriers we’ve erected between our colleagues who are standing on the edge of the cliff and treatment and recovery. Empathy, unity and understanding can help us shift the cultural framework toward acceptance and support. Mentally healthy physicians are safe, productive, effective physicians. The last lesson is about building a support network. My network has been the bedrock of my recovery. You can start small and gradually add trusted people, from your spouse and J UN E 2017 | S A N M AT E O C O U N T Y P H Y S I C I A N 7

Without question, my own successful recovery journey has made me a better physician.

family to friends, counselors, support groups and eventually colleagues. Then when you fall flat on your face, there will be someone to pick you up, dust you off and say, “Get back out there and try it again.” A support network can also hold you accountable, ensuring that you remain true to your own personal and professional standards. Without question, my own successful recovery journey has made me a better physician. My newfound perspective, passion and perseverance have opened up levels of compassion and

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empathy that were not previously possible. I still wear a scarlet A on my chest, but it doesn’t stand for “alcoholic,” “addict” or “ashamed” — it stands for Adam. I wear it proudly and unapologetically. When a colleague dies from suicide, we become angry, we mourn, we search for understanding and try to process the death . . . and then we go on doing things the same way we always have, somehow expecting different results — one definition of insanity. It’s way past time for a change. Originally printed in the New England Journal of Medicine Reprinted with permission Copyright © 2017 Massachusetts Medical Society

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Gurpreet Kaur Padam, MD

I R E A D T H I S Q U O T E R E C E N T LY : “No matter how you feel—get up, dress up, show up and never give up.” I love the inspiration, as it is uplifting and positive. That’s right, no matter how I feel, even on sick days, I slog myself out of bed, pop a decongestant, an antihistamine, put on a mask if I need to and move on with the day. We don’t give up on our patients or our families unless a dire situation arises.

Life happens, and for a moment let us imagine, what if? What if you, despite your best efforts, are unable to “show up”? What happens to your household? For example, how will you keep your home running smoothly, take your son to basketball practice, help with your daughter’s hair in the morning? Most importantly, how will you manage the very basics such as feeding yourself and your family for one day and perhaps for many more? I found myself asking these very questions after an injury last year. We got by for a few weeks on the kindness of friends who delivered food for my family each week. However, we needed a viable long-term solution. After many weeks of researching, trial and error from various restaurants and meal delivery services, I was guilt-ridden for feeding my family foods with less than ideal nutritional value. My focus then shifted from mere sustenance to nourishment.

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I discovered that there are numerous apps available for grocery delivery from Amazon’s Prime Now or Safeway; restaurant food delivery using Uber Eats, Munchery, Door Dash, Order Ahead, Yelp’s Eat 24, or Post Mates; or prepared meals from Taro. Each service offers a different desirable feature, such as next-day delivery for one or more persons or home-style cooked meals for the entire family. My preferred long-term options thus far are the meal preparation kits that are semi prepared, or give the option to cook from scratch. Blue Apron, Hello Fresh, Farmstead, Good Eats and Gobble.com are reasonable choices. They take the hassle out of grocery shopping and some chopping. Portioned meal ingredients also means avoiding food wastage.

IN MY EXPERIENCE Yelp’s Eat24 app is convenient for the spur of the moment restaurant delivery.

based on reliability, service, affordability, variety and flavor selections, the following services stand out: Taro offers homecooked meals for the family to appease the multi-ethnic palate.

By far, Gobble.com is a superior weekly dinner kit delivery service if you are looking to put fresh gourmet home-made meals from the box to the table in 10-15 minutes. Ingredients arrive in a cooler box, vacuum-sealed, fresh, prepped and portioned. Cheese, cream, butter are separately packed so you can control spice, salt and fat content. The food is flavorful and kid-friendly. The portion sizes are adequate, and most nights we have some leftovers. There is also a nice serving size of vegetable variety included in each meal. Typically when I am tucking in kids at night, they will let me know if we are out of breakfast items. It’s their delegated task to remind me to order what we need. On a short notice, I turn to Prime Now. As long as the order is $20 or more, Prime Now offers a two-hour delivery window for grocery delivery to the front door for Amazon Prime members. Recent stormy nights required tremendous courage to be able to leave the house late at night, so the convenience of home delivery is always an easy decision. In the spirit of physicians helping physicians, I am sharing my favorite apps with you, and I hope the above will add to your list of resources should your lifestyle not afford you the luxury of doing everything yourself. All of the services can be easily accessed from your smartphone or your computer. You may discover your own personal favorites depending on your needs, budget and dietary preferences. Share your ideas if you’d like them to be considered in a future Life Hacks column. Gurpreet Kaur Padam, MD, practices adult medicine and hospice with the Permanente Medical Group. She is fellowship-trained and boardcertified in hospice and palliative medicine, boardcertified in family medicine, and completed a minifellowship in ethno-geriatrics. She is a founding board member of the Sikh Family Center, which promotes healthy families in the Sikh American community by closing current gaps in access to resources and increasing community awareness and activism. You can connect with her on LinkedIn or via email Gurpreet.K.Padam@kp.org.

Disclaimer: The opinions expressed here are my own and not an endorsement of any products. I do not have any conflicts of interest to disclose. I am not affiliated with any services mentioned here.

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“Now it is time to take longer strides—time for a great new American enterprise— time for this nation to take a clearly leading role in space achievement, which in many ways may hold the key to our future on earth.” John F. Kennedy

American healthcare, according to many observers, is at a stage where change is inevitable. There are several movements that are creating this perfect storm—increasing cost of healthcare, digitization of healthcare data, demand for consumer convenience and availability of powerful information technology. This change can happen in small spurts or in large swoops. Innovators are in the driver’s seat. A “moonshot” is described as an “ambitious, exploratory and ground-breaking project undertaken without any expectation of near-term profitability or benefit and also, perhaps, without a full investigation of potential risks and benefits.” From the time when President John F. Kennedy addressed the Congress in 1961 to current day, we have been fascinated by moonshots. In recent times, the term “moonshot” has been popularized by Google and others working on projects that require a large amount of capital, taking on a huge risk of failure and the potential to change the world if successful. MOONSHOT = HEAVY INVESTMENT + HIGH RISK OF FAILURE + HUGE POTENTIAL BENEFIT President Barack Obama, during his 2016 State of the Union address, appointed Vice President Joe Biden to lead a new, national Cancer Moonshot program, which will focus on “making a decade of progress in preventing, diagnosing and treating cancer in five years, ultimately striving to end cancer as we know it.” Although this proclamation sounds modest compared to other moonshots declared recently in the technology world, the fact that the government is pushing focused research to solve a specific healthcare problem is laudable. Let’s compare this program with our prior definition: It does require a significant amount of investment. The president allocated $1 billion toward this project as an initial investment. Considering that we spend more than $3,000 billion, or $3 trillion, a year on healthcare, this may look small. The risk of failure may not be that high. If you want to double the speed of research in cancer, it’s not an unattainable goal, mainly because the technology to accomplish it is already here. Data can be generated, collected and shared much more easily. It is more of the meeting of the minds to focus on the problem to accomplish this goal.

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Potential benefits of successfully reaching this goal are tremendous. Many lives could be saved. Many cancers that are now considered incurable may be prevented. Hidden cures may be discovered. There is no doubt about the huge benefits of speeding up the research in this area. The phrase “low-hanging fruit” is used to describe a course of action that can be undertaken quickly and easily as part of a wider range of changes or solutions to a problem. This term was popularized during the ’90s in the business culture. Low-hanging fruit is the easiest problem to solve. It needs little resources, has minimal risk, and the benefit is modest. LOW-HANGING FRUIT = MINIMAL INVESTMENT + LOW RISK OF FAILURE + MODEST BENEFIT There are many ideas in healthcare that need minimal investment to make quality better and decrease the cost. With the increasing use of electronic health records, data is easier to collect, collate and analyze. The technology to study huge amounts of data is already here. Many of the data problems have already been solved in other industries. We surely can borrow the methodologies from banking and technology industries. What are the problems we are trying to solve? For one, American spending on healthcare keeps increasing. According to a recent study, U.S. healthcare spending now accounts for more than 17% of the U.S. economy. Financially speaking, healthcare is the biggest problem the U.S. is facing right now. With this kind of a crisis on our plate, there should be many more attempts at picking the low-hanging fruits and launching hundreds of moonshots. As the technological advances are moving faster and faster, moonshots become more achievable in shorter and shorter time frames. In conclusion, both strategies are needed to make progress in healthcare innovation. With the acceleration of technology, the moonshots are getting a little bit closer to the low-hanging fruits. Let’s take this once-in-a-lifetime opportunity to innovate and make a difference in the lives of people! Uli Chettipally is an emergency physician, researcher and an innovator. He is the CTO of CREST Network at Kaiser Permanente and the president of the Society of Physician Entrepreneurs (SoPE), San Francisco Bay Area Chapter. You can connect with him through LinkedIn or his website, www.InnovatorMD.com.

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