Official Magazine of the Santa Clara Medical Association
Vol. 26 | No. 3 Third Quarter 2020
Health Equity and Leadership in Times of Crisis The Bulletin | 1
CONTENTS | Vol. 26 | No. 3 | Third Quarter 2020
© Can Stock Photo / SeventyFour
In this issue SCCMA is a professional association representing over 4,500 physicians in all specialties, practice types, and stages of their careers. We support physicians like you through a variety of practice management resources, coding and reimbursement help, training, and up to the minute news that could affect your practice. The Bulletin is our quarterly publication.
Santa Clara County Medical Association President | Cindy Russell, MD President-Elect | Martin Wong MD Past President | Seema Sidhu, MD VP-Community Health | Lewis Osofsky, MD VP-External Affairs | Larry Sullivan, MD VP-Member Services | Randal T. Pham, MD VP-Professional Conduct | Gloria, Wu MD Secretary | John Brock-Utne, MD Treasurer | Anh T. Nguyen, MD
SCCMA NEWS & ANNOUNCEMENTS
Chief Executive Officer | April Becerra, CAE
Call for Nominations
CMA Trustee - District VII | Thomas M. Dailey, MD CMA Trustee - District VII | Kenneth Blumenfeld, MD
Councilors El Camino Hospital of Los Gatos | Shahram S. Gholami, MD El Camino Hospital | Anlin Xu, MD Good Samaritan Hospital | Krikor Barsoumian, MD Kaiser Foundation Hospital - San Jose | Priya Rao, MD Kaiser Permanente Hospital | Joshua Markowitz, MD O’Connor Hospital | David Cahn, MD Regional Medical Center | OPEN Saint Louise Regional Hospital | Scott Benninghoven, MD Stanford Health Care/Children’s Health | Sam Wald, MD Santa Clara Valley Medical Center | Harry Morrison, MD Opinions expressed by authors are their own, and not necessarily those of The Bulletin, SCCMA, or MCMS. The Bulletin reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted in whole or in part. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by SCCMA/ MCMS of products or services advertised. The Bulletin and SCCMA/MCMS reserve the right to reject any advertising. Address all editorial communication, reprint requests, and advertising to: Mike Wamungu, Managing Editor 700 Empey Way San Jose, CA 95128 760/671-2337 Fax: 408/289-1064 firstname.lastname@example.org © Copyright 2020, Santa Clara County Medical Association
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Diversity and Inclusion Webinar Series Recap
Opinion: Do Black Lives Matter?
To Be Young, A Doctor And Black: Overcoming Racial Barriers In Medical Training
On Racism: A New Standard For Publishing On Racial Health Inequities
Why Doctors are Posing in Swimwear on Social Media
How med schools, residency programs can diversify doctor workforce
Community News A Message from the President
CMA president issues statement on county health officer resignations
CMA president Statement on allegations of forced hysterectomies at ICE detention centers
Tough to Tell COVID From Smoke Inhalation Symptoms — And Flu Season’s Coming
A Message from the President
by Cindy L. Russell, MD
remain barriers to substantial long-term solutions.
2020 is the year of hindsight, and we all hope to use more foresight going forward. While the world is anxiously waiting to see how the U.S. President responds to his treatment of SARS-CoV-2, there is much to think about in terms of disease prevention. In this issue of the Bulletin, racial disparities in healthcare are spotlighted.
The SCCMA’s recent 4 part webinar series on Diversity and Inclusion featured highly respected physicians; Dr. Danielle Hairston, professor of Psychiatry at Howard University, who spoke on understanding and dismantling implicit bias in patient care; Dr. Arghavan Salles, a Stanford bariatric surgeon and international speaker, who discussed eradicating gender bias in medicine; Dr. Keith Carter, Past President of the American Academy of Ophthalmology and Chair of Ophthalmology at the University of Iowa School of Medicine who looked at physician diversity in medicine; and local pediatrician Dr. Rhea Boyd, co-author of “Stolen Breaths” and who testified to congress in 2020, speaking to us on “Health Equity, Resilience and Leadership in Time of Crisis”. Each talk was candid, enlightening and inspiring, moving us forward to change our perspectives, culture and involvement in this issue. We thank all of these speakers for the many contributions they have already made and will continue to make to guide policy on these critical issues. Healthcare Disparities and Marginalized Communities
Health cannot be separated from social, environmental and economic forces. Racial disparities in disease coincide with the disparities in the health and wellbeing of the local environment. Disproportionate pollution results in disproportionate adverse health outcomes. Lack of access to health care, coincides with poor health outcomes. Poverty and low socioeconomic status coincide with an increase in chronic disease. Racial bias and even the effects of childhood trauma and racism coincide with adverse childhood development, less resilience and long-term health issues. A lack of education or job opportunities are intricately tied to these issues. Social determinants of health have been acknowledged academically and studied extensively. Some progress has been made but there
Another issue in hindsight we wish we could have acknowledged and addressed earlier is global climate change. Our addiction to fossil fuels is unsustainable and has fueled the climate crisis. The invention of the internal combustion engine propelled us into the modern world but with an unintended unpleasant legacy of local air pollution, a warmer Earth and large-scale environmental decline which we continue to ignore. Fossil fuels produce a complex web of harmful effects on the environment and human health from drilling, to transporting and to combustion. Oil spills and pipeline leaks occur. There is contamination of massive amounts of clean water used to pump the oil out of the well, merged with highly toxic “proprietary” fracking chemicals and natural unearthed radioactive materials then disposed of as wastewater causing lifeless polluted waterways and deep well water contamination, that are not apparent to many who do not live near these areas. Fracking broadcasts fumes laced with benzene and toluene. And, of course, the transportation and burning of fossil fuels releases a myriad of toxic air pollutants, particulate-matter PM2.5 and CO2, the later which is the main climate-altering greenhouse gas. Climate Change, Pollution and Health Equity,
Pollution and climate change affect everyone but disproportionately those in low-income and disadvantages communities, a hallmark of environmental injustice. Despite the wealth of beautiful landscapes, many do not realize California is the 6th largest producer of oil in the nation. California to date has 105,000 unplugged oil wells. Over 350,000 Californians live within 600 feet of unplugged wells that emit toxic fumes and put those with asthma, children and the elderly at risk. These wells are largely in low income areas. The Union of Concerned Scientists released a 2019 report showing that Latinos and African Americans breathe significantly more vehicle air pollution than white Californians, showing racial disparity throughout the state. These pockets of unbreathable air intensify asthma rates as well as contribute to many other modern chronic health conditions. COVID-19 has further uncovered health disparities with significantly higher rates of mortality in peoThe Bulletin | 3
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ple of color, that point directly to social determinants of health (Brandt 2020; Hooper 2020). Climate change drives changes in weather patterns that promote increasingly destructive wildfires that also leave disadvantaged communities vulnerable due to lack of resources. This has been well documented in the recent California fires. The increase in intensity of hurricanes underscore that those of lower socioeconomic status are more vulnerable, as they live in areas more prone to flooding and have fewer resources to recover from natural disasters. Extractive economies take their toll on communities, ushering in the emergence of earth and climate justice movements. Chronic Disease and Racial Disparity
Chronic disease is an epidemic in America, both in adults and children. It is estimated that in 2023 it will cost us $4.2 trillion in treatment cost and lost economic output. According to the National Health Council, about half of all adults have a chronic illness and one third of adults have multiple chronic illnesses. For children, Bethell (2011) indicates that over 50% of children have one or more chronic illnesses if one includes obesity and developmental delays. Low income and minorities have twice the level of chronic diseases (Price 2013). Hindsight to Foresight
In hindsight we have put ourselves on a path that is not improving our health, well-being or security. Although we are now starting to shift direction, the climate change clock is ticking 4 | The Bulletin
faster and our response should be rapid. If we address health equity and consider justice, equity, diversity and inclusion (JEDI) as broadly integrated issues with environmental health, education and the economy, we will have a healthier, more sustainable and more compassionate society for everyone. The California Medical Association has begun to address the issue of health equity with a series of policy recommendations in the last several years supporting the inclusion of implicit bias training in medical school curriculums and efforts to implement pilot programs on social determinants of health. As we look to the horizon we should: Examine universal healthcare and community-based health interventions, reduce toxic exposures, tackle climate change, increase renewable energy, endorse green job initiatives, support healthy agriculture and local community food programs, improve educational opportunities, and engage in removing implicit bias throughout our society. We can all be involved in this solution. Author, James Baldwin, said, “Not everything faced can be changed but nothing can be changed unless it is faced.”
Diversity and Inclusion Webinar Series Recap
Towards a More Equitable and Thriving Future
For the month of September, we took a step SCCMA has never taken before: addressing the elephant in the room in our profession and throughout our nation’s history: systemic racism and the glaring ways in which it informs the disparate health outcomes we witness. The catalyst for this reckoning was a devasting a covid-19 pandemic that has wreaked havoc across every corner of our nation and disproportionally engulfed Black, Brown, and Indigenous communities. According to the C.D.C, nearly two hundred thousand Americans have died from SARSCOV-19. Though a shocking figure on its own, a deeper look into those numbers reveal a startling pattern: severe disparities in prognosis across racial and economic lines — the byproduct of “social determinants of health”, otherwise known as conditions in which people are born, grow, live, work and age. To make sense of these trends and empower our members with the tools to better understand and more expertly navigate these harsh realities, we developed a Free CME Diversity and Inclusion series. Through a combination of robust presentations from prestigious practitioners and experts on race, gender, and equity in healthcare, the four-part series highlighted the importance of diversity and inclusion in medicine and attracted over 500 total participants in the month of September. Session one: Understanding and Dismantling Implicit Bias in Patient Care, led by Dr. Danielle Hairston, deconstructed how systemic racism results in disparities in health and when combined with implicit bias in patient care, result in less accurate diagnoses, curtailed treatment options, less pain management, and deadly patient outcomes. With Dr. Hairston’s help, we defined these terms, explored ways to minimize our own biases, and learned specific techniques to screen patients for stress and
© Can Stock Photo / rmarmion
BY MIKE WAMUNGU
trauma and reduce bias in patient interactions. Session two: Eradicating Gender Bias in Medicine, led by Dr. Arghavan Salles unpacked the dangers of gender-based workplace discrimination, it’s striking toll on patient outcomes, and the prevalence of pay inequity, despite data supporting the tremendous patient outcomes facilitated by women physicians. Together, we discussed ways to address gender bias, correct it, and create safe, women-friendly and family-friendly work environments Session three: Minorities in Medicine — A look at Physician Diversity, dove deep into the institutional barriers and harmful systemic practices that limit, discourage, and penalize physicians of color across the nation — then explored tactics for reform and empowerment through a case study of Dr. Keith Carter’s work at Iowa University. And finally, our grand finale: Health Equity, Resilience, Leadership in Times of Crisis, led by Dr. Rhea W. Boyd, took an authoritative look at diversity and inclusion work as an effective tool for building institutional resilience, more robust scenario planning, and imagining community-centered futures. In an impressive presentation spanning policing, public health, and integrative medicine, Dr. Boyd dared us to render visible injustices within our healthcare system, and address them head on to create a more equitable world for all. For those who attended these sessions, thank you for your deep care and fervor. Patients across the country will be better for it. To our presenters, thank you for your conviction, courage, and expertise. For those unable to make it, all sessions are accessible on www.sccma.org, under resources. Join us as we do our part to ensure better patient outcomes for all. The work continues. The Bulletin | 5
Do Black Lives Matter? NORMAN T. REYNOLDS, MD Distinguished Life Fellow of the American Psychiatric Association
Racism is systemic in American society and culture. The field of medicine is no exception. Unconscious prejudice or implicit bias toward minorities undermines adequate medical care for them. In order to create a more just and equitable medical culture for minorities, all parts of the medical system must admit to past mistakes toward minorities and embrace valuing diversity. To do so requires deliberate efforts and should not be left to chance or taken lightly. This must be done in order to make Black Lives Matter. INTRODUCTION
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I am ashamed to admit that when I first heard the phrase “Black Lives Matter,” I thought: “Of course, Black lives matter. All lives matter.” I consider myself someone who is fair-minded--not tolerant or color blind on racial issues but embracing of diversity. So how could I think that? Well, I am white. I grew up in a culture dominated by whites--white thinking and white attitudes. I was educated using public school textbooks, authored by whites, and taught by white teachers. The white perspective presented in textbooks is guilty of omissions more than commissions about the history of African Americans in America. Unfortunately, it is hard for any of us to see what has been made invisible. Tragically, no matter how hard I try, I cannot rid myself of the racism that I have been brainwashed to accept without question.
Thankfully, I did not verbalize my thought. Thank God, I saw news of people taking to the streets to protest the killing of George Floyd. Thank God, I saw documented footage of the suffocation, “Please, I can’t breathe.” Rather quickly, I got it. However, that does not dismiss my initial response--a response that so easily discounts the message intended by Black Lives Matter. Unfortunately, black lives do not matter in a society that treats them as second-class citizens—inferior to whites. That is a reality that we can no longer ignore. I also recall my feeling from years ago when I heard Malcolm X speak in anger. At the time, I thought he was overly militant—an opinion shared by many whites. Really? At the time, I did not understand the significance of his statement: “That’s not the chip on my shoulder. That’s your foot on my neck.” It was as true then as it is now. Just substitute “knee” for “foot” on George Floyd’s neck in 2020. Tragically, George Floyd is not a one-off exception. Remember Rodney King. In his case, add police batons and kicking him with their feet. And, there are many more incidents—too many more. Without film footage, would white people believe a black person’s complaint over the word of a trained white police officer hired to enforce the laws of the land against those committing offenses or suspected of violating the law? Some whites may take solace that our society has made progress. Racism today may be more subtle than in the past. But nevertheless, it exists and is very real for the black people who live their daily lives under the domination of a white society and culture. Prejudice is difficult to root out. Although it is no longer politically correct to openly express some blatantly racist words or ideas, e.g., the N-word, in fact, being politically correct can force overt racism to go underground. Disguised, insidious racism makes it more difficult for people to have insight into their failure to understand and to recognize the harm it does to the misunderstood and mistreated. Lack of education about racism makes it difficult to empathize with the plight of black people. Racist values begin early in the educational process. Education of children is a requirement by law. Getting an accurate education is not a requirement. Throughout my education, I benefited from my whiteness without realizing it. During my medical education and professional development, I did not notice the absence of blackness—the absence of black physicians and very limited exposure to black patients. How would white people respond if textbooks were written by blacks, and the content expressed black viewpoints and experiences, and the courses were taught by black teachers and professors? Some well-meaning persons might object, claiming that the content was un-American or undermining of national pride. Hopefully, the majority of whites would welcome having the facts and a less bias interpretation of them. Having a better
understanding of African-American history would help whites understand and empathize that Black Lives do Matter. HISTORY OF RACISM IN THE MEDICAL PROFESSION
Although medicine is held in high regard by the public, even considered a noble profession, it too is part of American culture. Deeply embedded in the culture of medicine is a long history of overt prejudice against blacks—explicit bias, not implicit bias. The 1910 Flexner Report resulted in the closing of many black medical schools at that time, and thereafter the conditions of American culture made it difficult to establish others to generate numbers of black physician in proportion to the general or predominately white population. For generations, black physicians have been underrepresented in medicine. (Only 5% of US physicians identify as black, while 13.4% of the population is African American.) Professional organizations marginalized black physicians. For example, the American Medical Association (AMA) did not permit black physicians societies to join their membership. In 2008, the AMA formally apologized for more than a century of AMA policies that excluded African-American physicians from the AMA. The AMA pledged “to right the wrongs that were done by our organization to African-American physicians and their families and their patients.” The US government participated in experiments on blacks. The Tuskegee Experiment (from 1932 until 1972) involved studying the natural course of syphilis in poor black men afflicted with the disease. Black men were given free treatment, but never told of their syphilitic condition and, even worse, not treated for it. In 1997, President Clinton issued a formal apology acknowledging “The United States government did something that was wrong— deeply, profoundly, morally wrong.” He proposed measures to protect blacks from future abuses. The eugenics movement endorsed the sterilization of “undesirables.” Involuntary sterilizations were implemented by the government in many states. In California alone, approximately 20,000 individuals in state institutions were sterilized from 1909 to 1979. Involuntary sterilizations were performed on those deemed “unfit to reproduce,” predominantly persons of color. It was not until 2014, that California banned forced sterilization of imprisoned women as a means of birth control. In 2015, the US Senate voted unanimously to help surviving victims of forced sterilization. North Carolina and Virginia paid monies to surviving victims of eugenics sterilization programs. Reparations have not taken place in California.
“Knowing is not enough; we must apply. Willing is not enough; we must do.” Goethe
FAILURE TO EDUCATE PHYSICIANS ABOUT RACIST PRACTICES
I don’t know about you, but this kind of information, such as that noted above, was not part of the curriculum in the schools
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and training institutions that I attended. And, there is a lot more history of discrimination toward blacks that is a part of medicine’s history and identity. Failure to include this information in the medical curriculum perpetuates racism among white physicians and undermines the power of black physicians to have a meaningful place in the profession. Today, Implicit bias training is available improve communication. RACIAL DISPARITIES IN HEALTHCARE
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Racism continues to plague the culture of medicine. The Covid pandemic has made apparent the disparities in health care for minorities. The well-publicized statistics reveal the disproportionate toll that the Covid pandemic has taken on minority populations including the black population. Covid is a new illness, but its demographics are just one more example of the longstanding disparities in healthcare for minorities. In 2003, the Institute of Medicine published its report on racial and ethnic disparities in healthcare. “Stereotyping, biases and uncertainty on the part of healthcare providers can all contribute to unequal treatment.” White physicians who do not intend prejudice “typically demonstrate unconscious implicit negative racial attitudes and stereotypes.” The report created quite a stir and some controversy. Subsequently, other studies have reported the impact of implicit bias on patient care. • Communication between African American patients and white health care providers has been shown to be of poorer quality when compared with race-concordant patient-provider communication. • Interpersonal communication between patients and clinicians is of key importance to the delivery of equitable, high quality care. The quality of communication is linked to patient satisfaction, adherence to treatment recommendations, and health outcomes. • African American and other ethnic minority patients have been found to receive poorer interpersonal communication, including lower levels of affective behaviors such as rapport-building and overall affective tone, and greater physician verbal dominance, less patient centeredness, and shorter visits, compared with white patients. • Race concordance between patients and physicians has been linked with longer visits with more positive patient affect, high levels of patient trust, greater patient satisfaction and ratings of visits as being more participatory. • Physicians’ positive emotional tone is associated with higher trust, particularly in the visits of African American primary care patients. REMEDIES
Following the Institute of Medicine report of 2003, the culture of medicine has been changing, initially slowly and more recently
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with increased momentum. Training modules are available to help participants to understand the science of implicit bias and its effect on patient health. Participants learn to become more self-aware of implicit biases and demonstrate commitment to incorporating mitigation of strategies into practice. The US Department of Health and Human Services has published core concepts and principles of cultural and linguistic competence in health care. Many professional organizations have declared their commitment to address implicit bias and racism. For example, the American Academy of Family Physicians (AAFP) recommends educating physicians about implicit bias and strategies to address it in order to support culturally appropriate, patient-centered care and reduce health disparities. In August 2020, the Association for American Medical Colleges (AAMC) and the National Medical Association (NMA) announced a joint effort to convene an Action Collaborative that will address the under representation of African Americans in medicine. Some regulatory bodies and medical boards have begun to address racism. For example, beginning in 2020, Michigan medical professionals will need to undergo implicit bias training as a condition of licensure. Currently in California, “a physician and surgeon is required to demonstrate satisfaction of continuing education requirements, including cultural and linguistic competency in the practice of medicine.” As of January 2022, the curriculum of all CME must include “specified instruction in the understanding of implicit bias in medical treatment.” CONCLUSION
Because racism is systemic, all entities must participate in the process of rectification. This includes all components of the medical system. For the black community, actions speak louder than words. It takes more than rhetoric; it takes not one, but an ongoing track record of positive actions to gain trust. Rooting out racism is doing the right thing. It is a call for action from the white establishment. Doing so is a matter of conscience. Hopefully, the suffocation of George Floyd will awaken the nation, including the medical system, to see that Black Lives Matter--to finally do the right thing and to take action on many fronts to root out racism. Roderic Pettigrew, PhD, MD offers an important spiritual message to align us with our stated democratic ideals: When people learn that our shared humanity binds us one to the other, that differences which do not involve character actually bring character to our communal lives, that is when our society will honor its stated commitment to life, liberty and the pursuit of happiness of all.
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The Bulletinâ€‚ |â€‚ 9
In Memoriam Robert David Burnett June 26, 1925 – July 15, 2020
Robert Burnett (Bob), was a loving husband, father, grandfather and great grandfather. He had a kind heart and a generous spirit. He was born in Tacoma, WA, attended the University of Washington and graduated with a degree in engineering. He served in the US Navy and afterwards attended Stanford University Medical School. Dr. Burnett was a gifted, accomplished and caring human being and physician. He was a leader whose vision was to enhance the well-being of all of humanity. He was a quiet yet skilled politician not only within the field of medicine, but also within our greater community. In fact, for several years he was the chair of the SCC Republican Party. He inspired colleagues to join his team of physicians at the VMC who volunteer for the Clean Slate Program, a program that removes tattoos from juveniles and young adults with previous gang affiliations. He was a wonderful role model for our noble calling. Dr. Burnett, a pediatrician and emergency room physician, worked tirelessly during his long career to represent his colleagues and patients in establishing the policies of medicine, and was a leader of organized medicine on the local, state, and national levels for 64 years. Including as 1971-72 President of the then Santa Clara County Medical Society, President of the California Medical Association in 1983; Delegate of the Amer-
ican Medical Association Council on Medical Services; Chairman, of Lifeguard, a physician run HMO. Dr. Burnett’s years of service and dedication to patients and community earned him several awards, among them were recipient of the SCCMA Outstanding Contribution to Medicine Award and the Benjamin J. Cory MD in 1992. Dr. Burnett was the first recipient of his namesake award, the Robert D. Burnett Legacy Award in 2006. The Santa Clara County Medical Association honors the memory of former SCCMA and CMA President Robert D. Burnett, MD, who was beloved for his compassionate care of his patients, dedication to his family, and service to his community, and who as a steadfast medical leader helped improve the practice of medicine, uphold its ethical principles, and expand access to health care in his community and beyond.
SCCMA would also like to honor the memories of the following members: Robert B Baer, MD
Joseph H Clevenger, MD
Walter Saphir, MD
5/23/2029 – 6/12/2019
7/30/1935 – 10/1/2019
9/10/2027 – 4/20/2019
David Howard Campen, MD, FACP, FACR
Michael Russell Fischetti, MD, MPH
Frederick R Schlichting, MD
7/2/1943 – 10/29/2019
1/1/1930 – 12/13/2019
7/6/1955 – 10/19/2019
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Call for Nominations!
It’s that time of year to recognize those outstanding members at our annual awards gala. These awards are significant honors which reflect the respect, recognition, and appreciation of our membership. The recipients are selected from among our outstanding members who have distinguished themselves with extraordinary service to medicine in general, to the association, to the community, or to medical education. Selections are made by the Awards Committee, with the aid of input from the membership at-large. Your suggestions for recipients for each of the awards, outlined below, would be appreciated. Please visit JotForm https://form.jotform.com/202657133921149 to submit your nomination. Suggestions must be received by October 30, 2020. Thank you for your recommendations. If you previously suggested a candidate who was not given an award, please feel free to resubmit that name.
ROBERT D. BURNETT, MD LEGACY AWARD
For a physician member of the Medical Association who has demonstrated extraordinary visionary leadership, tireless effort, selfless long-term commitment, and success in challenging and advancing the health care community, the well being of patients, and the goals of the medical profession.
BENJAMIN J. CORY, MD AWARD
For a physician member of the Medical Association who has displayed forward- looking, pioneering ideas, enterprise, enthusiasm, and prolonged professional stature and ability.
OUTSTANDING ACHIEVEMENT IN MEDICINE
OUTSTANDING CONTRIBUTION IN MEDICAL EDUCATION
For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more medical education activities over and above that expected of the membership at-large.
OUTSTANDING CONTRIBUTION IN COMMUNITY SERVICE
For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more activities of the community over and above that expected of the membership at-large.
For a physician member of the Medical Association who, during his/her medical career, has made unique contributions to the betterment of patient care, for which he/she has achieved widespread recognition. Consideration shall be given to research and/or the development of procedures, methods of treatment, pharmaceutical agents, or technological advances in the field of medicine.
For an individual who is not a member of the Medical Association, who has achieved public recognition for a significant contribution in the health field. (This usually will be a non-physician, although physicians are not categorically excluded.)
AWARD FOR OUTSTANDING CONTRIBUTION TO THE MEDICAL ASSOCIATION
This award is named after the beloved long-time executive director of the Santa Clara County Medical Association and recognizes an individual whose leadership, innovation, and dedication have resulted in profound improvement to healthcare in Santa Clara and has left a lasting impact on the physicians and patients of the County. William Parrish is the first recipient of this award (established in 2018).
For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more activities of the Association over and above that expected of the membership at-large.
WILLIAM C. PARRISH, JR. LEADERSHIP IN HEALTHCARE AWARD
For a complete list of ALL award recipients since 1978 please refer to www.sccma.org
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To Be Young, A Doctor And Black: Overcoming Racial Barriers In Medical Training BY YUKI NOGUCHI NPR
r. Danielle Hairston, a psychiatry residency director at Howard University in Washington, D.C., trains and mentors young black doctors. Dr. Danielle Hairston grew up in a family that included many role models of what she refers to as Black excellence. “I had the example of a Black woman pediatrician, so it never occurred to me I couldn’t become a doctor,” says Hairston, who is now the psychiatry residency director at Howard University, where she herself now trains and mentors young Black doctors. Yet, she says, she and her Black colleagues are routinely questioned in the hospitals and clinics where they work about their rightful place in the halls of medicine. They’re questioned entering the physicians’ lounge; in the elevator, one woman accosted Hairston: “Oh, my God, you’re a doctor? You? You?” One of her white colleagues mistook her for a patient’s caregiver. “I don’t even necessarily think that he’s racist,” Hairston says. “It’s just that that’s the bias.” Black Americans make up more than 13% of the U.S. population, yet only 5% of physicians are black. That lack of representation isn’t just a problem within medicine, Hairston notes, but it perpetuates a sense that medical and mental health care is not of — or for — the Black community. As institutions everywhere confront the impacts of racism and inequity in their systems, medicine is not immune. Lack of access to health care isn’t just a problem for Black patients, who continue to face economic, social, and cultural barriers. The gaps are evident in the profession itself. Black physicians remain in a disproportionately small minority. And many African American doctors say that’s because medical training itself alienates
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them, perpetuating those gaps which, in turn, affects the care patients receive. “If you’re ignoring this part of their experience, if you’re not understanding the impact of being Black on them in this country and on their mental health, you’re doing a disservice to them,” says Hairston. “And I don’t know how you can treat them effectively.” Part of the problem — Dr. Danielle Hairston and the potential solution — lies in the pipeline of young talent coming through the U.S. system of medical training. Altha Stewart, who became the first Black president of the American Psychiatric Association, says she considered herself lucky to have Black mentors during her residency training in the late 1970s. They not only helped shepherd her, she says, they taught her about the needs of the African American community, and how the stress of racism affects both physical and mental health. But such peer support remains rare. “I know residents who don’t have that even today, in 2020,” she says. Medical training felt profoundly lonely and isolating for Dr. Anthony Chin-Quee, a Black ear, nose and throat surgeon who finished his training in Detroit four years ago.
© Can Stock Photo / michaeljung
“The number of Black men in medicine is very, very small; the number of Black men in surgery is orders of magnitude smaller, and the number of Black men in specialized surgeries like ENT is tiny, tiny,” says Chin-Quee. Chin-Quee says mistreatment came shrouded in subtlety; in fact, for years, he didn’t even suspect racism. “They wouldn’t say that ‘Tony’s lazy’ to my face; they would say, ‘Tony’s not efficient,” he says, in spite of the fact ChinQuee’s work and hours matched his white counterparts. He responded by working harder. Already stressed and sleep-deprived, he showed up to shifts earlier, or stayed later. When the criticisms persisted, making Chin-Quee question his sanity, he fell into a major depression. “That’s the danger of this whole profession, and being Black in this profession,” he says. Racism is hard to identify. “Because it’s so silent and because it’s so invisible, you just think you’re going crazy for thinking it, because you can’t prove it.” But Chin-Quee’s struggles became an open secret. The only other black physician turned a blind eye, Chin-Quee says, which made things worse. “It helped to bolster this idea that what was happening to me had nothing to do with race because I was thinking to myself, if it did, this Black doctor would reach out and let me know,” he says. “But he didn’t.” Chin-Quee gritted out the training and his depression. “And it was only last year, actually, that I sat down with my colleague — who went through residency alongside me and brought it up to me,” he says. Over that dinner, Dr. Matt Smith told Chin-Quee some of
their non-Black supervisors had made repeated comments during their residency that Smith took to be racist. “While nothing was overtly said as an inflammatory comment, I would say that there are those kind of biting remarks that lead to microaggressions and build up over time,” says Smith, who is white and now a pediatric ear, nose and throat surgeon in Cincinnati. The comments were undeserved, Smith says. “He is one of the smartest people I’ve ever met.” During their residency, Smith says, he objected to the comments directly to the supervisors — but said nothing about that to Chin-Quee. “I thought, if he didn’t know those things were being said, then it wouldn’t affect him necessarily directly.” Now Smith is an outspoken advocate for social justice with the medical students he supervises, as an assistant professor in pediatric otolaryngology at the University of Cincinnati. He’s also starting a mentor program for minority schoolchildren, hoping to get them into medicine. “Until there are changes made in the pipeline, all you’re going to get is what you put into the system,” he says. His friend Chin-Quee agrees, and notes that increasing the number of Black doctors in every medical specialty is important for Black patients, as well as for the doctors. “Having someone who cares for your health, who understands and has lived through the struggles personally and culturally that you’ve experienced is super, super super important,” ChinQuee says. It’s part of the systemic change needed, he says, to bridge some of the long-standing racial gaps in medical care. Copyright 2020 NPR. To see more, visit https://www.npr.org.
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A New Standard For Publishing On Racial Health Inequities BY: RHEA W. BOYD, EDWIN G. LINDO, LACHELLE D. WEEKS, AND MONICA R. MCLEMORE Health Affairs Blog, July 2, 2020
acism is, perhaps, America’s earliest tradition. Its practice pre-dates the founding of the nation, as settler colonialism and Indigenous genocide powered the land theft that established the United States. And enslaved humans were the capital that generated this stolen land’s economy. In spite of centuries of legal advancements that endeavored to excise racism from the roots of this republic, racism remains a bloodying force, structuring every facet of US life. In the wake of the police killings of Elijah McClain, Breonna
Taylor, Tony McDade, and Rayshard Brooks, the heart-wrenching public murders of Ahmaud Arbery and George Floyd, and the premature and disproportionate deaths of tens of thousands of African Americans from COVID-19, our national racism bleeds anew, into the open, exposing the intersecting forms of violence that continue to threaten Black lives. In short, racism kills. Whether through force, deprivation, or discrimination, it is a fundamental cause of disease and the strange but familiar root of racial health inequities.
© Can Stock Photo / hjalmeida
14 | The Bulletin
Yet, despite racism’s alarming impact on health and the wealth of scholarship that outlines its ill effects, preeminent scholars and the journals that publish them, including Health Affairs, routinely fail to interrogate racism as a critical driver of racial health inequities. As a consequence, the bar to publish on racial health inequities has become exceedingly low. There is no uniform practice regarding the use of race as a study variable and little to no expectation that authors examine racism as a cause of residual health inequities among racial groups. Absent rigorous standards, the praxis such scholarship offers can be conflicting, potentially dangerous, and ultimately ineffective. For example, Health Affairs recently published an Ahead-OfPrint article that evidenced striking racial disparities in COVID-19 hospitalizations in California. Overall, the study found, “Compared with non-Hispanic white patients, African Americans had 2.7 times the odds of hospitalization, after adjusting for age, sex, comorbidities, and income.” In an initial version of the article published online, the authors explored “several possible explanations for the observed disparities.” They noted that “one hypothesis is that there may be some unknown or unmeasured genetic or biological factors that increase the severity of this illness for African Americans.” They then discussed additional “societal factors” that could have contributed to the disparity, including unconscious provider bias, patient distrust, and financial stress. [Editor’s note: The final published version of the paper has been revised to clarify the authors’ conclusion that the disparities are most likely explained by societal factors.] But this analytical framing ignores racism as the mechanism by which racial categorizations have biological consequences. And despite exploring potential “societal” drivers, the term “racism” is never mentioned in the piece. This is unfortunately common and occurs across disciplines. A recent JAMA article exploring the association between air pollution, heat exposure, and adverse birth outcomes noted corresponding racial disparities but failed to examine how racism structures environmental exposures and health outcomes. Another recent study in the Journal of Public Health looked at racial disparities in knowledge, attitudes, and practices related to COVID-19 yet ignored how racism shapes access to information and information-sharing technology such as the internet. A quick search of the Health Affairs website reveals only 114 pieces include the word racism in the 39-year history of the journal. As was noted in a 2016 article in The Lancet on structural racism and health inequities, most articles in the medical canon that use the term “race” do not additionally use the terms “structural racism” or “systemic racism.” A 2018 systematic literature review of the public health literature additionally found only 25 articles that used the term “institutionalized racism” between 2002 and 2015. And a Pub Med Database search done on June 23, 2020, revealed as few as 86 articles that included both the word “race” and the terms “structural racism” or “institutional racism.” Of the 86 articles found, 32 were published in the past 18 months.
Denouncing Biological Race And The Insidious Harms Of Patient Blame
In the absence of a rigorous examination of racism, assertions that unmeasured genetic or biological factors may account for racial differences in health outcomes are troublingly frequent. Within four days of Health Affairs’ now revised article, a Journal of Internal Medicine article offered a similar hypothesis in a paper outlining racial disparities in COVID-19 infection and death rates stating, “It also remains to be determined whether there is a genetic difference in susceptibility, especially to severe disease, to COVID-19.” Claims such as these resurrect long-refuted and disproven theories about biological race. Historically, these theories were advanced to affirm the violent subjugation and painful experimentation forced upon enslaved Africans and other historically oppressed groups, such as Jews and women of color. In such cases, science, through the guise of objectivity, has abetted the indignities forced upon non-white populations by probing their innate propensity for disease and thus their biologic inferiority. In 2020, such unsubstantiated claims have no place in scholarship on racial health inequities. Similarly, assertions that patient mistrust drives disparities obscures the etiologies of racial health inequities and tacitly blames affected patients for their disproportionate suffering. This is particularly true for Black patients. Any mistrust Black patients may harbor toward the US health care system is a result of their never-ending mistreatment, not the cause of it. Suggestions otherwise essentially posit that trust, not racism, is the primary barrier between Black patients, equitable care, and positive health outcomes. This is simply untrue. And at this point, if Black patients harbor mistrust of the US health care system, a system that affords them inequitable access to every conceivable service save amputation, it exposes their valid assessment of the health care systems’ performance to date, not the root of their poor outcomes. Yet, article after article on racial health inequities, many written by long-time scholars from prestigious institutions, situate mistrust among the etiologies that create and widen racial gaps in health. This includes a recent New York Times article inaptly entitled, “Race and Medicine: The Harm That Comes From Mistrust.” Despite identifying discrimination and racism as causing racial health disparities, the article relies upon research that attributes poor Black male health outcomes, in part, to patient mistrust. To do this, the author draws upon “Tuskegee and the Health of Black Men,” a paper that focuses on how Black male patient mistrust, following disclosure of the Tuskegee Syphilis Experiment, shaped health care use behaviors and ultimately widened racial gaps in life expectancy in 1980. Yet, the focus on patient mistrust distracts from enrollees’ abject exploitation, sanctioned undertreatment, inadequate financial reparation, and increased burden of familial disease (not to mention the structural factors that likely advantaged white adults living over the same time period). These plausible alternate foci only emerge if
Southern trees bear a strange fruit Blood on the leaves and blood at the root Black bodies swinging in the southern breeze Strange fruit hanging from the poplar trees —“Strange fruit” by Abel Meeropol
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Why Doctors Are Posing in Swimwear on Social Media A study purporting to uncover “unprofessionalism” spurred a #MedBikini backlash
BY ARGHAVAN SALLES, RENA MALIK
Scientific American - BEHAVIOR & SOCIETY | OPINION
eginning on July 23, physicians all over the world took to social media to post pictures of themselves in bikinis, using the hashtag #MedBikini. Against the backdrop of the ongoing COVID-19 pandemic and our broad social awakening to a second pandemic of systemic racism, why would thousands of doctors post pictures of something so seemingly frivolous as themselves in swimwear? We are both surgeons, and watched this play out in real time. It initially started with a study published in the Journal of Vascular Surgery that purported to analyze the behavior of physicians on social media. The study, conducted by a team of researchers based at the Boston Medical Center and Boston University School of Mecicine, was an attempt to classify the posts of trainees in vascular surgery as either professional or unprofessional. Of course, we can point to any number of costly mistakes people have made on social media. Just in the last two months, Nick Cannon lost a contract with ViacomCBS for his longtime improv comedy show Wild ‘N Out because he made anti-Semitic remarks on his podcast. Similarly, Dee Nguyen, a cast member on MTV’s The Challenge, was fired after she made racist comments about the Black Lives Matter movement on Twitter and Instagram. So, one could understand why the authors were interested in ascertaining whether the posts of trainees in their own field might be professionally risky. When the article was widely disseminated on Twitter, however, the authors faced a backlash for what was seen as their own lack of professionalism. For one thing, people raised concerns about the methodology used in the study, in which three members of the research team created fake social media accounts to spy on the accounts of these young trainees. The bigger problem, which led to the #MedBikini hashtag, were the authors’ definitions of “unprofessional,” including “controversial political or religious comments,” “controversial
16 | The Bulletin
social topics” and “inappropriate attire.” In that last category, they included “pictures in underwear, provocative Halloween costumes, and provocative posing in bikinis/swimwear.” And whether something was provocative or not was judged by the nearly all-male research team The researchers also concluded that physicians should not post about “controversial” topics such as gun violence or abortion. But physicians have long been advocates for social causes. In recent years, physicians have risen up to fight gun violence with the #ThisIsOurLane movement, and with the current administration there have been many challenges related to abortion rights. Many physicians have rightfully spoken out about racial disparities in healthcare outcomes during the COVID pandemic, and when the murder of George Floyd sparked protests around the world, physician voices joined that battle cry as well. The Physician Charter on Professionalism, endorsed by over 108 organizations, says physicians should promote justice and advocate for the elimination of discrimination publicly. In addition, it’s completely inappropriate for researchers to determine whether a woman’s Halloween costume or swimsuit is too “provocative” to be professional. It’s unclear how posts of this nature, outside of work, relate to a woman physician’s career. But what this study has shown, and why there has been so much outrage around it, is how people with privilege can use the label “professionalism” to target women, people of color, sexual and gender minorities, and anyone else they don’t approve of. In the study’s defense, Dr. Erica Mitchell, the sole woman author of the manuscript, said on Twitter: “People get judged everyday by what is available on social media in all forms. It is the reality of today’s world in medicine or any other profession—like it or not. These impressions and the SM content stick and are hard to eliminate.” But in the face of withering criticism, she and some of the other authors and journal editors
ABOUT THE AUTHOR
Arghavan Salles, M.D., Ph.D., is a scholar in residence at Stanford University School of Medicine, where she leverages her doctoral research on stereotype threat to study issues related to diversity, equity and inclusion. You can follow her on Twitter @arghavan_salles. Original published in Scientific American
© Can Stock Photo / dolgachov
subsequently apologized for the paper and their approach to the study. The article has now been retracted. We don’t believe anyone had malicious intent. But that is exactly the point. One need not have malicious intent to cause harm. In the same way, the gender pay gap, though perhaps not intentional, affects women, and implicit bias of physicians impairs the care of Black patients. In this case, researchers harmed the medical community by suggesting that speaking up about social causes, consuming alcohol when not working, and wearing a bikini were unprofessional. We may be doctors, but that doesn’t mean we’re not human. The point is not who these researchers are or even what they did in this particular study. The authors, the institutional review board (which is supposed to watch out for ethical problems), the reviewers of the article and the journal’s editors all thought this was worth publishing. This is because in the culture of medicine, harassment and subjugation of those who don’t look like the dominant group is not only tolerated, it’s the norm. At least one good thing has come out of this, though. That is the outpouring of support for women in medicine, with a number of our male colleagues posting pictures of themselves in their swimsuits. We are still fighting COVID-19, despite not having all the necessary tools to do so, but maybe this study and the #MedBikini hashtag have brought us all together. Having a drink outside of work, wearing a bikini at the beach, and caring about social issues are just as appropriate for us as they are for anyone else. In our minds, advocating for social justice is more than appropriate: it’s our duty. The next time you see a doctor, remember that we’re human, too. And when you see your doctor post about wearing a bikini or going to a Black Lives Matter protest, we hope you won’t think it’s unprofessional.
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scholars position racism as a potential driver of the inequity. Instead, this approach remains an accepted way to investigate and interpret racial health inequities. And it illustrates a common misreading of the harms of the Tuskegee Syphilis Experiment, which stem from coercion and systematic exploitation, not mistrust. These harms include the creation and maintenance of an elaborate economy of suffering used to advance science. Since
© Can Stock Photo / MattiaATH
It permits authors to publish despite failing to cite at least two centuries of work, much of which has been accomplished by scholars of color (particularly Black scholars), that articulates how racism shapes conditions germane to racial health inequities. This process unfairly advantages white academicians and disadvantages scholars of color whose careers may be stunted when the academy undercites and thus undervalues their contributions. Obfuscating the role of racism in driving racial health inequities also gives frames such as implicit bias undue traction. This stalls progress to end inequities by entreating clinicians to tame “unconscious beliefs,” rather than confronting explicit practices that undergird systemic inequities. It also unfairly centers white authors’ reflections on racial inequity without demanding corresponding solutions to end racial inequity. This practice undertheorizes racism as a clinically relevant cause of poor health and underelaborates solutions to racism as a health intervention. As a result, patients who suffer the physical tolls of inequities are doubly burdened by the emotional toll of researchers interested in documenting inequities but not addressing them.
Tuskegee, decades of research have evaded the profitability of suffering to instead belabor patient trust as a cause of health disparities. As a result, innumerable interventions now aim, as a primary or secondary outcome, to increase patient trust as a solution to racial health inequities. While patient trust certainly shapes health care use behaviors and is an important part of the patient-physician relationship, incessant racial health inequities across nearly every major health index reveal less about what patients have failed to feel and more about what systems have failed to do. To be clear, patient trust will never solve racial health inequities or narrow gaps in outcomes, by race. The solution to racial health inequities is to address racism and its attendant harms and erect a new health care infrastructure that no longer profits from the persistence of inequitable disease. Obfuscating The Role Of Racism In Determining Health And Health Care
The academic publication process, through authors, reviewers, and editors, has legitimized scholarship that obfuscates the role of racism in determining health and health care. This renders racism less visible and thus less accessible as a preventable etiology of inequity. It enables the health care infrastructure to unduly blame individual patients for the neglect and harm of systemic processes that undergird individual and population health inequities. It subjects countless patients, spanning generations in communities of color, to ineffective behaviorist approaches to problems that are actually institutional in nature. 18 | The Bulletin
Rigorous Standards For Publishing On Racial Health Inequities
To address the shortcomings listed above, we propose several standards for publishing on racial health inequities, intended for researchers, journals, and peer reviewers. Researchers • Define race during the experimental design, and specify the reason for its use in the study. Such definitions should be couched within a sociopolitical framework, not a biological one, that explicitly reviews all relevant social, environmental, and structural factors for which race may serve as a proxy measure. For the reader, these additional details enable careful interpretation of study results and implications. But for authors, it engenders critical thinking about racial constructs that prevent the reification of race as a biological entity. • Name racism, identify the form (interpersonal, institutional, or internalized), the mechanism by which it may be operating, and other intersecting forms of oppression (such as based on sex, sexual orientation, age, regionality, nationality, religion, or income) that may compound its effects. A critical race theory framework lends authors a vocabulary for discussing racism and its potential relationship to the study’s findings. And naming racism explicitly helps authors avoid incorrectly assigning race as a risk factor, when racism is the risk factor for racially disparate outcomes.
• Never offer genetic interpretations of race because such suppositions are not grounded in science. If race and genetics are being expressed jointly, painstakingly delineate the intended implication. • Solicit patient input. Use community review boards or form patient panels to ensure the outcomes of research reflect the priorities of the populations studied. • Identify the stakes. “All policy is health policy,” and all research on racial health inequities has implications for broader public policy and clinical practice. Inform readers of these potential applications. • Cite the experts, particularly scholars of color whose work forms the basis of the field’s knowledge on racism and its effects. Journals • Reject articles on racial health inequities that fail to rigorously examine racism. This will require continuing education on the part of existing editorial staff and efforts to hire and promote new editors who are well versed in critical race theory and its application. • Revisit editorial and publication guidelines, including the uniform requirements for manuscripts submitted to biomedical journals, regularly to ensure they capture the evolution of racial definitions and sociopolitical structures. Publicly share the guidelines online and with peer journals.
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• Consider compensating reviewers particularly reviewers of color who are often asked to share their expertise without remuneration. • Use experienced reviewers who have demonstrated, through their own scholarship and work, facility with racism and its pathophysiologic mechanisms. Reviewers • Be critical of work that reifies biological race or provides a genetic basis for racial differences in health outcomes. Inform the editors and authors that such statements are unsubstantiated and request clear explanations of suggested genetic etiologies to ensure such claims are not misinterpreted as biological race. • Review the citations and when appropriate recommend authors expand their literature review to include the wealth of data on racism. • Consult experts and inform the editors if one’s individual expertise is insufficient to advise regarding an important aspect of the paper from study design and methodology to the analysis. Closing the gap in racial health outcomes in the United States will only be accomplished by identifying, confronting, and abolishing racism as an American tradition and root of inequity. Originally published in the Health Affairs Blog at healthaffairs.com
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How Med Schools, Residency Programs Can Diversify Doctor Workforce BY BRENDAN MURPHY News Writer | American Medical Association Increasing diversity in the physician workforce can lessen racial and ethnic health inequities. Addressing medical school admissions is an important part of the process to generate a physician population that more closely resembles the nation’s patient population. A recent AMA webinar—“Focusing on diversity: Promoting mission-aligned medical school admission and residency selection processes”—highlights the methods by which medical schools and residency programs are working toward increased physician diversity. A recording of the webinar is available in the resources area of the Accelerating Change in Medical Education Community (registration required). Addressing implicit bias
Members of committees for medical school admissions and residency selection may have implicit bias, which can have a significant impact on who gets selected. In 2012, all 140 members of the Ohio State University College of Medicine (OSU) Admissions Committee took an implicit association test examining their attitudes toward race, gender and sexual orientation. The results showed that: • The majority of male (64%) and female (52%) respondents had an implicit preference for white applicants. • A small portion of admissions-committee respondents— about 10% for men and women—expressed an explicit preference for white applicants. • Nearly 70% of all faculty had an implicit gender-career stereotype bias that associated men with careers and women with lives as homemakers. Facing such eye-opening results, OSU looked to remediate the situation. The school has since made annual implicit bias training mandatory for its entire admissions committee. Strategies covered at the workshops to mitigate bias include common-identity formation and perspective taking. “We found that after training our admissions committee in implicit-bias reduction, the very next class we admitted was the most diverse class in the history of our college of medicine,” said Quinn Capers IV, MD, vice dean of faculty affairs at the OSU medical school. Learn why assumptions are one big mistake that medical residents must avoid. 20 | The Bulletin
Realizing the need for increased diversity among residents, the internal medicine program at the University of California, Davis (UC Davis), made that a priority for residency selection. To do that the program set forth on a four-step plan to improve the process. Step one: Define mission of the program. UC Davis’ mission statement called for called an emphasis on diversity, inclusion and humility to match their community of patients and improve education of all learners. Step two: Changes to applicant screening. New screening procedures included giving applications reviews by multiple screeners, less emphasis on board scores and more emphasis on extracurriculars. Step three: The interview process. UC Davis has narrowed its interview pool to around 20 faculty members. Interviewers score applicants and speak over lunch that day. Final scores of interviewees are given by the end of their interview day. Step four: Ranking. Interview scores allow for UC Davis’ rank order list to be in near final form at the conclusion of the third step. The program estimates the interview scores cutoff based on the prior year’s Match and will adjust its rank-order list based on valued criteria. This program has yielded results. The baseline residency cycle prior to the program being initiated saw about 14% of incoming residents come from underrepresented minority backgrounds. That number has nearly tripled with the incoming class of firstyear residents who will start in July. “We have succeeded in getting residents with a tremendous diversity in backgrounds, life experiences and work in the community,” said Craig R. Keenan, MD, internal medicine residency program director at UC Davis. “We also have more residents from the LGBTQ community. Our residency definitely has a stronger sense of community than five years ago, and there’s a tremendous amount of grit.” Launched last year, the AMA Center for Health Equity has a mandate to embed health equity across the organization so that health equity becomes part of the practice, process, action, innovation, and organizational performance and outcomes. The center also developed the Health Equity Resource Center which provides tools and information for health equity.
© Can Stock Photo / alexskopje
CMA president issues statement on county health officer resignations CMA President Peter N. Bretan, Jr., M.D., issued the following statement in response to recent county public health offer resignations: “The California Medical Association (CMA) is severely troubled by the recent resignations of county public health officers in Placer and Humboldt counties. Earlier this month, Teresa Frankovich, M.D., announced her resignation as Humboldt County Health Officer, citing stress and fallout from COVID-19 as her reasons for leaving her post. In Placer County, Aimee Sisson, M.D., announced she will be leaving her post later this month after the Placer County board of Supervisors ignored her advice and opted to end the county’s COVID-19 state of emergency. The nearly 50,000 members of the California Medical Association want to offer our thanks to Drs. Frankovich and Sisson for their public service. Their departures now bring to 10 the number of county health officers who have resigned or left their positions since COVID-19 erupted on the scene in March. These physicians, and dozens of others who serve as county health officers around the state, have been on the frontlines of the worst pandemic in recent history, and have come under intense
political and sometimes personal pressure and attacks. Dr. Sisson’s resignation is a reminder that too often, politics continues to trump science in our policymaking. CMA is alarmed that basic science has become politicized in so many parts of our state, and our country. Public health officers are public servants who seek to do what their job description states – to protect public health. They use science and medical expertise to make their decisions. CMA wants to commend public health officers around the state for the bold and courageous work they do every day to keep their communities safe, often in the face of political pressure and personal attacks. These important roles will become increasingly difficult to fill if the recommendations of public health officers are ignored, and those who serve continue to be subject to personal attack. We are all tired and weary after months of dealing with COVID-19. We understand that millions of Californians are struggling economically, and that mental health concerns from shelter-in-place orders are very real. But if we are to get through this pandemic together, we must listen to what the science tells us and continue to rely on the wisdom and guidance of those who have the expertise to best protect the public health.” The Bulletin | 21
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CMA President Statement On Allegations Of Forced Hysterectomies At ICE Detention Centers CMA President Peter N. Bretan, Jr., M.D., issued the following statement in response to allegations of forced hysterectomies at ICE detention centers: “The California Medical Association (CMA) is gravely concerned by the recent whistleblower allegations regarding an irregularly high number of hysterectomies on women being held by Immigrations and Customs Enforcement (ICE) at the Irwin County Detention Center in Georgia. These allegations evoke dark chapters in our nation’s history of government officials ordering unnecessary medical procedures on patients without their consent. Historically, these cases have often targeted communities of color and have been motivated by bad science and racial animosity. Unnecessary hysterectomies without explicit patient consent are fundamentally at odds with basic standards of the medical profession, not to mention human decency. Physicians take a lifelong oath to ‘do no harm’ and must cherish the patient-physician relationship, at the core of which is a patient’s right to receive information about and provide informed consent for medical care and procedures. Holding patients in facilities that directly jeopardize their health, let alone performing unwarranted and nonconsensual hysterectomies is a violation of CMA’s values. CMA supports oversight and improvement of health and human rights conditions in ICE detention facilities and we urge a thorough investigation into these deeply disturbing allegations.”
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Tough to Tell COVID From Smoke Inhalation Symptoms — And Flu Season’s Coming BY MARK KREIDLER California Healthline
he patients walk into Dr. Melissa Marshall’s community clinics in Northern California with the telltale symptoms. They’re having trouble breathing. It may even hurt to inhale. They’ve got a cough, and the sore throat is definitely there. A straight case of COVID-19? Not so fast. This is wildfire country. Up and down the West Coast, hospitals and health facilities are reporting an influx of patients with problems most likely related to smoke inhalation. As fires rage largely uncontrolled amid dry heat and high winds, smoke and ash are billowing and settling on coastal areas like San Francisco and cities and towns hundreds of miles inland as well, turning the sky orange or gray and making even ordinary breathing difficult. But that, Marshall said, is only part of the challenge. Facilities already
24 | The Bulletin
strapped for testing supplies and personal protective equipment must first rule out COVID-19 in these patients, because many of the symptoms they present with are the same as those caused by the virus. “Obviously, there’s overlap in the symptoms,” said Marshall, the CEO of CommuniCare, a collection of six clinics in Yolo County, near Sacramento, that treats mostly underinsured and uninsured patients. “Any time someone comes in with even some of those symptoms, we ask ourselves, ‘Is it COVID?’ At the end of the day, clinically speaking, I still want to rule out the virus.” The protocol is to treat the symptoms, whatever their cause, while recommending that the patient quarantine until test results for the virus come back, she said. It is a scene playing out in numerous hospitals. Administrators and physicians, finely attuned to COVID-19’s ability to spread quickly and wreak havoc, simply won’t take a chance when they recognize symptoms that could emanate from the virus. “We’ve seen an increase in patients presenting to the emergency department with respiratory distress,” said Dr. Nanette Mickiewicz, president and CEO of Dominican Hospital in Santa Cruz. “As this can also be a symptom of COVID-19, we’re treating these patients as we would any person under investigation for coronavirus until we can rule them out through our screening process.” During the workup, symptoms that are more specific to COVID-19, like fever, would become apparent. For the workers at Dominican, the issue moved to the top of the list quickly. Santa Cruz and San Mateo counties have borne the brunt of the CZU Lightning Complex fires, which as of Sept. 10 had burned more than 86,000 acres, destroying 1,100 structures and threatening more than 7,600 others. Nearly a month after they began, the fires were approximately 84% contained, but thousands of people remained evacuated. Dominican, a Dignity Health hospital, is “open, safe and providing care,” Mickiewicz said. Multiple tents erected outside the building serve as an extension of its ER waiting room. They also are used to perform what has come to be understood as an essential role: separating those with symptoms of COVID-19 from those without. At the two Solano County hospitals operated by NorthBay Healthcare, the path of some of the wildfires prompted officials to review their evacuation procedures, said spokesperson Steve Huddleston. They ultimately avoided the need to evacuate patients, and new ones arrived with COVID-like symptoms that may actually have been from smoke inhalation. Huddleston said NorthBay’s intake process “calls for any-
one with COVID characteristics to be handled as [a] patient under investigation for COVID, which means they’re separated, screened and managed by staff in special PPE.” At the two hospitals, which have handled nearly 200 COVID cases so far, the protocol is well established. Hospitals in California, though not under siege in most cases, are dealing with multiple issues they might typically face only sporadically. In Napa County, Adventist Health St. Helena hospital evacuated 51 patients on a single August night as a fire approached, moving them to 10 other facilities according to their needs and bed space. After a 10-day closure, the hospital was allowed to reopen as evacuation orders were lifted, the fire having been contained some distance away. The wildfires are also taking a personal toll on health care workers. CommuniCare’s Marshall lost her family’s home in rural Winters, along with 20 acres of olive trees and other plantings that surrounded it, in the Aug. 19 fires that swept through Solano County. “They called it a ‘firenado,’” Marshall said. An apparent confluence of three fires raged out of control, demolishing thousands of acres. With her family safely accounted for and temporary housing arranged by a friend, she returned to work. “Our clinics interact with a very vulnerable population,” she said, “and this is a critical time for them.” While she pondered how her family would rebuild, the CEO was faced with another immediate crisis: the clinic’s shortage of supplies. Last month, CommuniCare got down to 19 COVID test kits on hand, and ran so low on swabs “that we were literally turning to our veterinary friends for reinforcements,” the doctor said. The clinic’s COVID test results, meanwhile, were taking nearly two weeks to be returned from an overwhelmed outside lab, rendering contact tracing almost useless. Those situations have been addressed, at least temporarily, Marshall said. But although the West Coast is in the most dangerous time of year for wildfires, generally September to December, another complication for health providers lies on the horizon: flu season. The Southern Hemisphere, whose influenza trends during our summer months typically predict what’s to come for the U.S., has had very little of the disease this year, presumably because of restricted travel, social distancing and face masks. But it’s too early to be sure what the U.S. flu season will entail. “You can start to see some cases of the flu in late October,” said Marshall, “and the reality is that it’s going to carry a number of characteristics that could also be symptomatic of COVID. And nothing changes: You have to rule it out, just to eliminate the risk.”
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