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
MEDICAL EDUCATION The SFMMS Student/Trainee Writing Contest! New Frontiers in Medical Curriculum Mobile Tech in Medical Education Skipping Classes Preventing Early Burnout . . . and more
Volume 91, Number 6 | September 2018
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IN THIS ISSUE
SAN FRANCISCO MARIN MEDICINE September 2018 Volume 91, Number 6
MEDICAL EDUCATION FEATURE ARTICLES
SPECIAL SECTION:
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20 The SFMMS Medical Trainee Writing Contest Twenty-one medical students, residents, and fellows answer the question: “Of all the patients you have encountered thus far, which one has been the most memorable and/or had the most impact on you and why?”
Musings on Undergraduate Medical Education: A Perspective John A. Davis, PhD, MD
12 There’s an App for That: The Role of Mobile Technology in Graduate Medical Education Ryan Guinness, MD, MPH, Jeanna Goo, MD, MPH, George Rutherford, MD, MA, and Jinwoo Kim, MD 14 Preventing Burnout and Promoting Professional Development through ARCH Weeks Catherine Lomen-Hoerth, MD, PhD, Era Kryzhanovskay, MD, and Karen Hauer, MD, PhD 16 Reflections of a Woman in Medicine Toni Brayer, MD, FACP
17 Teaching Future Physicians Is Its Own Reward: The UCSF Volunteer Clinical Faculty Michael Schrader, MD, PhD 17 What I Have Learned Since Medical School Linda Hawes Clever, MD, MACP
18 It’s Not Too Late: A Dozen Important Topics Too Often Neglected in Medical Training Philip R. Lee, MD, Steve Heilig, MPH, and Gordon Fung, MD, PhD 19 Medical Students Are Skipping Class in Droves— and Making Lectures Increasingly Obsolete Orly Nadell Farber
OF INTEREST 10 Why Medical Schools Are Building 3-year Programs AMA Wire
29 Medical Students Make the Worst Patients: The Tragicomedy of an MS1 Mara Olson 30 Launching New Physicians in 2018 David Nash, MD, MBA
31 New Southern California Medical School to Tackle Doctor Shortages Anna Gorman 31 Obituary: Margaret Kaplan Miller, MD, MPH
32 San Francisco Marin Medicine Readership Survey
MONTHLY COLUMNS 2
Membership Matters
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President’s Message: A Primary Problem in Medical Education John Maa, MD
1868 2018
Anniversary
13 Upcoming Events 31 Classified Ad
33 Community News: Kaiser Permanente Maria Ansari, MD 33 Advertiser Index
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
The Irwin Mansion, owned by the San Francisco Medical Society, housed the first community blood bank in San Francisco.
WHEN TWO SAN FRANCISCO PHYSICIANS began
Dr. Sidney Garfield and Henry J. Kaiser formed an association to organize and run a prepaid group practice for workers at the Richmond shipyards, which would later become Kaiser Permanente.
exploring ways to supply blood in adequate amounts to people who needed it, the concept of a community blood bank did not yet exist. The two pioneers decided to pursue the idea, and the Medical Society granted the fledgling blood bank permission to operate out of the basement floor of the Irwin Mansion, which it owned. On June 12, 1941, the Irwin Memorial Blood Bank, now Blood Centers of the Pacific, opened its doors to its first volunteer blood donors.
While advances in medical care and technology were important, how to pay for quality medical care was also important. In 1945, Kaiser Permanente introduced its unique prepaid health insurance coverage to the public. Today, Kaiser physicians continue to serve as officers, directors, and delegates of SFMMS.
Medi-Cal Moves Addiction Treatment into the Mainstream
Virtual Groups Toolkit for 2019 MIPS Performance Year Now Available
California is midway through a multi-year effort to dramatically expand, improve, and reorganize Medi-Cal’s system for treating people with substance use disorder. Forty of California’s 58 counties are taking part in the Drug Medi-Cal Organized Delivery System pilot (details at http://bit.ly/2w2wssq) program under California’s Medicaid Section 1115 waiver. A new California Health Care Foundation (CHCF) paper (viewable at http://bit.ly/2LfCc6S) outlines the experiences and challenges seen by four early adopter counties: Los Angeles, Marin, Riverside, and Santa Clara.
If you’re interested in forming a virtual group for the 2019 Merit-based Incentive Payment System (MIPS) performance year, you must follow an election process and submit your election to CMS via e-mail between October 1 and December 31, 2018. CMS has posted the 2019 Virtual Groups Toolkit (available to download at http://bit.ly/2NbIyWU) to help you understand the election process to participate in MIPS as a virtual group in 2019.
MIPS Scores and 2019 Payment Adjustments Now Available
Physicians can now log in to the Medicare Quality Payment Program (QPP) website to view their final 2017 Merit-based Incentive Payment System (MIPS) performance scores and payment adjustment information for the 2019 payment year. It is important to note the Centers for Medicare and Medicaid Services (CMS) will not be sending out letters this year, so physicians are encouraged to log into the QPP website (https://qpp. cms.gov/) to learn about any payment adjustments they will receive in 2019. Read more at http://bit.ly/2Puopgi. 2
New Medicare ID Card Mailing Completed in California CMS recently completed mailing new Medicare ID cards to California beneficiaries. The new Medicare ID cards contain a unique, randomly assigned Medicare Beneficiary Identification number, which replaces the previous Social Security-based number. CMS will allow a 21-month transition period that began in April 2018, where healthcare providers will be able to use either the patient’s current Medicare number or the patient’s new Medicare number for all Medicare transactions through December 31, 2019. Visit http://bit.ly/2BAnlV6 for more information.
SAN FRANCISCO MARIN MEDICINE SEPTEMBER 2018 WWW.SFMMS.ORG
Medi-Cal to Unveil Updated Provider Enrollment System The California Department of Health Care Services (DHCS) will soon be releasing an update to its Medi-Cal provider enrollment system, called the Provider Application and Validation for Enrollment (PAVE). According to DHCS, the process for completing an application through the new system is dramatically streamlined, dropping the average to complete an application from 1.75 hours to .7 hours. Read more at http://bit.ly/2NcIfL6.
Medical Board Releases Physician License Alert App for Patients
The Medical Board of California recently released its first mobile app, currently available on Apple iOS devices. A version for Android devices will be available in the near future. The technology notifies patients about changes to their physician’s license status, rather than patients having to actively seek out that information. Physicians are encouraged to periodically check their profiles for accuracy and to advise the board of any corrections, especially their addresses of record. The Board cautions physicians about using their home address as their address of record, however, because it becomes widely available on the Internet. If you believe the information on your profile is incorrect, please contact the medical board at webmaster@mbc.ca.gov or (800) 633-2322.
Marin Students Create Video on E-Cigarettes
Students from Tamalpais High School in Mill Valley recently created a very powerful video about e-cigarettes, including vaping and JUUL, as part of a documentary course. The six-minute video may be viewed at http://bit.ly/2Msxg47.
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.
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 dues-paying 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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September 2018 Volume 91, Number 6
Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH 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 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
SEPTEMBER 2018
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PRESIDENT’S MESSAGE John Maa, MD
A Primary Problem In Medical Education Despite financial incentives and loan repayment programs, the U.S. struggles to resolve a national shortage of primary care providers, particularly in rural and underserved areas. To create effective policy solutions, the complex process medical students face in making a career choice needs to be better understood. Although factors that influence medical student residency selection have been extensively studied, the student’s perspective has not been adequately explored, and could prove invaluable to policymakers to improve access for underserved populations. Clearly a number of factors play into the complex decision-
making process that medical students face, including their intellectual interest, demographics, cultural fit, aptitude and skills, geography, and financial and debt considerations. The important factors traditionally studied can be divided into three major categories: 1) characteristics of the medical school, 2) qualities intrinsic to the medical student and 3) specialty factors. Although student debt has been studied extensively, its impact on career decisions is not entirely clear. The AAMC reports the median debt for graduating medical students in 2017 was $192,000. Studies have been mixed, with some suggesting a large impact of indebtedness in specialty choice, and others showing only a minimal effect. A U-shaped effect has been noted in which the association between debt and career choice was most significant at the extremes. Students with both the least and the most (over $250,000) debt were less likely to choose a career in primary care. To reduce barriers to a career in primary care, novel solutions are needed. Some have suggested modifying federal loan-repayment and tuition-support programs to incentives practicing in an underserved area after residency. An alternative would be to offer tuition support for medical students who commit to practicing primary care after finishing residency, without any restrictions on where they practice. Another option is to redefine “underserved areas” in primary care to include urban areas, given the shortage of primary care providers across the country. Another trend is for medical schools to offer reduced-tuition or tuition-free programs. NYU announced in August that it will offer full-tuition scholarships to all of its medical students through an endowment. NYU follows UCLA, where a $100 million fund pays for the entire cost of medical school for 20 percent of the class based on need; a medical school affiliated with Case Western Reserve that covers tuition and fees for a five-year research program; and Columbia, which received a $250 million gift to provide full-tuition scholarships and grants based on financial need. Another innovative program is the three-year Family Medicine Accelerated Track MD program at the Texas Tech School of Medicine, which is among a handful of three-year MD programs in America. The Texas Tech program costs half of a four-year program by offering a one-year scholarship and WWW.SFMMS.ORG
condenses medical school into three years with placement in a three-year family medicine residency afterwards. During World War II, many American medical students completed school in three years to meet the needs of the country. Medical student organizations could take a leading role to advocate for these reforms to the medical educational system. Another solution is to address forces such as state budgets and the malpractice environment. The consequences of the dramatic increases in medical student tuition, particularly at state medical schools, should be studied for possible legislative solutions. These may include annual limits on the rate of student tuition increases, and regulating the differences for in-state and out-of-state student tuition. An AMA survey revealed that half of medical student respondents reported the medical liability environment as a factor in their own specialty choice. Perhaps the next important discussion is to reform and transform our legal system. Including the medical student perspective in the tort reform debate may identify new solutions. Ultimately, policymakers should strive for a deeper understanding of the drivers of rising costs of education and the impact on specialty choice. They should also look to the ways that other nations with universal healthcare and single payer systems finance medical student education, which is often provided free or at very low cost to the students. Furthermore, as our nation contemplates radical reforms to our healthcare system, it is imperative to ask physicians in training how this may impact their career decision. Their perspective has been underemphasized in the national debate, but what medical students and residents choose to do with their careers will shape the future of healthcare in America decades from now. Reframing the discussion with a deeper understanding of their perspective is essential to enable policymakers to identify new solutions. 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. SEPTEMBER 2018
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CURES Duty-to-Consult Mandate Takes Effect October 2 Effective October 2, 2018, physicians must consult California’s prescription drug monitoring database (the Controlled Substance Utilization Review and Evaluation System, or CURES) – before prescribing Schedule II, III or IV controlled substances.
When Must I Consult CURES?
Physicians must consult the database before prescribing controlled substances to a patient for the first time and at least once every four months thereafter.
Save the Date:
Free CURES webinar with the California Department of Justice on 8/22. Register at cmanet.org/events.
For More Information CMA CURES webpage: cmanet.org/cures CURES website: oag.ca.gov/cures
THE CALIFORNIA MEDICAL ASSOCIATION PRESENTS THE 22ND ANNUAL PRESIDENTIAL
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SAN FRANCISCO MARIN MEDICINE SEPTEMBER 2018 WWW.SFMMS.ORG
Medical Education
Musings on Undergraduate Medical Education: A Perspective John A. Davis, PhD, MD
IT’S THAT TIME OF YEAR AGAIN. I have now been in San
Francisco for a little over a year, and one of the things I love about being involved in education is achieving that one-year mark— the completion of the annual academic cycle. It is reassuring, just like the seasons. It is August (or, as I have come to learn here in SF, “fogust”) and the new class of medical students is about to undergo their welcome to our profession at their White Coat Ceremony. It is a time that serves to energize us with the enthusiasm and potential of the new learners, and simultaneously invites us to reflect on past iterations of the cycle. Quite a bit has changed since the time I went through medical school, and I anticipate the same is true for many of you. In particular, this becomes quickly apparent when we have that great opportunity to welcome medical student learners into our clinical environment to work alongside us and share in the learning experience that is clinical medicine. As a clinician, and an associate dean for curriculum, I am fortunate to see this process from multiple perspectives. It is in this context that I share a little on my perspective about recent trends in undergraduate medical education: the how, the what, and the why. One of the biggest changes in medical education has to do with how we educate. Gone are the days of discipline-based courses (pharmacology, physiology, anatomy) with many hours of lectures in a grand hall, only to be followed by countless evenings/nights spent in a library poring over textbooks. Cognitive and education scientists have taught us quite a bit about how we can learn better. Today’s medical students have far fewer hours of lecture, with much more hands-on and small-group based activity. Many medical schools are making use of the “flipped classroom” in which the old paradigm of hearing a lecture and then going home to apply concepts to homework is upended. Now, students do independent readings, and sometimes watch videos, about key concepts at home and only come together in a classroom setting to apply the concepts, usually with each other in small groups. We also know that students learn better when they learn about different disciplines together, to apply them to common conditions. For this reason, many medical schools have shifted to organ-system based courses, where students apply different scientific disciplines to similar clinical problems: for example, learning the pharmacology of medications used to treat congestive heart failure along with the pathophysiology of heart failure and its epidemiology. For the last decade or so, medical schools have also moved clinical experiences into the early years, in recognition of the fact that we all learn better when we can apply our concepts to real situations and patient WWW.SFMMS.ORG
experiences. A more recent addition is the extent to which learners have the ability to practice their skills in simulated settings. As with other techniques mentioned above, gone are the days of “see one, do one, teach one.” Whether with procedures such as central line placement and endotracheal intubation, or other skills such as breaking bad news or eliciting sensitive parts of a patient’s history, students in many medical curricula, including ours, have had many opportunities to practice, receive feedback, and improve upon these skills in low-stakes settings prior to ever trying them in the clinic or on the wards. The “what” of medical education has changed significantly, as well. The advances of biomedical sciences have contributed tremendously to our library of knowledge, including to what is considered “core” knowledge. In addition, other domains of science are increasingly appreciated for their contribution to medicine, including population science, and social and behavioral sciences, to name just a few. This explosion of knowledge is not likely to slow in the near future. This is why our curriculum includes an inquiry thread that teaches students how to evaluate and incorporate knowledge into their practice, how to understand the limitations of our knowledge as a profession, and how to address gaps in knowledge to contribute to the field. Another domain of science that is playing a very important role in healthcare is that of systems science. Our students are taught about health systems, systems improvement, and quality related work in healthcare from their first weeks in school. All students in our curriculum complete a health systems improvement project that is presented to their peers and leaders of their health systems in the second year of their curriculum. Yet another important domain is that of healthcare disparities and social justice. Our curriculum is anchored around the most common conditions in populations of the Bay Area—the UCSF 49. In addition, our students start learning concepts of diversity, equity, and inclusion within their first days at school. All of these skills—inquiry, systems science, and social justice—will be as important as any of the other foundational sciences in caring for patients in the years and decades to come. Another important shift in medical education that is less appreciated outside of education circles is that of the “why” of education: what we are doing this for, or what is driving learning? Increasingly, the answer is assessment, and not just of learning, but for learning. While the ultimate goal of providing excellent care for patients has remained, this shift has meant (Continued on page 11)
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Medical Education
Why medical schools are building 3-year programs August 20, 2018—AMA Wire
The effort to build three-year medical school programs is one element in the movement to modernize medical education, offering a challenge to the four-year model that has been entrenched for a century. Developing flexible, competency-based pathways— tailoring the time required in medical school to the ability and clinical background of the student—is one theme of the AMA Accelerating Change in Medical Education Consortium the AMA started in 2013.
1 program, 6 years: From med school to primary care practice
The AMA Consortium’s efforts reflect a general consensus that medical education “has needed to change in order to address significant gaps in physician training and prepare new doctors to practice effectively in our 21st century health systems,” according to the AMA’s “Creating a Community of Innovation” report. Among other topics, the monograph provides details on competency-based pathways programs. Evidence-based ways of rethinking the best length of time for physician education come at the right moment for two interrelated problems in healthcare: a looming physician shortage and six-figure physician education debt. “Proponents of accelerated pathways highlight the reduction of student debt and the desirability of acceleration for a subset of students who are seeking rapid entry into the workforce as clinicians or clinician–scientists with the ability to impact the worsening physician shortage,” notes a 2017 article in the journal Academic Medicine, which describes nine programs. “Some accelerated programs that focus on primary care also serve a social mission to provide increased physician access to rural and underserved populations.” The most recent physician workforce estimate by the Association of American Medical Colleges is that the nation could see a shortage of up to 120,000 physicians by 2030. The shortage of primary care physicians alone could be as high as 49,300. Meanwhile, high medical school debt has long been associated with at least some physicians opting for higher paying specialties than primary care. A 2017 survey from AMA Insurance shows that more than a third of medical students expect to owe
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more than $200,000, about a fifth will be between $150,000 and $200,000 in debt. A year less of medical school could cut tens of thousands of dollars from those amounts.
Speedier path to practice
The University of California, Davis School of Medicine (UC Davis), a member school of the AMA Consortium, operates its Accelerated Competency-based Education in Primary Care (ACEPC) program in partnership with Kaiser Permanente Northern California. The program provides a six-year path to practice—three years each of medical school and residency. Students in the ACE-PC program get a six-week jump on medical school with coursework that allows them to then immediately start in with supervised work at a primary care clinic. It is a striking departure from the traditional programs that start with two years devoid of direct patient care. “We have flipped the medical school curriculum. ACE-PC med students learn history and physical skills in their first few weeks of medical school,” said Tonya Fancher, MD, MPH, associate dean for workforce innovation and community engagement at UC Davis told AMA Wire earlier this year. From early on, Kaiser Permanente places students within its system and provides each with a mentor for all three years of medical school. “The partnership with Kaiser allows medical students to learn population management, chronic disease management, quality improvement, patient safety, team-based care and preventive health skills within state-of-the-art ambulatory facilities,” notes the AMA’s Consortium report. The students are given conditional acceptance into UC Davis or Kaiser Permanente residency programs, where they do rotations in their first and third years of medical school. A three-year primary care residency in one of those programs awaits them on graduation. The first of the program’s new physicians entered residency in 2017 and early reports are “fantastically positive,” Dr. Fancher said.
SAN FRANCISCO MARIN MEDICINE SEPTEMBER 2018 WWW.SFMMS.ORG
(Continued from page 9)
that the intermediate steps have changed tremendously. In particular, if our goal is to help students become excellent physicians, then it makes sense for us to determine what it is that an excellent physician does (or can do), and make sure that all our graduates can do those things. This move toward “outcomesbased” or “competency-based” education has come along with a move away from grades based on comparing one person to how others are doing, and toward a more constructive assessment that is based on gaps that remain in the learner’s achievement, and importantly, on how to address those gaps. This has led to a situation in which learners actively seek out feedback. We have encouraged and fostered this in our curriculum by supplying an educational coach to each medical student who can help them with reflecting upon their performance and their formulation of next steps in their growth as developing physicians. In the end, this is all part of the trajectory of medical education. We have all been beneficiaries of advances in biomedical sciences that have helped our understanding of disease and its treatment and prevention. Our students continue to benefit from the same, while simultaneously having their learning improved by advances in education science, systems science, and social science. Our patients may still be very similar, but the world in which we all exist, and in which we practice medicine, is very different, and today’s medical students—tomorrow’s physicians—will need all the skills they are learning to help address their patients’ and society’s health needs. I am grateful to be in my dual roles of clinician and educator. I know I learn just as much from my students as they learn from me. They teach through their questions, and through sharing the fresh perspective they bring on the profession and its practice. It is a process that pushes me not just to be a better physician for my patients, but also to be worthy of educating a generation or more of future physicians. It is a thought that comforts me, even in the long, gray, cool San Francisco summer.
Sutter’s ACE unit is one of a kind.
John A. Davis, PhD, MD, is Associate Dean for Curriculum and Associate Professor, Infectious Diseases, at the UCSF School of Medicine.
1868 2018
Anniversary
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At Sutter, we know that part of healing means being in the hospital less. CPMC’s collaborative team in our Acute Care for the Elderly unit provides personalized care plans for older adults that help reduce patient stay and improve mobilization. Call 415-527-0726 to refer a patient. sutterhealth.org/aceunit
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Medical Education
There’s An App For That: The Role of Mobile Technology in Graduate Medical Education Ryan Guinness, MD, MPH, Jeanna Goo, MD, MPH, George Rutherford, MD, MA, and Jinwoo Kim, MD
The past decade has witnessed an explosion of mobile technology, which has quickly begun to find its place within the medical field as both a personal and a professional tool. Its role in graduate medical education (GME), in particular, continues to expand with advances in mobile technology and addition of novel applications. In this perspective, we describe the current and potential uses of mobile technology in GME as well as barriers to ongoing implementation, and provide recommendations for incorporation of mobile technology as a medical education platform. Current and Potential Use Mobile technology use in GME is now widespread. Both residents and their patients benefit from the wide-ranging capabilities of mobile technology in the healthcare environment: • Medical calculators facilitate the use of clinical equations, scores, and risk prediction and prevention models at the bedside. • Physical examinations are made easier by using applications to administer point-of-care ultrasound. • Illustrations and videos formatted for mobile display can assist with obtaining informed consent at the office or bedside in the hospital. • Videoconferencing can be used for those patients who have difficulty making it into the office for an appointment. Additionally, it can provide video interpreter services around-theclock and real-time physician-to-physician consultations with the patient. • Trainees can review important clinical concepts and conduct board-review preparation using mobile application resources on-the-go.¹
Given the nature of GME, where trainees are expected to assimilate a vast amount of constantly evolving information, and often are away from traditional classroom settings, the benefits of mobile learning with its uninterrupted access to educational resources can be of immense value. In addition to these current uses, the potential for further innovation is profound. One research group demonstrated that they could accurately diagnose acute stroke on brain-computed tomography scans through the use of iPhones with identical accuracy to standard workstations.² Prehospital wireless electrocardiographic transmission to a cardiologist’s smartphone was found to significantly decrease emergency department door-to-reperfusion time for patients with acute myocardial infarction.³ Handheld ultrasound scanners are being paired 12
with smartphones through an associated mobile application, which can guide procedures such as nerve blocks and targeted injections.⁴ Medical researchers have also created a computer program that attaches to an electronic stethoscope to organize lung sounds into five diagnostic categories with a high accuracy rate.⁵ Through these examples, and many others, it has become clear that mobile technology has the potential to provide a wide spectrum of functionalities for residents-in-training and other healthcare providers alike.
Barriers to Implementation
Despite these notable benefits, there are a number of challenges that come with incorporating mobile technology into GME. It can be costly to purchase and keep up to date, especially with monthly subscription plans on top of the original cost of the mobile applications. Given the increasing availability of different mobile applications from a vast number of organizations, assessment of accuracy and quality control can be difficult, which raises concerns about the reliability of their medical content, and the consequences for resident learning and patient safety. Problems with wireless connectivity can impact accessibility, a concern for using mobile technology when conducting timesensitive patient care. With the possession of identifiable patient information, there are legal and ethical factors to consider in order to ensure patient confidentiality. There have also been concerns about appearing unprofessional while using mobile technology in the clinical setting.⁶
Future Considerations
More high-quality research is needed to both monitor and measure the impact of mobile technology on improving the educational and clinical goals of GME. Given the diversity of learning experiences in residency, research should be tailored to specific mobile interventions that are unique to different specialties, clinical environments and educational topics. Cost-benefit analyses
SAN FRANCISCO MARIN MEDICINE SEPTEMBER 2018 WWW.SFMMS.ORG
should compare outcomes from traditional teaching methods to mobile technology interventions to assess whether it is financially sound to incorporate such technology into the medical education curricula. Establishing appropriate regulatory procedures for the creation and maintenance of new mobile applications will lend more credibility for their use among trainees while helping to ensure patient safety. Special attention should also be made to the advent of social media, which has been increasingly integrated into medical education, yet remains to be formally evaluated as a residency teaching tool.
Conclusion
Utilization of mobile technology in GME continues to expand at a rapid pace. It has revolutionized medical communication, decision supports, and clinical practice in the trainee environment. Despite these benefits, some challenges remain prior to ongoing implementation in order to ensure that such technology does not conflict with the goals of medical education or patient care. As mobile technology and GME continue to evolve in tandem, residents and faculty need to identify best practices for teaching and learning using this new educational platform.
Ryan Guinness, MD, MPH, is a fourth-year resident in the Internal & Preventive Medicine Residency Program at Kaiser San Francisco and the University of California, San Francisco. Jeanna Goo, MD, MPH, is a Hospitalist and Assistant Program Director of the Internal & Preventive Medicine Residency Program at Kaiser San Francisco and the University of California, San Francisco. George Rutherford, MD, MA, is the Salvatore Pablo Lucia Professor of Epidemiology, Preventive Medicine, Pediatrics and History and Program Director of the General Preventive Medicine and Public Health Residency Program at the University of California, San Francisco. Jinwoo Kim, MD, is a Hospitalist, Program Director of the Internal & Preventive Medicine Residency Program and Assistant Chief of Inpatient Information Technology at Kaiser San Francisco.
References 1. Franko O, Tirrell T, “Smartphone app use among medical providers in ACGME training programs,” J Medical Systems, 36(5):3135-3139 (2012). 2. Mitchell JR, Sharma P, Modi J, et al, “A smartphone clientserver teleradiology system for primary diagnosis of acute stroke,” J Medical Internet Research, 13(2):e31 (2011). 3. Adams GI, Campbell PT, Adams JM, et al, “Effectiveness of prehospital wireless transmission of electrocardiograms to a cardiologist via hand-held device for patients with acute myocardial infarction,” AJ Cardiology, 98(9):1160-1164 (2006). 4. Jones D, “Smartphone-compatible ultrasound probe.” J Diagnostic Medical Sonography, 30(4):200-204 (2014). 5. Ohshimo S, Sadamori T, Tanigawa K, “Innovation in analysis of respiratory sounds,” Annals of Internal Medicine, 164(9):638-639 (2016). 6. Katz-Sidlow RJ, Ludwig A, Miller S, et al, “Smartphone use during inpatient attending rounds: prevalence, patterns and potential for distraction,” J Hospital Medicine, 7(8):595-599 (2012). WWW.SFMMS.ORG
UPCOMING EVENTS CMA Presidential Gala October 13, 2018 | Sacramento Convention Center Each year, the CMA honors the extraordinary leadership of individuals and organizations making a difference in the health of Californians. The incoming CMA president will be recognized at the Presidential Gala, which includes a cocktail reception, dinner and exciting entertainment. This year’s black-tie event, which has been reimagined to transport attendees to a world of surprise and intrigue, will take place on the evening of Saturday, October 13, at the Sacramento Convention Center. For more details including hotel and attire, visit http://bit.ly/2uIwioG.
2018 CMA House of Delegates October 13-14, 2018 | Sacramento
The House of Delegates convenes annually to debate and act on resolutions and reports dealing with myriad medical practice, public health and CMA governance issues. Policies adopted by the House are implemented by the Board of Trustees, which also deals with the many interim policy issues that arise between annual sessions. Visit http://bit. ly/2zOYv2J for more information.
2018 West Coast Minority Women Professionals (MWP) Conference October 27, 2018 | Oakland Asian Cultural Center
This year’s theme is “We are Family,” and the one-day seminar will focus on providing attendees with the tools for success and showcasing endurance from prominent women of color or other disadvantage. Visit http://bit.ly/2LsuNlE for more information.
2018 AMPAC Campaign School December 6-9, 2018 | AMA Office, Washington, DC
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.
SAVE THE DATE: 2019 SFMMS Annual Gala Friday, January 25, 2019 Cavallo Point, Sausalito, CA
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Medical Education
Preventing burnout and promoting professional development through Assessment, Reflection, Coaching, and Health (ARCH) weeks Catherine Lomen-Hoerth, MD, PhD, Era Kryzhanovskay, MD, and Karen Hauer, MD, PhD
Burnout is increasingly recognized as a problem Figure 1. among physicians, and yet a proven successful Purpose approach to promoting well-being during medical school does not exist. 1 Medical students and practicing physicians are expected to master large amounts of medical knowledge and continue to learn skills and knowledge through their careers, all while seamlessly developing strategies to maintain their own wellness. As a part of the newly redesigned Bridges curriculum at UCSF, eight ARCH weeks (Assessment, Reflection, Coaching, and Health) were developed to help students gain skills to address these challenges (see Figure 1). ARCH Weeks fosters personal wellness while also ensuring students’ progress towards competence on the foundation of a learner-driven, program-guided approach to lifelong learning.
In ARCH Weeks, students engage in reflection on progress and meaningful experiences with longitudinal “coaches.” Coaches are faculty clinical educators who provide advice, teaching and mentorship for two groups of six students each in two different classes. ARCH Weeks supports students’ development by providing dedicated time to review their competency trajectory via performance data and feedback with their coaches. The students reflect on their progress and create learning plans. Additionally, large group didactics and small group workshops allow students to consider their professional identity as future physicians and make space for promoting well-being in their daily work. The eight ARCH weeks in the new Bridges curriculum are organized around six threads: (1) Assessment, (2) Career Exploration, (3) Coaching, (4) Professional Identity Formation, (5) Team-Learning and Communication Skills, and (6) Well-Being. Assessments occur in most ARCH weeks, to gauge students’ progress in their competencies. The assessments include clinical skills exams, practice for licensing exams, interprofessional assessments (working with other healthcare team members), and a written exam about working in complex health systems. Students receive feedback on their performance and coaching on any apparent deficiencies to help them develop into well-rounded physicians and to prepare them for their licensing exams. Reflection refers to guiding students to think about their life experiences in a way to move forward in their career exploration, specialty choice or professional development. Reflection exercises are used in multiple formats over the weeks, including writing and discussing impactful clinical experiences on the wards (critical reflection) to student and resident panels discussing their own career paths. In the first ARCH week, students 14
A R C H
Purpose To conduct longitudinal, integrated assessments of skills and knowledge To provide opportunity for students to reflect on their performance to date and goals To enable coaches and students addi:onal :me to meet individually and in small groups To promote students’ planning for their own wellness
are introduced to career advisors from all the different specialties as a preview of their fields and to start a relationship that continues throughout medical school. Students have protected time during the various weeks to meet with these advisors and consider the best career path. Similarly, small group work provides students an opportunity to use critical reflection to process experiences throughout the curriculum as a part of understanding physician roles. Team learning and communication small groups focus on how to work together in small groups and how to give and receive feedback. Coaching is the favorite part of ARCH Weeks for students. Every six students are assigned a faculty coach at the start of medical school who works with them weekly in their clinical environment during the first 1½ years of medical school and has 1:1 meetings with the students every ARCH week. Students set SMART goals (specific, measurable, achievable, relevant, and time-based) with their coaches each ARCH week focusing on wellness and on career goals. Coaches also led small groups covering topics such as imposter syndrome (telling of not belonging and deserving to be at UCSF) and the hidden curriculum (unwritten expectations of faculty, staff, and patients—some positive and some negative—based on our current culture and environment). Health is broadly defined to include wellness activities, community building, and strategies to develop into a balanced physician. Students are educated on the literature around wellness and strategies to prevent burnout. They are introduced to the many different types of wellness activities led by students and faculty—contemplative activities such as knitting and mindfulness, physical such as archery and hiking, and skill building such
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Table 1. Examples of Wellness Activities Offered During ARCH Weeks Contemplative Activities
Physical Activities
Skill-Building Activities
Community Activities
Knitting
Yoga
Photography
YMCA outreach
Mindfulness
Archery
Healthy cooking
Caroling to patients
Adult coloring Hiking Nutrition on the run
Tour of Asian Art Museum
Painting Jogging Coping with stress
Attending the San Francisco Symphony
Book club
Tour of North Beach
Acting improv
Writing group
Sutro Stewards
Sleep hygiene
as healthy cooking and coping with stress, as shown in Table 1. Feedback from students indicates that this focus significantly changes the way they approach promoting well-being in their lives. Many students continue to practice the skills they learned during the wellness activities after the ARCH Weeks end. Community-building activities include sharing meals, scavenger hunts, caroling to patients in the hospital, and serving together in various community organizations.
Overcoming burnout
Catherine Lomen-Hoerth, MD, PhD, is Richard K. Olney Endowed Professorship, Professor of Clinical Neurology, Director, ALS Center, and Director, ARCH Weeks at UCSF. Irina (Era) Kryzhanovskaya, MD, is Assistant Professor of Medicine, Division of General Internal Medicine at UCSF. Karen E. Hauer, MD, PhD, is Associate Dean, Competency Assessment and Professional Standards and Professor of Medicine, UCSF.
Conclusions
ARCH Weeks promotes students’ well-being and development as lifelong learners who review and reflect on their performance. ARCH Weeks emphasizes maintaining personal wellness while experiencing challenging situations such as the “Hidden Curriculum”3 as an important aspect of professional development. Formal evaluation of each ARCH week will continue to inform development of subsequent weeks. Overall, the wellness and community-building activities and the 1:1 coach meetings are highlights of the ARCH Weeks. Future directions in improving ARCH Weeks will aim to achieve the goal of Bridges graduates understanding the potential for burnout and being more prepared to handle the stresses inherent in the field of medicine.
REFERENCES
1. The Impact of a Required Longitudinal Stress Management and Resilience Training Course for First-Year Medical Students. Dyrbye LN, Shanafelt TD, Werner L, Sood A, Satele D, Wolanskyj AP. J Gen Intern Med. 2017 Dec;32(12):13091314. doi: 10.1007/s11606-017-4171-2. Epub 2017 Aug 31. PMID: 28861707. 2. Hidden Curricula, Ethics, and Professionalism: Optimizing Clinical Learning Environments in Becoming and Being a Physician: A Position Paper of the American College of Physicians. 3. Lehmann LS, Sulmasy LS, Desai S; ACP Ethics, Professionalism and Human Rights Committee. Ann Intern Med. 2018 Apr 3;168(7):506-508. doi: 10.7326/M17-2058. Epub 2018 Feb 27.PMID: 29482210. WWW.SFMMS.ORG
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Medical Education
Reflections of a Woman in Medicine
Toni Brayer, MD, FACP
I KNOW IT IS A CLICHÉ, but it really does seem just like
yesterday when I attended a medical staff meeting at Children’s Hospital San Francisco (the precursor to CPMC) and heard the president of SFMS talk about the CMA and the influence it had on medical practice and good patient care. I was hooked! I was already new in practice after completing my internal medicine residency, but I could see that this would be a place I could interact with other professionals, learn a bunch and influence the direction of the profession and patient care. I loved building a practice, but I also loved healthcare policy and dealing with macro issues that affected all physicians and patients. It wasn’t easy being a woman in medicine back then, but I felt welcome in organized medicine. First as a delegate to the CMA and then on to serving as the multi-year editor of San Francisco Medicine and the board of SFMS, I was exposed to issues that would impact my ability to provide patient care the way I liked. In 1993 we were hearing brand new terms like “managed care,” “PPO” and “purchasing networks.” The Clintons were designing the new health reform plan but they excluded doctors’ input as we were only “interested parties.” The CDC finally gave a definition to AIDS and as the 90s progressed we saw a “merger madness” of hospitals, health systems and corporations that is being replicated today, 22 years later. I became the third woman president of SFMS in 1996 with an 8-month-old son, an incredibly supportive husband and a busy internal medicine practice. HIV was still ravaging young men but antiretroviral meds were starting to make a difference, and at SFMS we were very active in public health and advocacy for our patients—and physicians—with AIDS. That year we were bold and after surveying our physician members, we took a stand in favor of access to medical cannabis. We were the only medical society to support Prop 215, the Medical Marijuana Initiative. We hosted the White House Drug Czar, and we debated him on the issue. We stressed there should be no government interference in the exam room between a doctor and her/his patient. That certainly put us on the map! That year we took on abortion rights with RU486, opposed concealed weapons and supported medical savings accounts all the way up to creating AMA (and then government) policy. This was also the year that “hospitalists” arrived and changed the way hospital medicine was practiced. The model began at UCSF and after publication in NEJM it has grown exponentially. SFMS was a great training ground for me. I never had a “me-too” moment there; I always felt I was in the company of mental giants; and any success I had was because I stood on the shoulders of those who preceded me. I wasn’t trained to be a leader but the on-the-ground experience was priceless. I never looked for money for committee work or delegation attendance. I considered it to be continuing education and it did enhance my patient skills, office practice and sense of purpose. What I learned through organized medicine catapulted me to other 16
roles as the first woman Chief of Staff at CPMC, numerous board of director seats, and being a director of the newly formed Institute for Medical Quality. I wish to conclude with short words of advice to my younger self and to young physicians, now that I have some wisdom and years behind me:
• Your medical learning and knowledge are just barely beginning. Your patients will teach you more about medicine and how to be a good doctor than you have ever learned in Med School. Listen actively! • Your medical colleagues will be with you and be a main part of your life just like your family. Some will die, get divorced, rise in prestige, have kids that grow with your kids, get famous, and disappear suddenly, but all will be part of your community. Be kind to everyone. Your reputation is your most important asset. Protect it! • The four “A”s really are the secret to success: Ability, Affability, Affordability and Accessibility. I would add Accountability. • Enjoy every experience every day as much as you can. Resilience requires a 3:1 ratio of positive emotions to negative. We focus too much on the negative. If you are out of balance with this ratio throughout the day, change it. This will help prevent burnout, and you will thrive—as I very much hope you will do! Toni Brayer, MD, FACP, practices internal medicine in San Francisco. She is the immediate past CEO of Sutter Pacific Medical Foundation and is a director at Medical Insurance Exchange of California (MIEC), a medical malpractice insurer. She lives in Marin and continues to work on her tennis game.
A Brief Thought for Medical Trainees “Medicine can be very competitive in some ways, from med
school admissions onward. But in most cases, patients don’t pay much or any attention to whatever vaunted credentials and honors one might have. They want somebody who will truly listen to them and try to understand what they are going through. In other words, patients don’t give a damn if you are in AOA. Sit down, listen, and be true to them and yourself.”
—Pratima Gupta, MD, ob-gyn, SFMMS delegate, fellow of Physicians for Reproductive Choice and Health, and recipient of the 2017 California Medical Association’s Compassionate Service Award.
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Medical Education
TEACHING FUTURE PHYSICIANS IS ITS OWN REWARD: The UCSF Volunteer Clinical Faculty Michael Schrader, MD, PhD THE VOLUNTEER CLINICAL FACULTY (VCF) comprise an
integral part of the education of UCSF medical students and residents. VCF physicians provide clinical teaching in various community settings in hospitals and private offices in the Bay Area, Fresno, and at non-affiliated sites, including Kaiser and Highland Hospital. They are a corps of physicians who donate their time to teach the next generation of physicians. UCSF has long incorporated community physicians as faculty. In the past, volunteer clinical faculty have served as department heads. Volunteer faculty were previously represented by the Association of Clinical Faculty (ACF), which was an independent organization of dues-paying members. The mission of the ACF was to organize, assist, and advocate for the volunteer faculty. The ACF would meet yearly for a banquet with a guest speaker, culminating in the bestowing of the Charlotte Baer Award. In 2016, the ACF transformed into the VCF Advisory Board. The current VCF is comprised of approximately 300–400 members with the number projected to increase to approximately twice that size. Earlier this year, the Liaison Committee on Medical Education (LCME) informed UCSF that it must mandate that all physicians supervising medical student learning be members of the school’s faculty as a condition for accreditation. To comply, UCSF has pledged to streamline the appointment process and standardize the promotion process. VCF appointments are made for a term of up to five years. VCF are eligible for promotion every 10 years. VCF are required to submit evidence of clinical competence on appointment and then every five years at the time of reappointment. Faculty promotions are based on both years of service and recommendations from department faculty, residents, and medical students. In addition to a faculty position, VCF benefits include courses on teaching development, CME vouchers, library access at UCSF and UC Berkeley, listing in the UCSF campus directory, and discounts for fitness, recreation, and outdoor programs. Every year the VCF Advisory Board selects exemplary physician educators for awards. The Charlotte Baer Award is given to physicians who have contributed throughout their careers to educating students and residents. Nominations are submitted to the VCF Advisory Board by the UCSF department chairs. The award is named in honor of Dr. Charlotte Baer, who was a practicing internist in San Francisco and a member of the volunteer clinical faculty for almost 30 years. She was an outstanding clinician with exceptional humanistic qualities who served as a role model and teacher. This award has been given yearly since 1979. In addition, the VCF gives Special Recognition Teaching Awards to VCF members who have made significant contributions to teaching medical students and residents. Participating in the VCF is a valuable way for physicians to engage on a part-time, non-salaried, voluntary basis in the areas of teaching and clinical expertise. Interested physicians should WWW.SFMMS.ORG
contact Ivan Mendez at ivan.mendez@ucsf.edu or visit this link https://meded.ucsf.edu/ faculty-educators/our-community/ volunteer-clinical-faculty. As former ACF president, Wade Aubrey, MD, says, “Teaching future physicians is its own reward.” Michael Schrader, MD, PhD, an internist in San Francisco, trained at UCSF and is on the SFMMS Board of Directors, cochair of the SFMMS delegation to the CMA and is current President of the UCSF Association of Clinical Faculty.
What I Have Learned Since Medical School Linda Hawes Clever, MD, MACP ONE OF MY SENIOR RESIDENTS, CLAY FELDMAN, would
spend some nights—after admits and workups—on what he called “social service rounds.” He would ask and listen, then harvest stories or perspectives or unexpected nuggets of history that entertained us. I think Clay himself was entertaining—and that helped us take better care of our patients. The patients liked it, too. We understood more about them and their triumphs, travels, tales of derring-do, values, kids, fears, joys, preferences and hope-to lists. I wish I had listened better and longer to patients; I wish I’d taken the time to absorb more of their stories. Now I would say to my younger, rushed and maybe brasher self: listen more, judge less and pay full attention to what people say during the in-between times.
Linda Hawes Clever, MD, MACP, is a member of the Institute of Medicine of the National Academy of Sciences, Clinical Professor of Medicine at UCSF, Associate Dean for Alumni Affairs at the Stanford University School of Medicine, founding Chair of the Department of Occupational Health at California Pacific Medical Center, and former editor of the Western Journal of Medicine. She is also founding President of RENEW, a not-for-profit aimed at helping devoted people maintain (and regain) their enthusiasm, effectiveness and purpose, and author of The Fatigue Prescription, Four Steps to Renewing Your Energy, Health and Life. She is a member of the SFMMS Editorial Board. SEPTEMBER 2018
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Medical Education
It’s Not Too Late: A Dozen Important Topics Too Often Neglected In Medical Training Philip R. Lee, MD, Steve Heilig, MPH, and Gordon Fung, MD, PhD Note: This is a revised and truncated version of an article that has been reprinted in quite a few publications over the past decade, including our own. We believe that there have been varying degrees of advances and improvement regarding some of these topics, sometimes out of urgency and necessity; but in any event it is a list worth keeping in mind as medical education evolves with the times.
MEDICAL TRAINING IS FILLED with important topics, and
as knowledge increases, it is ever more difficult to “triage” what is most essential. Thus it is problematic to suggest that even more be taught in those finite years of formal medical education. However, there is also much evidence that historically, some important topics have been too often neglected. What follows is a somewhat subjective list—but one based upon research, reports and experience. 1. ADDICTION: The AMA long ago called drug abuse our nation’s number one public health problem, and our opioid abuse epidemic sadly seems to confirm that. The addicted are not just the stereotypical street junkie, but everyday patients misusing legal drugs such as alcohol, tobacco, and prescription medications. Co-diagnoses of depression and other psychiatric issues are also often neglected. Many MDs are not very knowledgeable about addiction and are uncomfortable addressing it. 2. NUTRITION AND COMPLEMENTARY THERAPIES: Many patients can benefit from improvements in what they eat, and many utilize nutritional supplements and other “alternative” or “complementary” approaches most physicians know little about —and patients often suspect that. Physicians should become informed about and counsel their patients regarding nutrition. 3. SEXUALITY: How comfortable is the average MD in talking about sexual practices and health? Homosexuality? Sexual dysfunction? Sexually transmitted infections? Contraception? Taking the time to delve into the “uncomfortable” realms of sexuality can not only strengthen rapport but will allow an MD to address specific health needs that tend to go unrecognized.
4. PAIN: Pain, particularly chronic pain, is often under-treated
in this country, particularly toward the end of life. On the reverse side of the equation is the epidemic of prescription drug abuse, which often requires a delicate balance of needs. Much improvement in measuring and treating pain has taken place in recent years; more physicians need to become current on such skills.
5. END-OF-LIFE CARE: Medicine is not only about “cure,” but
also about caring for patients when that is no longer an option. Palliative care is a growing discipline with great rewards. Physicians 18
need to know how to help ease patients (and their loved ones) into a palliative mode, to use therapies and medications in optimal ways as death approaches, and to work with skilled hospice and other such professionals.
6. PHYSICAL FITNESS: We all know exercise is good. Our
bodies are built to be used vigorously. But too many people are sedentary, which is reflected in our nation’s obesity problem. How many MDs are able to effectively address and motivate patients towards fitness and weight loss? 7. MEDICAL ETHICS: Ethical questions are common in clinical practice. Hospitals are required to have an ethics committee to address ethical issues. But ethics education ethics varies widely in quality, and as with other clinical skills many MDs need training about current ethical standards and practice.
8. VIOLENCE: We unfortunately live in a violent world. Anyone
who has spent much time in an emergency department knows that, but most violence is more concealed. “Domestic” or partner violence is endemic in our society. And it too often goes unrecognized, untreated, and unreported. Physicians need to learn optimal methods of recognizing and treating intimate/partner abuse. 9. ENVIRONMENTAL HEALTH: Our environment affects our health in many ways. Knowledge is rapidly growing about the impact of pollution, chemicals, and the “built environment” on our health, and an “environmental history” may become a part of good clinical assessment—particularly for children, who may be more severely impacted. Physicians have the unique opportunity to link personal and environmental status. 10. HEALTH POLICY: Clinicians may wish that their practices exist in social vacuums, but decisions made in legislative arenas impact clinical problems. Public health and prevention have long been neglected factors in medical education and practice. Yet physicians have high credibility among the public and legislators, and that prestige is heightened when a respected clinician speaks and acts on behalf of policy issues and public health. Get involved—it’s both frustrating and rewarding, like medicine itself.
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11. THE “BUSINESS” OF MEDICINE: Physicians are often
not taught much about how to run a medical practice, or at least about the financial side of medicine. Depending on what type of practice environment a doctor works in, this is more or less important, but all should know about managing a practice, health insurance, managed care, and so on, including details of the “medical market” where one intends to practice.
12. YOUR OWN WELL-BEING: Physicians can be at elevated
risk for depression, substance abuse, and even suicide. Frustration in meeting expectations both external and internal, stress, and the challenge of leading a balanced life are common problems. Combine that with a reluctance to show or share such problems, let alone seek assistance, and many physicians may struggle with an unrewarding life and career. Physicians need to be aware of resources available to address their needs, able to define and maintain priorities, and recognize the numerous daily rewards that are unique to the medical profession— because there are indeed many! Again, there are resources to help clinicians become adept in addressing all these issues as needed as you practice and continue to learn; we wish you a most rewarding career. Philip Lee is Chancellor Emeritus of UCSF, former United States Assistant Secretary of Health, and Professor Emeritus at both UCSF and Stanford. Steve Heilig is Director of Public Health and Education for the San Francisco Marin Medical Society, and Co-editor of the Cambridge Quarterly of Healthcare Ethics. Gordon Fung is Professor of Medicine at UCSF and Editor of San Francisco Marin Medicine.
Medical students are skipping class in droves—and making lectures increasingly obsolete Orly Nadell Farber StatNews, August 14, 2018 The future doctors of America cut class. Not to gossip in
the bathroom or flirt behind the bleachers. They skip to learn— at twice the speed. Some medical students follow along with class remotely, watching sped-up recordings of their professors at home, in their pajamas. Others rarely tune in. At one school, attendance is so bad that a Nobel laureate recently lectured to mostly empty seats. Nationally, nearly one-quarter of second-year medical students reported last year that they “almost never” attended class during their first two, preclinical years, a 5 percent increase from 2015. According to 2017 data from the Association for American Medical Colleges, 1 in 4 preclinical students watches educational videos—like those on YouTube—on a daily basis. And according to two video developers, tens of thousands of medical students subscribe to their products—one of which costs $250 for two years, the other $370 for one year. WWW.SFMMS.ORG
Leaders in medical education have begun to scramble. Some medical schools, like Harvard, have done away with lectures for the most part. Instead of spending hours in an auditorium, Harvard students learn the course content at home and then apply the knowledge in mandatory small group sessions. Other institutions, like Johns Hopkins, are moving in the same direction, but have yet to make a full switch. Hopkins cut down on lectures and boosted sessions that require active student participation. Preclinical lecture attendance hovers around 30 to 40 percent, according to Dr. Nancy Hueppchen, associate dean for curriculum. Full story at: https://www.statnews.com/2018/08/14/ medical-students-skipping-class/ Orly Farber is a medical student at Stanford University’s School of Medicine.
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SPECIAL SECTION
THE SFMMS Writing quality is of course largely subjective, but we decided to try a contest anyway. The guidelines were simple: In 350 words or so, respond to this question:
“Of all the patients you have encountered thus far, which one has been the most memorable and/or had the most impact on you and why? Winners will be published in an upcoming issue of our journal, San Francisco Marin Medicine. The top winner will receive a cash prize to be determined. Please use anonymous re-naming for any patients and others as judged necessary. Publication can be anonymous if requested and appropriate.” This offer was sent out to as many medical student, resident, and fellow lists as we could access. The response was heartening, as you can see for yourself in the 21 entries published here. Judging for the winner(s) will be done by SFMMS leaders and announced later, but really that is not as important to us as the quality and diversity of responses. So, take a look and see how these brief responses to our question make you feel about the future of medicine here. We expect you’ll be glad to read these.
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MEDICAL TRAINEE WRITING CONTEST
Yegua Streetpeople
During my sub-internship, we cared for a retired street performer and songwriter with end stage renal disease, who also happened to have rare nephrocutaneous manifestations. Amidst her multifaceted identities, the identity of “fascinating case report of Kyrle’s disease” began to overshadow the others. One evening she confessed to me her exhaustion after a cavalcade of four teams of three learners came by on physical exam rounds to look at her skin findings. They entered, caked their hands with antiseptic gel, donned unwelcoming blue nitrile gloves, undressed her gown, and shone penlights over her body, as if she were a specimen. Admittedly, I was guilty of this academic voyeurism and fascination too. On a rotation where we had immense physical pressures, the threat of burnout arose not from the hours, but rather from the realization that I also felt guilty of dehumanizing our patients. Before starting the rotation, I had printed out this reminder on my desk: “We must not see any person as an abstraction. Instead, we must see in every person a universe with its own secrets, with its own treasures, with its own sources of anguish, and with some measure of triumph.” And already, I found myself reducing patients to abstractions. Here, the solution rested in music. That night on 30-hour call, I found our patient’s old recordings from her performing days, sat with her for hours, and listened to her music. A blush and chuckle washed over the uremic frost on her face as she shared interpretations of her lyrics, “That one I wrote when I fell in love with a circus boy while hitchhiking in Mississippi.” She passed away one week later when I was again on call. Our team sat with her partner and we listened to her albums in remembrance of her. For us learners, these resuscitating experiences—such as the humanizing capacity of music—helps to fight burnout, more so than any physical respite could. The pager’s cry pulled me away into a sleepless night. And I walked off reassured: Our patient was no longer identified by the obscure eponym of Kyrle, but by her own chosen pseudonym, Yegua Streetpeople.
“Es que no tengo papeles,” responded the worried appearing woman to my questions. Maria was an undocumented immigrant admitted to labor and delivery who had expressed her concerns about being hospitalized because of her immigration status. I tried in so many ways to break through her concerns but to little avail. My attending, Dr. C, however, knew exactly what to do. She walked up to Maria and sat down at her eye level. She paused to allow for silence and looked directly in her eyes and said, “No le preocupe que no tenga papeles”—Don’t worry about your immigration status. In that moment, the entire room let out a sigh of relief. I struggled to understand the magic that transpired in that room. Dr. C’s questions were not any different from other providers’. And yet, her patients accepted her as more than their provider and formed a connection that seemed beyond my grasp. But when I saw her interaction with Maria, I started to understand. It was not one single thing, but it was not a cluster of unrelated acts either. It was a combination of actions born out of genuine empathy. It was the cultural competency to speak Spanish. It was the act of sitting with her patient. It was her silent acknowledgement of the patient’s fears, and the confident reassurance that followed. It was the brief moment of looking in Maria’s eyes and seeing her, completely and thoroughly. To see and be seen, to reach this ultimate form of mutual understanding that broke through the barriers of race, culture and language; this is what I had observed that was so special. Empathy, respect, cultural competence, patient-centered care. We often discuss these ideals, but too often we do not teach how to incorporate them into our care. And perhaps it cannot be taught. Perhaps it must be shown. This is what Maria taught me. I aspire to not just listen to my patients, but hear them. I aspire to not just spend time with my patients, but share a moment. I aspire to not just express empathy, but to feel it.
Ravi Akshay, PGY-1 Resident, UCSF
Andrew Ikhyum Kim, MD, MPhil, UCSF Resident, Internal Medicine/Primary Care
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Medical Trainee Writing Contest DUAL DIAGNOSIS
It was not long after she traded her white lab coat for the shorter white one. Suddenly she was crying and laughing, noticing everything while remembering nothing, and having an avalanche of thoughts tumbling out like pebbles, stuck between the cracks of her broken consciousness. Eventually, after the needle on the scale kept dropping, she brought herself to the ER. She pretended to be working there, presenting herself in the third person and frantically running into other patients’ rooms. She was sure, this is just a test to see if you can be a doctor. They gave her an empty white room and a tiny white pill. She slept on the floor, curled in an endless cosmic swirl. She went home after a strange weeklong vacation. She had learned how to play bongos, how to blow bubbles in coffee to dissolve the sugar, and how to stare out the hospital window, waiting. Back home, she was left with a pile of hospital papers and profuse scribblings, her desperate attempts to diagram the chaos. Soon she was back in the ER wearing the short white coat. A patient screamed, “You don’t know what it’s like!” She looked at the patient and then at the empty white room nearby. The patient softened. Later she traded the short white coat for a long one. A patient asked, “Bipolar disorder? Is this good or bad?” She looked at the patient and then at her hands. She took a deep breath. This is who you are, but this does not define you. All your dreams are possible. Today she looks at herself in the mirror. Staring back is a patient-doctor, learning both roles. Part of her is inside the empty white room, pleading for escape yet grateful for sanctuary. Another part of her is outside the empty white room, looking in, waiting to open the door, and fighting to break down the walls with breakthrough science tethered by compassion and hope. Her pager goes off, and she straightens her glasses. Her patients need her. As she crosses the threshold, the chaos begins to make sense.
Resident physician, anonymous by request
Ms. A lived with a bicarbonate in the 40s and a BMI even higher. Her severe obesity-related hypoventilation had progressed to obtundation, intubation and admission to the ICU where I was rotating as a resident. She had failed spontaneous breathing trials but didn’t seem to require any sedation, and so she would happily greet us every morning despite being intubated and unable to vocalize any words. We would always hand her a pen and paper to solicit questions, and she would always wave them away. Not until later did I realize that the reason for this was not a lack of questions but rather poor written literacy. One morning, though, we found her furiously mouthing her lips around her endotracheal tube as if trying to say something. No, she shook her head, it wasn’t pain or discomfort. I insisted that she use a pen to communicate, and this time she acquiesced. 22
She slowly scribbled M-E-C-C-A onto the paper. “Mecca?” I asked out loud. She looked as confused as me. “Me?” “Mean?” I quickly grew as frustrated as her – this was going to be a long morning if we were going to keep guessing. I was about to give up and say that we’d come back later when my senior resident asked: “Machine?” Ms. A quickly nodded, and my senior presciently jumped a step further: “You want to know if we can use your home CPAP machine instead of this vent?” Ms. A excitedly nodded yes, and we answered her question and thoroughly explained our plan before leaving the room. This story resonates not because of what CPAP meant for Ms. A but rather because of what our interaction means for me. It’s clear that Ms. A had poor written literacy. However, defining literacy as an ability to understand, it’s me who demonstrated poor patient literacy that day. And the solution to this is not to come back later but rather to sit and listen, which is what I’ve strived to do with every patient since. Have I gotten better at this in the three years since I met Ms. A? Hopefully, but not because of clinical experience alone. For ultimately, the key to overcoming patient illiteracy is increased patience, not increased patients.
Rahul Banerjee, MD, Fellow, Hematology/Oncology
I think about him frequently. I think about him because it was the first time I had cried, no truly sobbed over a patient. I think about him because it was the first time I had that tremendous, overwhelming feeling that “This could have been me.” Our similarities were uncanny. He was a young man, full of potential, with his full life ahead of him. He was an intern doctor finally realizing a long-held dream. He was a gay man who had moved to San Francisco to feel the freedom of acceptance and the joy of living out and proud. I had seen him around the hospital and we had given each other that knowing glance that only gay men and women can understand. That brief pause when you both acknowledge you are part of the same tribe, both struggling to be who you are even when at work. When he arrived to the Emergency Room I recognized him immediately, but adhering to my professional courtesy I waited for him to point out our shared past. And then the blow, in the pit of my stomach—HIV/AIDS. I was new to being a doctor and hadn’t cared for many new HIV patients—How do I act? What do I say? Should I say I am sorry? There are patients that always seem to be unlucky—they tend to be the nicest ones. And then there are patients where it feels like fate has reached out and smacked them for no apparent reason. He had incurable pleural cancer—a death sentence at 28 years old. As my team broke the news to him I could barely stand upright. When I left that day, I waited till I was outside of the hospital and called my fiancé, also a young gay doctor, and cried and screamed at the injustice of it all. But what got me most, what has stood with me forever, is that this could have been me. One mistake, one accident, one slip in judgment years ago and now he lay there staring at the healthy mirror image of himself.
Christopher Berger, 3rd-year Pulmonary Critical Care Fellow at UCSF
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It was a few minutes into the encounter before I noticed the three garishly outlined, green-blue teardrops tattooed on his cheek. I had become absorbed by the story of his path to homelessness, his isolation from his family, his deep regrets, his cyclic search for relief through substances. The conversation had quickly shifted from his mild asthma to his overwhelming sense of hopelessness. He tossed the filthy inhaler on to the ground and pointed to it with a shaking finger. “It’s empty, doc.” Like many encounters in this clinic, it ended when a minimal medical intervention was decided and the real intervention was complete. A trace smile crinkled the tattoos as I shook his hand, and I smiled too—he clearly was a man grateful for someone who listened. Shortly after, I learned those teardrops signified his murder of three men. As physicians, we have the privilege of caring for patients regardless of their beliefs or actions. We lift up shirts to listen to breath sounds, whether they are polo shirts or orange jumpsuits. We suture wounds, whether they are made by scalpels or gunshots. And we listen to all kinds of words without judgment. Within minutes of meeting, we learn about a person’s most intimate hopes and deepest pains. There is simply no way of disentangling a person’s health from their life. We’re not perfect at it, but at our best we have the chance to empathize across some uncommonly traversed divides. And we are increasingly learning the extent of a gaping cultural divide in this country. Every patient encounter is a potential connection between different political, socioeconomic and cultural groups. Our country has deep wounds and we are professional healers. What can we do? We can form a connection between segments of the population that rarely meet. We can trace the threads of inequality and hopelessness, tangled up in bigotry, that underlie this story. We can work to understand without accepting the hate that surrounds us. We can paint a picture of the humanity of all Americans. We can advocate for the most vulnerable populations at a time when they need it most. In all of this, we may find a core of real conversations that illuminate an absurd perimeter. Rather than turning away from the disturbing sight of tattooed tears, we can look carefully for the real tears that we know are not far behind.
Meredith Bock, MD, Resident Physician, PGY-3, UCSF Department of Neurology
The Ghost’s Footsteps
The physician is an observer of human life: listening to everything from the wails of a newborn breaking unspoken tension to the silence that fills a room as one takes their last breath. Thus, it is no surprise that one of my most important lessons in medicine has not come from a lecture nor textbook, but rather from a description: a 43-year-old alcoholic presenting with an acute exacerbation of liver failure. Underneath his trembling body, unkempt hair and overgrown nails was a failing liver, rigid and distended from repeated insults of alcohol. The result was a belly engorged with fluid leaking out of his blood vessels and WWW.SFMMS.ORG
diffuse bruises that were a grim sign of a fading ability to clot. Though it was the blood sluggishly moving through his liver that was most concerning. Backing up into the veins of his esophagus, they dilate like little balloons that can pop at a moment’s notice, unleashing a torrent of red that would empty the entirety of his circulatory system into his stomach. I met a man on death’s doorstep. Two lines stand out from our conversation. The first: “God makes mistakes, and I am one of them.” Perhaps he was right. Born into an alcoholic family, drinking since a young teenager, and living off the streets since, one must ask where was his chance? The second: “A good doctor treats his patients, a great doctor checks on them frequently, and the best loves them no matter who they are.” I imagine the devastating withdrawals and the abuses he must have faced. I imagine him floating through life as a ghost evading people’s notice as they shun their eyes. Yet, I met a 43-year-old poet on death’s doorstep that left a permanent impression. He taught me the look the fear of death has and the unspoken desires of a patient. So, as I begin this journey in medicine, humbled by my path ahead, I aspire to accept, forgive and love my patients.
Vikas Daggubati, MD/PhD student in the Biomedical Sciences Program at UCSF
On November 8, 2016, Donald Trump was elected President of the United States. The following day, MM attempted suicide. The election was not in and of itself the stressor that drove MM to consume half of a box of rat poison; rather, painful exchanges with his family following the election had made him feel isolated, misunderstood and, as a consequence, suicidal. He had sat in his car for hours, downed several beers, and finally consumed the poison. He immediately regretted his decision and called 911 which brought him to my care. He was placed in a psychiatric room, that is a room devoid of sheets, soap and other potentially dangerous items. I briefly introduced myself, explained that I first wanted to evaluate him physically before returning for a lengthier conversation, and matter-of-factly progressed down my resuscitation algorithm. I then left to place orders and discuss the case with the Poison Control Center. Upon returning to MM’s room, his nurse informed me that he was no longer speaking to any providers. But, when I re-entered, he was eager to speak to me. I was the only black provider in the department. MM is a black man adopted by a white family. He felt loved during his childhood but he likely had undiagnosed depression for much of his adult life. He was finally overwhelmed by his negative thoughts when his family had uniformly voted for Donald Trump and, in conversations that followed, discounted his fear surrounding the result. As a black physician, I can certainly relate to feelings of racial isolation within and outside of the hospital. In his moment of extremis, MM was not seeking sympathy; he was seeking empathy, something only I could provide. SEPTEMBER 2018
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Medical Trainee Writing Contest I was made acutely aware of how my race had given me a unique power in caring for MM. That power brought with it a sense of privilege and responsibility. Assisting my white psychiatry colleague, I spent significant time with MM gathering history and providing support. Our conversation was diagnostic, my presence was therapeutic. My charting was neglected, necessitating that I stay many hours after my shift to finish notes. But, ultimately, at the end of the night, I felt a satisfaction that I had yet to experience previously in my career. I walked out of the department with the sense that, because of me, MM had felt a bit more seen and heard.
Tomas Diaz, MD, UCSF-SFGH Emergency Medicine Resident
Losing a patient is never easy. When it is someone that you got to know well, it can feel like you have a lost a member of your own family. For me, it is the teenagers that have passed on that keep me up on night. Because even though they frequently disobey and misbehave, they are the ones whose impact on the world we will never know. A great example of this was a patient of mine named Roger. He was an 18-year-old young man that was getting ready to start college on a baseball scholarship after many universities had worked tirelessly to recruit him. Just days before classes began, what was initially thought to be a chronic sports injury was now diagnosed as a rare form of a soft tissue sarcoma. He soon battled through months of chemotherapy, radiation and surgeries, and was fully cured of his disease. Months later, Roger re-enrolled in college and began training so that he could once again dominate his favorite pastime. However, not long after he started, his dreams were once again shattered as symptoms of fatigue and bleeding led to a diagnosis of acute leukemia, a rare complication related to his prior therapies. Unfortunately, the only cure for this condition was a bone marrow transplant. His treatment resulted in many complications, yet Roger fought each day as if he was down to his last strike and was not going to let the pitcher strike him out. But in the end, the leukemia won. To this day, I often imagine what Roger would be doing if he was still alive. Perhaps he would have been a major league ballplayer. Or maybe a professor of some kind. There is just no way to know what he would have done and what his impact would have been on the world. And that is why someone like Roger is so hard to forget. He had his entire adult life ahead of him, and yet very quickly, it was all taken away. When I think of him, I am reminded how lucky I am to be alive and healthy, and that I have so much love and support around me. Each day has its challenges and I don’t always hit a home run, but I’m just glad to have the chance to play again tomorrow.
Brian Friend, MD, MS, Pediatric Bone Marrow Transplant Fellow, Division of Pediatric Allergy,
Immunology, and BMT, UCSF Benioff Children’s Hospital
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Between the Heaves of Storm
I learned early on in my training how to deal with a dying patient. I became skillful at pausing racing hearts, at jumpstarting sluggish ones. I learned how to sedate and intubate, paralyze and pronate, ventilate and oxygenate. I developed a clearcut understanding of what dying in the hospital looked like: a sudden, messy, tumultuous affair filled with barked commands and screeching alarms. A fight to save a life. With time, my worldview evolved. I learned about palliation and comfort care. My toolkit grew as I replaced pressors with painkillers, antiarrhythmics with antiemetics. I now felt comfortable helping patients through both extremes of the dying process. Then I met Joseph. It was the beginning of my hospitalist fellowship and my first time as an attending. He had been admitted with respiratory failure, and we soon realized that ECMO – the process of oxygenating his blood externally via machine – was the only intervention that might save his life. Everything moved quickly. Joseph was whisked off to the OR. Unfortunately, due to multiple complications, inserting the ECMO catheter proved impossible and the procedure had to be aborted. Just like that, it was over. We were out of options. And for the next few hours, we watched Joseph die. I sat in a chair at his bedside. His family showed me photos as the monitor overhead broadcast an incrementally declining oxygen level. The room was eerily calm. When his blood pressure dropped even lower, my resident asked if we should add another vasopressor; I silently shook my head. Joseph died that evening. He was 21 years old. Despite all my training, all the skills I had mastered for treating a dying patient, I was utterly unprepared for his death. Joseph’s gradual decline gave me the chance to reflect in the moment, rather than after the fact. To get to know his father, as we both sought to come to terms with his passing. It was memorable, moving and heartbreaking. Because while I was taught early on how to deal with a dying patient, I’m still learning how to deal with a patient’s death.
Zachary G. Jacobs, MD, Clinical Fellow, Academic Hospital Medicine, UCSF
A Tale of Two Patients
When we entered the room we met one patient. When we left, we knew another. We entered the room fumbling with the trappings of white coat privilege, hoping that we won’t still feel like kids playing dress up at the end of our four years of med school. Our coach introduced us as “student doctors.” We met a confident woman, cracking jokes with us about the show she was watching on television. She asked where we were from and if we liked medical school. Her face registered comical shock when she heard how many years of training we had left. Our chuckles were still dying down as one of my classmates bravely began taking her history. She was pregnant, and presenting with nausea, heartburn and fainting spells. My classmate asked questions empathetically. She answered them honestly.
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We were all smiling gratefully at the patient, already applying sanitizing gel to our hands to exit the room, when our coach crouched down on eye level with the patient, took her hand and asked, “And how are you doing?” In the litany of questions we had just asked this had never come up. A new patient emerged. She immediately began to cry and said that she didn’t know if she wanted to keep this baby. She considered terminating the pregnancy when she first discovered that she was pregnant, and now with the nausea and dizzy spells she felt this pregnancy was more than she could handle. This patient, this second patient that our coach unearthed, was not the patient that we interviewed. Or rather she was, but she was also much more. Sometimes I don my white coat and stethoscope and feel that so early in my training I am doing little more than performing the role of doctor for my patients. I now know that in some ways my patients are also performing for me, and they can only perform within the confines of the stage that I set for them. In any one encounter I will meet only a few aspects of our patients. Such is the nature of being and caring for multifaceted beings. It is my responsibility as a physician to set the stage for each appointment such that my patients can present whichever aspect of themselves most needs healing during our time together.
Shakkaura Kemet, MS2, UCSF School of Medicine
What makes a good doctor?
Initially, I was scared of Anthony. He came to the inpatient psychiatry unit after a violent outburst at his locked treatment facility. Each time I asked about a psychotic symptom, Anthony just stared at me, looking vulnerable and defeated. Embarrassingly, it took weeks for me to try a new approach. But when I asked this 29-year-old patient if he enjoyed basketball, our relationship transformed. Apprehensively, Anthony’s shoulders relaxed. Did he even smile? “You know about basketball?” he asked. Our time together developed into conversation. We discussed sports, movies and our favorite candy. During this time, Anthony would give me subtle insights about the internal war torturing him. In brief moments of distress, he cried, “I just wish I could quiet the voices,” or he shamefully admitted “they tell me to hurt people.” By the last month of my intern year, I began to feel proud. Anthony had opened up to me—only me! Did this mean I was a good doctor? But the year was also coming to a close, and I informed Anthony that I would be switching to a different hospital. He just shook his head, retreating under his blanket as if to say “not again.” On my last day, Anthony called me profanities. He yelled, “I’m glad you’re leaving!” Sure, I intellectualized that this childish response stemmed from years of trauma and a primary psychotic disorder rendering him unable to process these emotions. But still, I was hurt. As I was exiting the unit, Anthony pleaded, “I thought you were going to help me?” My eyes filled with tears, WWW.SFMMS.ORG
no longer feeling like the good physician from weeks prior. I would like to hope my time spent with Anthony brought him some joy, some human connection. But I often fear that I did more harm than good. How was I any different from all the other people who abandoned him? And yet, if Anthony could only open up to me, how could he ever recover and function outside the hospital walls? I returned to the county hospital for a call shift two months later and I found myself back on the psychiatry unit. Anthony was still a patient, the door to his room closed. As I approached it to knock and say hello, I paused. Was I doing this to help Anthony? Or to ease my own guilt? I stood there, pondering, realizing how much I have left to learn.
Kate Kinasz, PGY-2, Psychiatry Resident, UCSF
The overhead page for a Code Blue pierced through the palpable dread within the radiology reading room. I had a dizzying feeling that I knew the subject of this announcement before the echo of the room number confirmed my fears. On the screen, a bright blush of contrast burst from her hepatic artery. Additional aneurysms, like little water balloons, taunted from within the hemorrhage. This CT scan was a modern means of fortune-telling, a static prediction of how this woman would die within the hour. That morning, during sign-out, the overnight resident described how this middle-aged woman presented with abdominal pain. An ultrasound showed a nonspecific abnormality within her liver, but her vital signs and the remainder of her testing were normal. A plan was in place. On my checklist I added: follow-up CT. My attending and I crossed paths at her room during our respective pre-rounding routes. I was surprised by how well this woman looked despite her complaint of right upper quadrant pain. Her abdomen was mildly tender, but her examination was otherwise unremarkable. With my hand on the doorknob, she admitted she was grateful to have women doctors. I blushed, and we left, planning to meet at the radiology suite after her scan. Memories of this conversation replayed on loop as I bolted back to her room through a maze of hallways. I arrived as the Code Leader methodically listed the ACLS “H’s and T’s.” I croaked the results of the CT scan and there was another explosion of activity. But despite our best efforts, this was not something we could outrun. Years later, I am sitting in the resident room. It is 6:30 in the morning and I am meticulously organizing my rounding sheet, waiting to grab the pager from the overnight resident. I remember her as I scan new names on my patient list. I think about how crucial those first few hours in the hospital can be. I think about my role during sign-out: being a patient advocate and a devil’s advocate. Assimilating all the data but also constantly challenging the differential. I open a chart and I start to read. I cannot wait to meet them.
Sara C. LaHue, MD, Adult Neurology Resident, UCSF SEPTEMBER 2018
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Medical Trainee Writing Contest
When I was a third-year medical student, my pockets ambiguously bulging with tools—stethoscope, pen light, phone charger—I was sent to the hospital basement to request recently filed clinical notes for a patient. Waiting for the clerk to return, I noticed the corner of a dirty, three-hole punched paper jammed under the counter. Extracting and unfolding it, I was amazed to find the following chart note: Afanasy Kusmov had been in perfect health until six months ago, when he began to feel a little tired and weaker than he was used to. However, this did not stop him from taking his usual strenuous hike once a month with his son. He visited his acupuncturist who prescribed him an herbal remedy that he thought helped. Only two weeks ago, Kusmov was laying down moss in his yard when suddenly he began to shiver and sweat. His wife measured his temperature to be 103 degrees Fahrenheit. “I feel terrible,” thought Kusmov. Kusmov’s wife took him to the hospital. His doctors did many tests but his fevers continued. “I wonder what is wrong with me?” thought Kusmov. Kusmov’s doctors did not know. Kusmov did not improve. There was some optimism that it might be the unpasteurized cheese from a Danish farm nearby his house. It was not the cheese. His wife and son visited him in the hospital. “What could it be?” the son asked. His doctors shrugged. One day a very famous doctor came to see Kusmov. “Very interesting,” he said. He administered steroids to Kusmov. Kusmov began to become better. His fevers went away and he got out of bed. He walked in the hallway. “Very interesting,” all of the doctors said. One day the doctors told Kusmov that he could go home. “Am I better?” he asked. “Yes,” they replied. “What was wrong with me?” he asked them. “We don’t know,” they apologized. Kusmov packed his things. At home, his wife had cooked him a hot meal and his son greeted him. “Well,” thought Afanasy Kusmov as he sat down to soup, “that’s over. Thanks, God!” Years later, I often find myself wanting to write a note like this one—one that, like the king’s surprised barber, you whisper into a hole in the ground and bury, or lose in the basement of the records office of the hospital—but I never do!
Andrew Levine, MD, PhD, Clinical Pathology Resident, Department of Laboratory Medicine, UCSF
Sometimes it’s not the dying ICU patient or the life you helped to save that imprints the most on your mind as a clinician. For me, the patient that stands out was a completely healthy little boy who was just a little different. I was a medical student in the urology clinic when I met him, and I think I felt such a strong connection because he looked so much like me at that age. He was a six-year-old adopted Chinese boy with a very stern-appearing mother and a history of penoscrotal hypospadias that was unrepaired. He was evaluated years ago elsewhere, and endocrine workup had shown him to be XY and otherwise well, a standard candidate for hypospadias repair. However, mom had friends in the intersex community that encouraged her to let him decide
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if his differences should be operated upon. Never mind that he was being raised with a boy’s name, boy’s clothing and playing with toy trucks in clinic; mom was completely uninterested in hearing our concerns about psychosocial development among his peers, forming memories of genital surgery as he got older, or the technical difficulties of surgery as he grows. For me, I wanted to help this child have as normal a childhood as possible, and it bothered me so much that she did not want to let us help. Currently, genital surgery in children is a hot topic in California politics. There are circumstances where the genetic sex is not clear, and, as always with pediatric surgeries, forethought and a comprehensive discussion and decision is essential. I remember debriefing with the attending after seeing this patient and expressing my frustration. He impressed upon me the delicate nature of these disorders and the gentle hand needed to help guide and counsel families. Regardless of what decision is ultimately made, we must remember that for the parents of these children, the decision is always a difficult one. Our role as surgeons and doctors is to provide our advice and perspective and to be accepting and supportive as best we can.
Yi Li, MD, PGY4, UCSF Department of Urology
“What is going on? Please tell me what’s going on,” Mrs. Braxton implored as I stepped out of the operating room. “I’m so sorry,” was all I could manage before my eyes welled up with tears. Mr. Braxton had end-stage liver disease, the result of a longstanding autoimmune disease, and this was his last chance for a transplant. In fact, he was one of the 120,000 patients in the U.S. waiting for a transplant every year; less than a quarter will live to receive one. In fact, Mr. Braxton had waited for a transplant for over 10 years. Before I met him, I could not appreciate what it meant to be perpetually waiting to know if there is more time, knowing that more time might never come. Mr. Braxton’s bed had been the first and last stop of my many long days on the medicine ward. Over the course of his admission, I had gotten to know the Braxtons—Mr. Braxton, a protestant minister, his wife and two daughters—as my own family. It was a family that I need as much as they needed me, as I struggled to get through the first few months of my medicine internship with my family and close friends thousands of miles away. Growing up as a first-generation Chinese-American, my choices were often made at a crossroad of two cultures, faiths and ideologies. I remember standing in line for my driver’s license when I was 16. The clerk had asked, “Are you an organ donor?” As I eagerly nodded, my mother interjected, “No.” Organ donation, my mother later lectured me, is a violation of the wholeness of the body and spirit. Ultimately, Mr. Braxton’s new liver came a day too late. By the time he made it to the top of the list, he was too ill and his longawaited surgery had to be aborted. After that, he deteriorated rapidly, and when he could no longer recognize his daughters, his wife transitioned him to hospice. Those poignant memories haunt me still: from his charisma, bravery, faith and bad jokes to when I had held his hand in mine as he breathed his last. I
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remember his advice to me: that life—and death—are not for man to decide, but the choice to live life to the fullest is. It is a lesson a physician should never forget. Caring for him and losing him were the most painful but powerful lesson for me, as a physician and as a citizen. A few months later, I signed up to be an organ donor and now I volunteer for organ donation campaigns in his memory.
Yun Rose Li, MD, PhD, Resident Physician, UCSF Radiation Oncology
I made my most memorable connection with a patient while on my community inpatient psychiatry rotation. Fists tightly balled, eyebrows furrowed in dismay and a frown etched on her face, Ms. N was the picture of fury, and she was marching toward me. “Hey! Michelle! I need to talk to you!” she shouted at me loudly. It is my natural inclination to want to be helpful, and normally I would be delighted that a patient would directly seek me out for help. However, this situation was unusual for two salient reasons: first, my name is not Michelle, and second, I had only ever seen this patient be demure and charming to everyone around her, including myself. She grabbed the name badge hanging around my neck and accused me of switching identities. My pulse quickened, as I was not in the habit of having people lunge toward me. Then, I noticed her eyes scanning my face. They were intensely scrutinizing yet distant—as if she did not see me—and my tachycardia dissipated, replaced by empathy and curiosity. Over the following weeks I had the distinct honor to be a part of her treatment team. I listened to her describe in our daily sessions how her life sometimes became distorted and how she would (or could not) make sense of it. I also witnessed how the genuine compassion, creativity, and active listening of her psychiatric team slowly helped her to regain herself. I was inspired by the ability to heal through human connection, and I became eager to learn and practice this art form. On the day of her discharge, Ms. N stood up during our community meeting to thank the team and apologize for her “bad behavior,” adding that she “was embarrassed for acting that way.” Her parting words stuck with me. Needing treatment is not something to ever have to feel sorry about. I want to be a part of the effort to end the stigma and discrimination of mental illness so that Ms. N and others like her can get help in a dignified manner.
Kerry-Ann Pinard, new Psychiatry Intern (PGY1)
Nighttime Memories
Mr. M was an elderly Chinese man who arrived at the emergency department after suffering cardiac arrest at home. When I met him, he had been resuscitated, intubated, sedated and placed on vasopressors. When I called his wife with a Cantonese telephone interpreter, she told me that she had called 911 when he had become dyspneic. She thanked me for caring for WWW.SFMMS.ORG
Mr. M, and confirmed that no further heroic measures should be performed. I told Mrs. M that her husband was critically ill and recommended that she come to the hospital as soon as possible. But she could not come before the morning. I admitted Mr. M to the ICU and continued life-sustaining measures. I knew he was dying and I yearned for his wife to be by his side. Even though she lived only a couple miles away, those miles may as well have been light-years that evening. I called her one last time, racking my brain for any way to help her be with her husband. Through the interpreter, she told me, “I know you did everything you could. Thank you for helping him. Please just make sure he’s comfortable.” As she said this, as if in response, her husband’s heart rate dropped to zero on the monitor. It was as though he had felt his wife give her permission for him to leave. I stepped into Mr. M’s room and held his hand as I listened to his silent chest. I took his hands in mine, closed my eyes, and reflected on the brief but intense time that he, Mrs. M, and I spent together. And then I returned to work. The night was young, and more patients needed my care. In the morning, I told my colleagues about the patients with cystic fibrosis and gout. But no one heard about Mr. M. Initially, I felt lonely and isolated after desperately trying to reunite Mr. and Mrs. M one last time. The rest of that night, I bore the weight of my failure to ensure Mr. M would not die alone. But now I know that this is not true. I spent the night by his bedside. We were together when he passed away. It was a privilege and an honor that I will never forget.
Akshai Subramanian, MD, Resident Physician, UCSF Internal Medicine Residency Program
Throughout my five years with the Mobile Clinic Project at UCLA, I encountered countless homeless and underserved individuals who had learned to accept their poor health as a mere fact of life. Moize, a regular at our clinic, would come with the same request every time—400mg ibuprofen. Having spent over 20 years on his feet as a hairdresser, he could barely keep a straight posture without debilitating back pain. Though we both knew that ibuprofen was a temporary fix, with no other options, Moize had come to accept his pain. Week after week, it was disheartening to simply continue to put a Band-Aid on a much larger issue. Complementing my efforts with the Mobile Clinic, for months I worked with the deans and faculty of USC’s Physical Therapy program to successfully integrate their services into our streetside clinic. I still remember the frustration on Moize’s face as he begrudgingly worked through numerous exercises with the physical therapists. He looked defeated and felt he was wasting his time when he could have been on his way with his weekly tablets of ibuprofen. Despite his frustration, he trusted me and came back for another session where he was given an exercise regimen to follow. For weeks, he was nowhere to be found. It was not until two months later that I felt a tap on my shoulder. SEPTEMBER 2018
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Medical Trainee Writing Contest His smile said it all—he had been diligent with his exercises and was now nearly pain-free. The physical therapy services not only treated our patients’ chronic musculoskeletal pain, but they also changed the way our patients viewed their health. These patients were initially passive victims to their own pain, but had gradually become agents of their own health. Our clinic supported their progress by showing up every Wednesday night, building deep relationships with them while providing a stable medical home. My time with Moize and the homeless population in West Hollywood reinforced my desire for a career in family medicine where progress is driven by the strength of the relationships we have with our patients. Today, I am proud to be a family medicine resident here at the UCSF Family and Community Medicine program. Patients like Moize continue to remind us to not just accept the status quo. Rather, we need to continue to innovate and always remember to treat the world the patient comes from.
Eric Tam, MD, UCSF FGM Resident, PGY1
I first noticed your baseball cap, which looked still new, so starched it held its shape perfectly, balancing over the arch of your skull. You are a smoker and by definition eligible for the study. But, I remember you as an inventor. You shared with me your creative ideas. They came one after the other, rapid fire. The one I remember most is this: you wanted to create a car that would light up during distracted driving, so as to warn others on the road. Do you know your chart says you are “cognitively impaired”? I never understood this; you had so many ideas. And do you know I can’t enroll you in the study because of this? But, I keep talking to you. Because you are funny and you are kind. Do you remember the chocolate chip cookie you dug out of your bag and gave to me that day? It came in a tin, decorated with snowflakes and a tuxedoed penguin. I kept the cookie in my desk for months. It reminded me of you. How generous of you to give me this, especially when I entered the conversation only looking for a research subject. I think about you, and the cookie, often. And I am struck by how joy, and kindness, and generosity can grow so easily in these unexpected places.
Rachel Tenney, Medical Student, UCSF
course, obliged. When I returned to her room, blanket in hand, she started to cry and thanked me profusely. Given the circumstances, I was surprised at how grateful she was for such a small gesture, and after visiting for a few more minutes, I wished her good night and asked her to let me know if she needed anything during the night. Ms. Wanda died peacefully in her sleep early the next morning. When I walked into the room shortly after, I saw that she was tucked into the blanket that she had so hesitantly requested just a few hours earlier. In her final moments, I believe that the intervention she appreciated most was not the leads monitoring her heart or the medication dripping into her arm, but the human gesture of asking how she was feeling and providing a small comfort, a warm blanket that made her hospital bed feel just a little more like home. In today’s world of complex and heroic interventions, it is important to remember that medicine is not simply about fighting a disease or completing a procedure—it is about caring for a person. The importance of humanism in medicine is mentioned often in lectures and textbooks, but, in my experience, it is the patient who really teaches us how fundamental empathy and compassion are in the practice of medicine. I will never forget Ms. Wanda, and I am grateful to her for teaching me the value of not just treating, but truly caring for my patients.
Quinn Thibodeaux, MD, Clinical Research Fellow, Psoriasis and Skin Treatment Center, Department of Dermatology, UCSF
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I stood quietly as Ms. Wanda signed her “do not resuscitate” forms. After a long discussion with her and her family about treatment options, they decided the best course of action was to bring her home, where she could spend her remaining days in the company of her friends and relatives. I was covering the floor patients that night, and after Ms. Wanda’s family went home for the evening, I asked if there was anything I could do to make her more comfortable. She looked surprised at my question, and after thinking for a moment she asked in a slightly embarrassed tone if I would mind getting her another blanket. I, of 28
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Medical Education
Medical Students Make the Worst Patients: The tragicomedy of an MS1 Mara Olson
Lying in an MRI machine, I start to laugh. The enclosed space resonates with the technician’s pleas to hold still and the aching expansion of my bruises, yet I can’t help giggling. If “humor is tragedy plus time,” then the past few days, on top of the last many months, have provided the proper incubation period for tragedy to become comedy. And so I laugh. Doctors notoriously make the worst patients; but I
argue medical students have them beat. First, we believe pain is standard: if we aren’t sleep-deprived and stressed and pushing our limits, we must be slacking. Second, we know just enough about medicine to be dangerous, but not enough to be effectual. Medical Student Syndrome is well documented; students commonly report symptoms that correspond to diseases they are learning in the classroom. We self-diagnose rare disorders while accepting actual damage as “rite of passage.” Still rooted to my life as a professional runner, in January I decided to train for my first marathon. This new jump in distance provided a singular challenge and point of pride, even when fraying hip flexors prevented me from getting up out of a chair without using my arms, or when plantar fasciitis forced me to single-leg hop to the toilet in the morning, or when the little ache in my right shin became excruciating. During this time, I learned to diagnose innumerable diseases; but I refused to see how neatly I fit the epidemiological picture of an underweight, sleep-deprived, 100-miles-a-week runner with a stress fracture. So I taped my shin and raced Bay-to-Breakers. Five days later I ran a 22-mile workout. When it hurt too much to run, I swam until I saw spots. I cried a lot, not in remorse for the five months of constant, relocating pain, but because my lacrimal ducts were insisting I be a patient instead of a stubborn medical student. Three weeks before the marathon, I relentingly go to Student Health for the pain in my shin. Denied an x-ray referral for reasons I still don’t understand, I barge into Radiology just before closing time and hand them my insurance card. (After imaging, I pound on the locked door until a janitor helps me retrieve said insurance card). I spend the next hour failing to open the CD-ROM on my Mac, and then running around campus in search of a compatible PC. Fortunately, an orthopaedic surgeon I have come to know is willing to read the results, which are negative for a fracture, and he schedules me to see one of his colleagues in sports medicine. Between appointments with the orthopaedist and a sameday MRI, I’m meant to be shadowing a pediatrician at the offcampus hospital. Ignoring the stabbing throb in my shin, I’m making record time on my bike until a car door flings open and WWW.SFMMS.ORG
I hit asphalt. The call of doctoring is louder than my aches, however. I pedal away, then hurriedly scrub blood off my white coat before performing histories and physicals at the hospital. En route to the MRI during rush hour, bike helmet firmly secured on my head, my insurance company calls. With one hand, I click through automated responses until a live representative begins soliloquizing about in-network radiological imaging options. I brake hard with my left hand as a Camry runs a stop sign, which sends me over the handlebars and back onto asphalt. I extract a sizable piece of gravel from my elbow, retrieve my cracked phone, demand authorization from the stunned insurance representative still on the line, and arrive only five minutes late for my MRI. After an hour in a closet-sized waiting area (beside an individual I mentally diagnose with tuberculosis and a severe deficiency in respect for personal space), I begin to laugh. I laugh at the time I spent waiting; I laugh at the two cars that hit me today; I laugh at the trouble I had scheduling and obtaining and interpreting an x-ray. Most of all, I laugh at the absurdity of my cliché: it took me being stuck in an MRI machine to finally allow myself to be a patient. This is Life telling me to “sit down, and shut up,” because I am not taking care of myself. Medical students make the worst patients because we want more than anything to be doctors; and doctors make terrible patients because they consider it impossible to provide care when they’re the ones who need it. Yet, with all the time I’ve spent in student health, radiology, the waiting room, and this machine, I could have helped countless patients. Not only does the stress fracture in my fibula physically hurt, it is also detracting from my ability to give to others. Of all the patients I have encountered thus far, I have been the most memorable. My own tragicomedy has taught me that it is necessary to be a patient in order to be a provider. After only one year in the medical field, I forgot the importance of self-health; by serving health, I thought I was exempt from its laws. What a laughable notion. Mara Olson is a UCSF medical student, class of 2021.
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Medical Education
Launching New Physicians in 2018 David Nash, MD, MBA
For me, the month of May will forever be associated with graduations, and this year I was honored to be the speaker at two medical school graduations. Having spent a 28-year academic career on the faculty at Jefferson University in Philadelphia, my adult children consider me a dinosaur—so, to prepare my speeches, I asked the medical students who were enrolled in my seniors-only elective course what I should say. Here is what they told me: • Reaffirm your career choice. • Tell us it is okay to get off the bus occasionally. • Above all, be optimistic about the future. Armed with this advice, I crafted my addresses, the first of which was directed to the graduates of the Geisinger Commonwealth School of Medicine in Scranton, Pa. I was nearly overcome with emotion when I delivered the second address to a class of freshly minted physicians at my alma mater, the University of Rochester School of Medicine in Rochester, N.Y.—an almost surreal experience given that I barely passed my first and second years. Here, in a nutshell, is what I shared with them about the dynamic environment in which they will be practicing medicine.
Ten years ago in a watershed article called “The Triple Aim: Care, Health, and Cost,” Donald Berwick, MD, and colleagues set forth three now-familiar goals for U.S. healthcare; despite Herculean efforts (e.g., the Affordable Care Act), many challenges remain.
GOAL 1: Improve the health of the population. Even though we spend nearly $3 trillion annually on care, the U.S. ranks #17 in the world in terms of population health and, for the first time since 1945, you and your peers may have shorter life spans than your parents’ generation. Socioeconomic factors are game changers; your patients’ Zip codes are more relevant than their genetic codes in predicting life expectancy (e.g., 88 years vs. 68 years, depending on Zip code, in the city of Philadelphia).
GOAL 2: Reduce per-capita cost. Anyone can cut costs by ending
a program, closing a hospital, or limiting diagnostic testing. It is far more difficult—but exceedingly more effective—to effect change in individual patient behavior, reduce clinical waste (e.g., reduce medical error—the third leading cause of death in the U.S.), and eliminate operational waste (e.g., system failure, duplication of effort).
GOAL 3: Improve the patient experience of care. Health lit30
eracy and cultural competence are essential ingredients in providing truly patient-centric care. Your generation would
never watch a movie, go to a restaurant, or make a purchase without checking a Yelp review—why should healthcare be any different? Some of the nation’s most prominent thought leaders have suggested a fourth aim—one that should resonate with each of you:
GOAL 4: Reduce physician burnout. A form of depression, burn-
out is characterized by emotional exhaustion and depersonalization that can lead to a heightened risk of suicide when compared to the general population; it is insidious and it happens more often than you might imagine. The etiology of burnout is complex; the differential diagnosis list is lengthy and there is no single unifying thread. The Mayo Clinic, with its deeply patient-centric culture, contends that physician burnout is the proverbial “canary in the coal mine”—an early indication of system malfunction. This goal is one in which we all have a vested interest!
I have supreme confidence that the Millennial Generation
will achieve laudable goals; I hope that you will embrace the “Quadruple Aim” construct and reflect it in your professional role. My parting advice is that you be grateful for this nation of immigrants—remembering that you stand on the shoulders of your ancestors—and that you try every day to put yourself in the shoes of your patients. Like the ancient physician educator Maimonides, seek to practice “tikkun olam”: save the world; save a life; reduce pain; lift up a community; give hope to young people. David Nash, MD, MBA, is founding dean of the College of Population Health at Thomas Jefferson University in Philadelphia, and a board certified internist renowned for his work in public accountability for outcomes, physician leadership development, and quality-of-care improvement. —Reprinted from MedPage with permission
SAN FRANCISCO MARIN MEDICINE SEPTEMBER 2018 WWW.SFMMS.ORG
New Southern California Medical School To Tackle Doctor Shortages By Anna Gorman The Claremont Colleges plans to open a medical school, the
fourth new campus designed to produce physicians for parts of Southern California struggling with shortages. The Keck Graduate Institute School of Medicine will focus on primary care and treating the growing Latino population in California, institute officials announced this week. The school hopes to hire its founding dean by next summer, and open a few years after that. Administrators hope many of the graduates will stay to practice medicine in eastern Los Angeles County or the Inland Empire, an ethnically diverse region that encompasses Riverside and San Bernardino counties and is home to about 4 million people. “Our goal is to recruit them from here, train them here and keep them here,” said Sheldon Schuster, president of the Keck Graduate Institute. “There is such an incredible demand for people who . . . understand the community and who speak the language,” Schuster said. The campus joins a wave of new medical schools across the nation that began opening in the early 2000s. “There has been a huge increase in the last 15 years,” said Atul Grover, executive vice president of the Association of American Medical Colleges. The California University of Science and Medicine, funded by the Prime Healthcare Foundation, is debuting this summer in Colton, in San Bernardino County, with a class of 60. The University of California-Riverside School of Medicine, which opened in 2013, recently graduated its second class, made up of 49 medical students. Kaiser Permanente’s medical school in Pasadena is under construction and expected to welcome its first class next year. The new schools in California and around the nation not only can expand the workforce, but also increase its diversity, said Holly Humphrey, president of the Josiah Macy Jr. Foundation, which focuses on medical education. Only about 5 percent of physicians in California are Latino, though Latinos make up about 38 percent of the population, according to a recent report by University of California researchers and funded by the California Health Care Foundation. New medical schools will have to make a concerted effort to find the students who want to remain in the area in which they train, said Janet Coffman, UCSF professor of health policy and co-author of the report on physician shortages. There also need to be more local opportunities for recent graduates to complete their residencies, she said. “Just having a new medical school and more folks graduating medical school is no guarantee that those new physicians are going to practice in the parts of the state where they are most needed,” she said. “Medicine is going to change very dramatically in the next decade. We want the school to have a real emphasis on both community and on science.” This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. WWW.SFMMS.ORG
OBITUARY Margaret kaplan Miller May 20, 1922 - May 5, 2018
Margaret “Peg” Kaplan, MD, MPH—a.k.a. Dr. Margaret Miller—passed away peacefully in her sleep on May 5, 2018, shortly after watching her beloved Giants trounce the Braves 9-4, and joined with her cherished husband Bill (d. 2012) to celebrate the victory with a fine bottle of champagne. Peg was raised in San Francisco, graduating Washington HS (1939) and UC Berkeley (1943). She was one of only four women in Dr. Miller was a 47-year her Univ of Nebraska Medical member of the SFMMS. School class of 1949, and later obtained her MPH from Cal, launching her distinguished career in public health and public service with the SF Health Dept, SFUSD, Golden Gate Regional Center, SF Council for Seniors and Adults with Disabilities, SF Village and the Community Living Campaign, as well as 20 years teaching as an Assoc Clinical Professor in UCSF’s Dept of Preventive Medicine. While at the DPH, she pressed the button to fluoridate the SF water system, forever endearing her to the city’s dentists. Peg and Bill were passionate devotees of the arts, including the SF Opera and Symphony. Peg proudly joined the 2017 Women’s March, affirming her lifelong belief in the positive power of women past, present and future. She is lovingly remembered by children Paul (Chris) and Susan (Perry), and forever “Tutu” to grandchildren Erica (Nick), Sarah, Julia and Ian, and “Tutu the Great” to Will and Charlie. Peg lived life to the fullest right until the end, attending Giants opening day and recently hosting a concert in her home featuring her beloved Lamplighters, where donations can be directed in her memory. Published in the San Francisco Chronicle on May 13, 2018.
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HELP US GET BETTER! HELP US GET BETTER!
y rvrevey uu S ip S rrsshhip e d e RReeaad
COMMUNITY NEWS KAISER PERMANENTE Both nationally and locally here in Northern California,
Maria Ansari, MD
Kaiser Permanente recognizes that the opiate epidemic is a major public health problem, one that is driven in large part by physician prescriptions. We have been at the forefront of efforts nationwide to find solutions at both the policy and practice level, with a broad, systemic approach focused on physician education and support, pharmacy-level checks, patient safety, and patient and family education. Our integrated system offers a unique advantage in allowing everyone involved in a patient’s care to see a record of all medications prescribed and the dates of refills. This enables full communication and coordination between physicians and pharmacists. Our concern for patient safety extends to the use of naloxone treatment in the case of a drug overdose. Our pharmacies distribute naloxone kits as a covered benefit, a policy we instituted in coordination with the implementation of changes in California law. In recent years, we have also increased efforts to raise awareness of the overdose risk associated with benzodiazepines, particularly in regard to the interactions with opiates and alcohol.
Kaiser Permanente is also a leader in the world of addiction treatment. Since 2005 we have offered buprenorphine-based treatment for opiate use disorder and currently offer the full complement of medical treatment options including naltrexone and methadone. We work within the law to coordinate care between addiction treatment providers and prescribers of opioids, to the greatest extent possible. Kaiser Permanente physicians both in San Francisco and elsewhere in the country take active roles in policy setting and advisement, serving as representatives to the American Society for Addiction Medicine and sitting on the executive board of the California Society of Addiction Medicine. As a result of these efforts, Kaiser Permanente achieved a nearly 40 percent reduction nationwide in Kaiser Permanente patients on 90 morphine milligram equivalents or more per month between 2014 and 2017.
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