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VO L . 68 N O. 1 Wi n t er 201 7

FAMILY PHYSICIAN st ron g

med i c i n e

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Ca l i f o r n ia

in this issue WELLNESS, JOY AND RESILENCE CAN A SENSE OF GRATITUDE MAKE YOU HAPPIER? BEGINNING THE NEW YEAR WITH A NEW OUTLOOK: TIPS FROM A FELLOW TRAVELER

Photo: Susan Hogeland, CAE Victoria Falls, Zimbabwe

EMBRACING A TOOL OR PRACTICE FOR RESILENCE RX: CHOOSING WISELY


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1520 Pacific Avenue • San Francisco, California 94109 • www.familydocs.org Phone (415) 345-8667 • Fax (415) 345-8668 • E-mail: cafp@familydocs.org California

Officers and Board

Staff

President Lee Ralph, MD

Susan Hogeland, CAE

FAMILY PHYSICIAN s tron g

President-Elect Michelle Quiogue, MD Immediate Past President Jay W. Lee, MD, MPH Speaker Lisa Ward, MD, MPH Vice-Speaker Walter Mills, MD Secretary/Treasurer David Bazzo, MD Executive Vice President Susan Hogeland, CAE Foundation President Anthony Chong, MD AAFP Delegates Jeff Luther, MD Carla Kakutani, MD

Executive Vice President shogeland@familydocs.org

for

C a l i f o r ni a

Nathan Hitzeman, MD, Editor Shelly Rodrigues, CAE, Managing Editor

Conrad Amenta Director, Health Policy camenta@familydocs.org Morgan Cleveland Manager, FP-PAC and Membership mcleveland@familydocs.org Jerri Davis, CHCP Director, CME/CPD jdavis@familydocs.org

Communications Committee: Nathan Hitzeman, MD, Chair • Julia Blank, MD • Nathan Hitzeman, MD • Jeffrey Luther, MD • Jay Mongiardo, MD • Michelle Quiogue, MD • Albert Ray, MD

Brian Devine

Manager, Finance bdevine@familydocs.org

The California Family Physician is published quarterly by the California Academy of Family Physicians. Opinions are those of the authors and not necessarily those of the members and staff of the CAFP. Non-member subscriptions are $35 per year. Call 415-345-8667 to subscribe.

Adam Francis Director, Government Affairs afrancis@familydocs.org Shannon Goecke

Director, Membership and Marketing sgoecke@familydocs.org

AAFP Alternates Carol Havens, MD Jay W. Lee, MD, MPH

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CMA Delegation Ashby Wolfe, MD, MPA, MPH (Chair) Mark Dressner, MD Sumana Reddy, MD Kevin Rossi, MD Lauren Simon, MD, MPH Felix Nunez, MD, MPH

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Manager, Communications and Social Media elukrich@familydocs.org

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m e dic in e

Quarterly publication of the California Academy of Family Physicians

Created by Publishing Concepts, Inc. David Brown, President • dbrown@pcipublishing.com For Advertising info contact Michele Gilbert • 800.561.4686 ext 120 mgilbert@pcipublishing.com EDITION 21

Looking for a job? Go to www.fpjobsonline.com Questions? Call 888-884-8242 and a HEALTHeCAREERS representative will help you.

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California Family Physician Winter 2017


California

Winter 2017

FAMILY PHYSICIAN s trong

medi ci ne

for

C al i fo r nia

features 14 Can a Sense of Gratitude Make You Happier?

Melissa Hemphill, MD

16 Beginning the New Year with a New Outlook: Tips from a Fellow Traveler 18 Family Medicine Clinical Forum Invite 20 Winter 2017 / Generational Voices

Elaine Skoch Chris Flores, MD and Carol Havens, MD

Carol Havens, MD, Karen Muchowski, MD and William Woo, MD

22 Wellness-Joy-Resilience: Embracing a Tool or Practice 24 Rx: Choosing Wisely

Rev. Nicole Reilley Catherine Sonquist Forest, MD MPH

departments 6 Editorial

Finding Joy in Our Lives

Nathan Hitzeman, MD

8 President’s Message

From Where I Sit: Stand Up!

10 Political Pulse

CAFP Wins AAFP Advocacy Award for Third Consecutive Year

Carla Kakutani, MD

12 Legislative News

CAFP Wraps Up Historic Year for Family Medicine Advocacy

Adam Francis

26 From Sacramento

New Laws May Affect Your Practice and Your Patients

28 Membership News

For Senior CAFP Members, Age Is Just a Number

30 EVP Forum

If Ever There Was a Time...

Lee Ralph, MD

Jodi Hicks Shannon Goecke Susan Hogeland, CAE

For upcoming CME activities visit familydocs.org/cme California Family Family Physician Physician Winter Winter 2017 2017 California

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editorial

Nathan Hitzeman, MD

Finding Joy in Our Lives

What leads to joy is a matter of great commercial interest, as many self-help books speak to financial success, good parenting, spiritual or religious connection, meditation and crafts and hobbies. Even the classic “The Joy of Sex” written by British gerontologist Dr. Alex Comfort in 1972 offers help in finding joy. Are we really so complicated that we need to research all of this stuff? Think of your kid’s pet hamsters. What do they really need beyond warmth, food and water, companionship and some fun chutes and ladders. Now think of your kids who say they are bored and want to surf your smartphone and eat something out of a box. “We’re bored!” Are we a society seeing overstimulation and overconsumption lead to diminished returns? Would other cultures with a slower or more traditional way of life, or even aliens for that matter, marvel that we have to rediscover basic human capabilities like being able to eat communally as a family, eat foods that look like they grew somewhere, know how to have a bowel movement without using the latest medication shown on TV or even how to breathe? Take a deep breath. Fill your lungs. Now let it out. How did that feel? Family docs are unique – unique because we like to check in with patients about their joy. “How’s it going? No, how’s it really going? I know things were rocky with your partner last time we talked. Have you been able to get out and take those after-dinner walks like we talked about? Tell me

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California Family Physician Winter 2017

about that trip to India you just went on. What was that like?” We remind patients that the basics do matter. But when we leave the office, who checks in with us? Hopefully, we have supportive family and friends to check in with, but let’s face it, our job is one of active listening and being there for others, and after a full day of that, our batteries need recharging, too. Of course, we all have a colleague like Ned Flanders, that person who seems to have it all down: the right boundaries with patients, the trained and efficient clinic staff, the polite and accomplished kid (perhaps playing first violin this Saturday), and who just ran his latest marathon – and you’re just wondering how you are going to get all your charts caught up. How do they do it? Do we need to study them? I would argue that no one has it figured out and no one is perfect. This issue is about joy in family medicine. It is alive and well, but needs vigilant cultivation and weeding out. So stop and think about what your spice of life is. It might not be as elusive as you thought, and you may not even need to buy a book to rekindle it.

Family docs are unique – unique because we like to check in with patients about their joy.

The English language has almost as many words for joy and happiness as the Inuits have for snow, so you would think it is ubiquitous in our lives. Unfortunately, it has become all too easy in our busy routines to forget what joy is. One of our interview questions for residency applicants is “When was the last time you felt really alive?” I ask that of myself from time to time, perhaps even last night as I was wrestling our leaky bathroom sink. So when is the last time you felt really alive?


Join your family medicine colleages

2017 All Member Advocacy Meeting March 4-6, 2017 The Citizen Hotel Sacramento, CA Sac Lobby Day Monday, March 6

All Member Advocacy Meeting March 4-6, 2017 Sacramento

Register Today! For more information and hotel reservation links: www.familydocs.org/allmember-advocacy-meeting membe

“Through CAFP I have fostered personal and professional relationships that will last throughout my career. CAFP has given me the tools and resources to be the family doctor I wrote about in my medical school application.”

WHY JOIN CAFP?

Grow your professional network with like-minded family physicians and healthcare leaders. Stay current and connected with educational opportunities and practice management resources. Learn to lead by serving on a CAFP committee or becoming a legislative key contact.

Sutter Pacific Medical Foundation (SPMF) has an opportunity for a BC/BE Family Medicine physician to join Sutter Medical Group of the Redwoods (SMGR), a growing multi-specialty group in beautiful Sonoma County. Spanish speaking a plus! Benefits: • 1-2 years guaranteed income • Relocation allowance • Sign on bonus negotiable • Option for shareholder track after two years of employment • Generous compensation and benefits, including paid CME, up to six weeks’ vacation, pension plan and 401(k) Modalities: • Good opportunity for work/life balance • Completely ambulatory. No inpatient work • Patient panel can be established within three to six months SMGR is a 105+ member physician-owned, multi-specialty medical group that has served the City of Santa Rosa and surrounding areas for over 20 years. SMGR has been nationally recognized as a medical group that provides the highest quality and most complete health care possible. Located 55 miles north of San Francisco and 30 miles east of the Pacific Ocean, Santa Rosa is a warm and friendly city of 170,000 within Sonoma County, population 500,000. You will enjoy a unique blend of culture with exceptional art, wine, food, and recreation. Amenities include 400 wineries in Sonoma County, 27 golf courses, hot air ballooning, hiking, spas, river sports, and world-class cuisine. Sonoma County also has a professional symphony, excellent public and private schools, fantastic weather, and some of the most affordable housing in the Bay Area. You would live and work where others only dream of visiting. Contact: Isabelle von Tobel

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Alex McDonald, MD

Resident Chair of 2017 AAFP National Conference


p r e s i d e n t ’s m e s s a g e

Lee Ralph, MD

From Where I Sit

Stand Up!

In the spirit of this edition of the CAFP magazine reflecting on wellness, joy, and resilience, I have to change my quarterly tag line to reflect my current activity pictured above. I was excited to have the opportunity to be on the sidelines serving as the team physician for one of our local high schools – a high school playing in the Southern California Division 3 State Championships, no less. Fortunately, we prevailed and won the game, despite a shoulder subluxation, an AC joint separation, a groin injury, a calf injury and numerous other contusions, sprains and strains. Thankfully, no concussions! Being a team physician is one of the volunteer activities I happily embrace; it brings me great joy and pride despite the extra time commitment it entails. Volunteering in this capacity helps me remain balanced and feeling more fulfilled. The personal benefits of serving as an important team member on an activity outside the office helps me to find joy and stay healthy. The experience is enhanced by the fact that one of my daughters acts as the team statistician and my son is the water boy, making this a family friendly Friday night activity! On reflection, my personal experience with team sports moves me to honor the many family physicians who volunteer time and energy in our communities locally, nationally and internationally. Many family physicians donate their free time to schools, covering sporting events, performing preparticipation physicals or even attending free clinics or working on missionary projects. This spirit is part of who we “are” as family physicians. Volunteerism encompasses a wide variety of activities and reinforces the message of my presidential acceptance speech at the All Member Advocacy Meeting last year in Sacramento, where I challenged each of you to become more “engaged.” As I stated at that meeting, engagement can take many shapes and forms. By giving back to our communities or through political advocacy, we are remaining “engaged.” Being connected to something we passionately care about can keep us healthy and make us more resilient to the daily office tasks. I can think of no time when “engagement” is more

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California Family Physician Winter 2017

necessary than this year, given this election and the ensuing administration change. We need to remain proactive in spearheading our academy policies to continue fighting for our profession and patients, regardless of which political party is in office. CAFP has heard from members on both sides of the political aisle following the election of Mr. Trump and his appointment of Dr. Thomas Price as Health and Human Services Secretary. Some expressed their support of the results and had been disappointed with how the Affordable Care Act evolved. More than 60 wrote or called to tell us of their extreme concern about what this election could mean for the recently insured, and for the freedom of family physicians to continue providing care as they are used to for all patients. While we always listen to all sides, CAFP has clear policies in support of the Affordable Care Act and on other issues to guide us as plans are revealed by the Trump administration. I have always been accused of being an eternal optimist, a “glass half-full type of person.” I am convinced we still can make a difference, particularly by remaining engaged in our communities and advocating for our patients and colleagues. Likewise, we must band together in finding causes such as access to health care for all Californians, improving the practice opportunities and payment for all family physicians and continuing to build a pipeline of future family physicians to care for the future medical needs of Californians. So stand up! Don’t remain seated. Get involved. Standing up doesn’t have to be time consuming or onerous. In fact, hopefully, standing up will be “healing” for you, just like it is for me to be on the sidelines of a high school football game. Standing up helps me to stay connected with my children’s school and my community, while nourishing my family physician “soul.” And with luck, by the time you read this, we will have succeeded and won the State Championship game. But win or lose, my being on the field will help with the more important goal of keeping me happy and healthy and avoiding the “burn-out” that has become too prevalent. So how about joining me on the sidelines, In the classroom, free clinic or even at the State Capitol in Sacramento in March! Stand up for family medicine!


Mark your calendar for next yearʼs forum! “best conference all year” “reminded me why I chose this specialty” “practical information I will immediately use”

Empowering . Refreshing . Enlightening

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EISENHOWER MEDICAL ASSOCIATES Faculty, Family Medicine Residency Rancho Mirage, California

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Become an integral part of an exciting new residency program! Eisenhower Medical Center in Rancho Mirage, California recently welcomed its fourth class of residents and has a full 10-year ACGME accreditation. Eisenhower Medical Associates, Inc., a California Professional Corporation is seeking to enhance its team of employed physicians to serve as Family Medicine Residency faculty members for the Eisenhower Medical Center Residency Program. You will have in-patient and out-patient care responsibilities as well as precepting FM residents in the Eisenhower Center for Family Medicine. You will have protected time for curriculum management, resident advising, and scholarly work.

Board certification in Family Medicine is required. An academic appointment will be confirmed from the Keck School of Medicine, University of Southern California and rank will depend upon experience and qualifications. Eisenhower Medical Associates seeks candidates whose experience, teaching, research, and community service has prepared them to contribute to our commitment to serving the Coachella Valley. Qualified applicants, including recent residency graduates, are encouraged to apply. Candidates should submit an electronic CV and statement of interest to Anne Montgomery, MD, MBA, Program Director, at amontgomery@emc.org with a copy to tdunn@emc.org. For questions or inquiry, please contact Michelle Harding, FM Residency Program Manager at mharding@emc.org or 760-773-4504. California Family Physician Winter 2017

9


political pulse

Carla Kakutani, MD

CAFP Wins AAFP Advocacy Award for Third Consecutive Year Despite uncertainty at the federal level, 2016 was an incredible year for CAFP advocacy. Throughout the year, CAFP fought to advance our priorities at the state level. Because of that hard work, and the dedicated efforts of our members to reach out to their elected representatives, CAFP had one of its most successful years in memory. Please see the article in this magazine by CAFP’s Director of Government Affairs, Adam Francis, for a full run down of our successes. I’d like to highlight the biggest of our wins, a $100 million State Budget appropriation dedicated to support primary care physician residency training. In recognition of this achievement, AAFP chose CAFP as one the recipients of its Leadership in State Government Advocacy Award. This is the third consecutive year CAFP has received this award. The award recognizes outstanding chapter contributions to further family medicine through legislative accomplishments and initiatives or that support public policy efforts. Mr. Francis accepted the award on behalf of CAFP at the 2016 AAFP State Legislative Conference in Phoenix, Arizona. Thanks to the dedicated efforts of CAFP’s Lobby Day participants, Key Contacts, Government Relations team and the massive effort by our residency programs to send letters, make phone calls and host legislators at their programs, we secured a historic $100 million appropriation of General Fund money into the Song-Brown Workforce Training Program. CAFP worked with the California Medical Association (CMA) and the California Primary Care Association (CPCA) and successfully negotiated with the Office of Statewide Health Planning and Development (OSHPD), legislative budget staff, the Department of Finance and the Governor’s office to invest General Fund money in Song-Brown for the first time in a decade and in an amount not seen in California’s history. For those unfamiliar with SongBrown, it is a state-run program that administers grants to primary care residency programs that demonstrate a commitment to recruiting diverse, culturally competent physicians from underrepresented minority groups, provide care to a high uninsured, underinsured or Medi-Cal population, and place graduates in areas of unmet need. 10

The $100 million appropriation will be transferred to Song-Brown over a period of three years (roughly $33 million a year). It will backfill the tens of millions of dollars in cuts facing primary care residency programs over the next several years, as well as provide new funding to increase California’s primary care physician supply. The total appropriation is required to be completely disbursed by OSHPD before June 30, 2022. The $100 million is intended to be allocated in the following ways: • $60 million to support existing primary care residency programs. • $17 million to support existing Teaching Health Center (THC) primary care residency programs. • $10 million to expand primary care residency slots at existing residency programs. • $10 million to support the creation of new primary care physician residency programs. • $2 million to support increased OSHPD staffing and administration. • $1 million to augment the State Loan Repayment Program. Along with our coalition allies at CMA and CPCA, and in partnership with the CAFP Residency Network, we are working hard to ensure OSHPD distributes the funds as intended and has all the resources it needs to ensure the continued growth of the California primary care physician pipeline. Dr. Kakutani is chair of CAFP’s Legislative Affairs Committee and FP-PAC.

CAFP’s Director of Governmental Affairs Adam Francis accepts our third consecutive AAFP Advocacy Award from Sarah Sims, MD.

California Family Physician Winter 2017


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l e g i s l a t i v e n e w s

Adam Francis

CAFP Wraps Up Historic Year for Family Medicine Advocacy 2016 may go down as CAFP’s most successful advocacy year in its history. The Academy had several major successes in the Legislature, through the State Budget and at the ballot box, each of which alone could be seen as a landmark achievement. With the uncertainty of what health care policy changes may be coming at the federal level, CAFP members can be proud and excited about what was accomplished in our state in 2016.

In the Legislature

More than 20 CAFP-supported bills were signed into law in 2016. These bills will make a positive change in countless patients’ lives. A few of the major successes are listed below. Please visit our website to see all of the CAFP-supported bills signed by the Governor. • As described elsewhere in this magazine, Governor Jerry Brown signed the 2016-17 State Budget, a more than $122 billion spending plan that includes a provision allocating $100 million to support primary care residency programs over three years (roughly $33 million a year). • SBX2-5 (Leno) requires electronic cigarettes to be regulated under the same rules as tobacco products. (See E-cigarette Use among Youth and Young Adults: A Report of the Surgeon General for more information on this issue.) • SBX2-7 (Hernandez) raises the age at which Californians can legally purchase tobacco products from 18 to 21. • SB 1177 (Galgiani), authorizes the Medical Board of California (MBC) to establish a Physician and Surgeon Health and Wellness Program (PHWP) for the early identification and appropriate interventions to support a licensee in his or her rehabilitation from substance abuse. • AB 1696 (Holden) requires Medi-Cal tobacco cessation services to include all intervention recommendations assigned a grade A or B by the United States Preventive Services Task Force. • AB 1795 (Atkins) ensures patients in remission for breast and cervical cancer who are later re-diagnosed with the same cancer are not turned away for treatment and permits individuals who are symptomatic for breast cancer to receive necessary breast cancer screening services. 12

California Family Physician Winter 2017

• •

AB 2394 (Garcia) requires Medi-Cal to cover transportation for a beneficiary to obtain covered MediCal services. SB 999 (Pavley) authorizes a pharmacist to dispense a 12-month supply of United States Food and Drug Administration-approved, self-administered hormonal contraceptives and requires insurance to cover the cost.

After negotiations to reach a compromise proved unsuccessful, CAFP worked to prevent three bills that inappropriately expanded the scope of practice of non-physician health professionals from reaching the Governor’s desk. • SB 538 (Hueso) would have allowed naturopathic doctors to independently prescribe all Schedule V controlled substances, as well as any drug approved by the federal Food and Drug Administration and labeled “for prescription only.” • SB 323 (Hernandez) would have allowed independent practice for nurse practitioners. • SB 622 (Hernandez) would have laid the ground work to allow optometrists to diagnose and treat diabetes, hypertension and hypercholesterolemia, administer immunizations, perform scalpel and laser eye surgeries, and perform or order appropriate laboratory and diagnostic imaging tests.

The Ballot Box

Of the 17 propositions placed on the ballot last November, CAFP focused our advocacy on four initiatives that the Legislative Affairs Committee and Board targeted as the most important to health care in California. Of the four, Proposition 56 was by far our top priority. CAFP was involved with Prop 56 from the very beginning – weighing in on the legislative language of the proposition before it was submitted, gathering signatures to help qualify it for the ballot, financially contributing to the campaign through the Family Physicians Political Action Committee (FP-PAC) and reaching out to our members and their patients to ensure they got out to vote on the measure. Its passage means the tax on cigarettes will increase by $2.00 per pack, with equivalent increases on other tobacco products and electronic cigarettes containing nicotine. The funds generated by Prop 56 are to be used primarily to increase access to care for Medi-Cal patients by raising MediCal provider payments to Medicare levels and annually invests


CAFP also was excited to see the majority of voters approve three other initiatives we supported. Proposition 52 made permanent a fee on hospitals that is used to draw down roughly $2 billion a year in additional federal money to fund hospital-provided uncompensated care, Medi-Cal services and support children’s health coverage. Proposition 55 extends by twelve years current income tax levels for high earners which have generated crucial funding for state health programs; their loss would have meant health care cuts of up to $2 billion per year. Proposition 63 makes it illegal to own large-capacity ammunition magazines, requires background checks to purchase ammunition and persons convicted of stealing a firearm from possessing firearms in the future.

2017 and Beyond

CAFP will not rest on its laurels, especially given the uncertainty of the future of the Affordable Care Act (ACA). We should celebrate

More than 20 CAFPsupported bills were signed into law in 2016. These bills will make a positive change in countless patients’ lives.

$40 million in primary care and emergency medicine residency funding. Funds also will be used for tobacco use prevention/control programs, tobacco-related disease research, law enforcement and dental disease prevention programs. The passage of Prop 56 is an incredible win for public health in California.

the tremendous year we’ve had, but prepare for future health care fights at both the state and federal level. CAFP needs your voice and actions now more than ever. Please consider joining our Grassroots Advocacy Strike Force (www.familydocs.org/advocacy/key-contact) to ensure our elected officials know the consequences of their decisions before they are made. Adam Francis is the CAFP Director of Government Relations.

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wellness-joy-resilence

Melissa Hemphill, MD

Can a Sense of Gratitude Make You Happier? Dateline: December 2016

With Thanksgiving over and the end of the year fast approaching, these weeks can feel hurried and rushed. However, it also can be a wonderful time to pause and reflect. We can take stock of our lives, reminiscing on the ups and the downs, and be grateful for our blessings. When I was in medical school, a patient taught me a valuable lesson. In the exam room, she told me a heart-wrenching story about struggling to care for and obtain custody of her granddaughter after she’d lost both her husband and her daughter in a car crash. Despite the enormous stress in her life, she said she was getting by. In addition to seeing her care team, exercising and eating well, she kept a journal where she wrote her prayers and recorded things that made her happy. Not a diarist, I was intrigued when she told me that she found her journal to be the most helpful part of her self-care plan. She said her little book helped her get through the hard days and cherish the good days. I hadn’t yet heard the term “gratitude journal,” and I didn’t think to apply this practice to my own life at the time.

with me. I started to save nice emails from my boss and positive feedback in a “happy” inbox folder. I realized I was keeping my own gratitude journal. So I formalized the process. I started writing three happy memories from each work day before I packed up to leave. It allowed me to record positive moments and reframe my day. Instead of labeling each day “stressful,” I started counting the happy moments and positive impacts I had. The journal became a ritual, a way of reviewing the day, shedding stress and leaving work at work. I found this ritual uplifting, and it’s no surprise. There has been increasing public interest in the ideas of positive thinking and gratitude. People have dedicated entire websites and books to the theory that we can be happier if we express gratitude. There was even a social media phenomenon, the #100happydays challenge, which is essentially a photographic gratitude journal. (Yes, I did it.) Gratitude is being studied, and there is increasing evidence that a daily

Years later, the idea returned to me. Working full time, I found myself feeling ever more stressed as my practice ramped up. It became harder to bounce back from the challenges of being a new physician caring for underserved patients. On the other hand, it became easier to gripe to colleagues about a hard day. I often felt drained when I left work. I felt even worse if people asked me about my day because I often couldn’t remember many positive things. I knew there had to have been some, but I couldn’t put my finger on them because I wasn’t taking note. To avoid getting worn down by the daily grind, I started looking for happy moments. I found myself saving every drawing my pediatric patients gave me, and posting them on my wall. I saved sticky notes with “thank you” and “good job” on them. As I grew to know my panel better, I took special note when a patient shared a success story or a deeply personal moment

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California Family Physician Winter 2017

Keeping thank you notes from patients and words of encouragement from colleagues helps me keep things in the proper perspective.


gratitude practice is good for us. Martin Seligman, Ph.D., of the University of Pennsylvania found that writing a gratitude letter helped study participants feel happier for a month at a time.

moments helped me reframe my day and cherish the good moments. Our thanks to Melissa Hemphill, MD for permission to reprint her December 20, 2016 blog. Dr. Hemphill is faculty at Providence Oregon Family Medicine Residency and practices in an urban underserved clinic in Portland, Ore. You can follow her on Twitter at @MhemphillMD.

Other research suggests gratitude may help people be healthier, too. Studies conducted by Robert Emmons, PhD, of the University of California, Davis, and Michael E. McCullough, PhD, of the University of Miami showed that people who kept weekly gratitude journals experienced more happiness and complained of fewer health problems. Specifically, Emmons proposed that practicing gratitude can improve immune system function, blood SEEKING EXPERIENCED, HIGHLY MOTIVATED FAMILY PHYSICIAN pressure, pain scores and sleep, in addition to Federally qualified health center clinic in central San Diego seeks a highly subjective happiness and compassion. motivated family or int med MD with a vision for the future of community medicine. San Diego Family Care operates 8 clinic sites in San Diego, with a Gratitude can help people function better at PCMH model & EHR system in place. NCQA recognized. Visit website at work, too. In a more positive environment, sdfamilycare.org. CA lic required. Competitive salary/benefits with retirement people tend to work harder and derive more match. Looking for a special doctor, committed to our mission! satisfaction from their jobs. Adam Grant, PhD, of the University of Pennsylvania showed Send CV to Dr. Jonathan Baker, M.D., Medical Director, at that employees performed better after jonbakermd@gmail.com. their manager gave them a pep talk that included gratitude. I posit that a gratitude journal can be an excellent tool for the practicing physician. I challenge you to start a gratitude journal specifically centered on work. To create a ritual, write down three happy memories from the day before you leave work. You could start by writing just a few times a week. The memories could be positive patient outcomes, when someone thanked you, or a hug from a patient. It could even be a prior authorization that went more smoothly than expected -anything that brought you a moment of joy. As for me, I will keep writing work-related gratitude entries, especially on hard days at clinic. Recently a patient arrived 40 minutes late on a day that I was already overbooked. I ran behind schedule, and then one of my most challenging patients needed to be admitted to the hospital but refused to go. By the end of the day, I was exhausted and had many charts left to complete. Before I left, I took a moment to remember some good moments. I had a good discussion about health goals with one patient, I found out another had quit smoking and I got to see a precious 2-week old (the patient who arrived late). Writing down these

Physician Opportunity’s Santa Barbara, CA

Based in Santa Barbara, Sansum Clinic is the oldest and largest non-profit, multi-specialty group between San Francisco and Los Angeles with over 200 physicians and surgeons and a staff of healthcare professionals in over 30 specialized areas of medicine. Sansum Clinic has garnered recognition, accreditation and awards from national and state agencies.

Our current openings are Primary Care Urgent Care Pediatrician Geriatrician/Palliative Care

For More Information Contact: Shawneen Flanders-Clark Physician Recruiter sflander@sansumclinic.org 805-689-8256 www.sansumclinic.org

Benefits Free Medical/Dental/Vision CME Stipend 1 MA Per Provider

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Elaine Skoch

Beginning the New Year with a New Outlook: Tips from a Fellow Traveler

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There is probably no more important time than the opening of a new year to strive to maintain balance in your life.

5.

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Burnout, change fatigue and post-holiday distress – all are terms we hear during the last couple months of the year. The emotional and physical stress coupled with the continuous work put into practice transformation can overwhelm even the most determined and head strong among us. So how do we avoid “burning out” during the holiday season, or, for that matter, during any time of the year? Below are a few tips to help buoy resolve and spirit: 1. Begin the new year by taking the time to revisit what has been accomplished either personally or in your group setting. Create an opportunity to recognize and celebrate your accomplishments. No matter how small the change, your impact might have been huge. Wrap a bow around it (either figuratively or literally) and give yourself and your team the gift of accomplishment and celebrate it! This exercise will renew your energy and help you continue the journey. 2. Resist the temptation to launch new, major initiatives until the new year. Changing the way phones are answered in your practice, for example, or implementing new technology can all wait until January. Set realistic goals for what can be accomplished post-holiday season and continue to plan for what can be tackled. Ask your team members to help prioritize commitments and focus on those challenges. Continue then to evaluate and provide feedback on the ongoing process improvement. 3. Plan a group activity with your team. Christmas caroling at a nursing home; adopting a family (or two) in need in your community; planning a celebration dinner with gift exchange among team members; creating a cookie exchange – all are examples of what has been done to reinforce the meaning of the season and the collective “family” of co-workers. How about practices you can integrate into the entire year’s calendar? Contributing year-round can often give a sense of meaning and nurtures team development. 4. Be more deliberate and intentional in your personal life. Said another way, focus on simplifying. This involves setting realistic priorities and avoiding things like finding the “perfect gift” instead of spending time with your family and friends. The truth is, most of us really just want to know that someone cares about us. Additionally, do not become a slave to lists as is prone to happen during this busy season. Allow yourself to stay flexible, and focus on the things that are really important to you. When you think about adding things to your list, first

ask, “In the grand scheme of things, will the world end tomorrow if this doesn’t get done?” Take the time to comfort yourself. Recognize your stress and do something to feed your soul and calm your heart. Activities might include listening to relaxing music, practicing deep breathing, going for a walk along one of your favorite trails or getting a massage. Most importantly, take the time to recognize where you are emotionally and physically and focus on being “present” rather than being overwhelmed by all outside influences that bombard us during this time of year. The mantra continues: “Be flexible!” Prepare yourself for the new year. This means developing sustainable skills and techniques (some of which have been described above) to manage stress and the demands of life on an ongoing basis. Absolutely nothing is wrong with being more mindful, deliberate and intentional throughout the year or learning how to take care of yourself. We are never too old to learn how to be more resilient.

There is probably no more important time than the opening of a new year to strive to maintain balance in your life. To avoid burning out, you must take care of yourself, be present in the moment and be present with your loved ones. Be realistic in your efforts, both personally and professionally, and take the time to celebrate accomplishments that gave meaning to your life. Elaine Skoch, PCMH-CCE is a CAFP consultant, board certified Nurse Executive at the advanced level and recognized as a PCMH Clinical Content Expert by NCQA.


Join the faculty of one of the nation’s premier Family Medicine Residency Programs

The Ventura FM Residency, affiliated with the UCLA School of Medicine, is seeking two full time faculty physicians, one with sports medicine experience, to join a growing and robust program.

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For more information, visit venturafamilymed.org/jobs

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NAPA VALLEY WINE COUNTRY OUTPATIENT FP POSITIONS

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Hospital supported outpatient FP positions in desirable growing community of 135,000 nestled in the Napa Wine Country 45 minutes to San Francisco associated with award winning 200 bed health system. Refer inpatients to Hospitalist program. New and modern clinic facilities. Excellent 5 year salary guarantee, signing bonus, production bonus, benefits and relocation. High income projection.

Vista Community Clinic

With locations in Vista/No San Diego County, Lake Elsinore/So Riverside County and La Habra/Orange County Seeking: Full-time, part-time and per diem Family Medicine Physicians and Pediatricians. Requirements: California license, DEA license, CPR certification and board certified in family medicine. Bilingual English/Spanish preferred.

Contact Us:

314-984-0624

Visit our website at www.vistacommunityclinic.org Forward resume to hr@vistacommunityclinic.org or fax resume to 760-414-3702

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• Sunny California locations with easy access to San Francisco, Napa, Lake Tahoe, Los Angeles and San Diego

Please contact/send your CV to: Physician Recruitment providers@dignityhealth.org | 888-599-7787 www.dignityhealth.org/physician-careers

TM

Hello humankindness


you are

Cordially Invited We are thrilled to invite you to attend the 2017 Family Medicine Clinical Forum. Your Committee on Continuing Professional Development works diligently to offer an educational experience you won’t want to miss! This meeting is a terrific opportunity to learn the latest important clinical information and gather new resources for your practice. It includes one-on-one time with forward-thinking and innovative colleagues, opportunities to talk directly with faculty and to share experiences and stories with learners interested and involved with the many issues you address every day.

We are thrilled to announce:

Achieving Joy at Work and the Triple Aim by Moving Health Care Upstream with Rishi Manchanda, MD, MPH. Dr. Manchanda will discuss the role of social determinants of health, their impact on the Triple Aim and physician joy at work, and ways to improve the effectiveness of primary care through clinical-community interventions and tailored quality improvement approaches that address health risks where patients live, work, eat, sleep, learn, and play. Improvisation and the Art of Medicine: Adaptable Skills for an Uncertain World with Belinda Fu, MD, MPH. Dr. Fu will guide you in using improvisational skills and teaching methods to expand your ability to connect with patients and colleagues in a collaborative, compassionate way. Other topics include Zika, Hep C, Seniors and Polypharmacy, Cannibis Use, Telemedicine, Urgent Care, Integrative Medicine, Adverse Childhood Experiences, Cancer Survivorship, Adolescent Health, Assessing Suicide Risk and much more! The Forum also offers optional activities: Three Knowledge Self-Assessments (KSAs – formerly known as SAMS) on Mental Health in the Community, Heart Failure and Maternity Care; two workshops: Long Acting Reversible Contraception (LARC) Hands-on Workshop and Palliative Care Workshop. The Forum will be sponsored for up to 28.75 CME hours – AAFP Prescribed credit, AMA PRA Category 1 creditTM, and California Bureau of Registered Nursing credit.

Carol Havens MD and Chris Flores,MD Co-Chairs, CAFP Committee on Continuing Professional Development

Application for CME credit has been filed with the American Academy of Family Physicians. Determination of credit is pending. Please check back regularly for updates. 18

California Family Physician Winter 2017


Jay W. Lee, MD, MPH Chair, CAFP Nominations Committee

The CAFP Nominations Committee met November 7, 2016 and is pleased to present the following slate for election in 2017. The election of officers takes place at the All Member Advocacy Meeting, March 4, 2017, at The Citizen Hotel, Sacramento.

2017 Proposed Slate of Officers President-elect

Lisa Ward, MD

Speaker 2017-18

Walter Mills, MD

Vice Speaker 2017-18

David Bazzo, MD

AAFP Delegate 2017 (One-year term to fill vacancy created by resignation of Carla Kakutani, elected to serve 2016-2017)

Carol Havens, MD

AAFP Delegate 2017-2018

Jeffrey Luther, MD (incumbent)

AAFP Alternate Delegate 2017 (One-year term to fill vacancy created by potential election of Carol Havens to delegate for 2017)

Lee Ralph, MD

One Nominating Committee member for 2017-18 Elected from the AMAM (two-year term)

Tonatzin Rodriguez, MD

Secretary/Treasurer 2017-18 (one-year term) This is a recommendation to the CAFP Board of Directors; the Secretary/Treasurer is elected of and by the Board.

Shannon Connolly, MD

Rural Director, CAFP Board – 2017-2020

Steve Harrison, MD

Faculty

John Muir Health’s Family Medicine Residency Program, Walnut Creek, CA

John Muir Health is a nationally-recognized healthcare system that offers a full range of outpatient and inpatient services. We are proud to be launching our UCSF-Affiliated John Muir Health Family Medicine Residency Program in the San Francisco East Bay area.

NORTHERN CALIFORNIA, NAPA Independent Medical Group is seeking qualified candidates to staff their minor emergency department.

Candidates include: Near Retirement Emergency Physicians Family Practice Physicians Urgent Care Physicians Emergency Department NPs and PAs

We are seeking a faculty member to help develop an innovative, dynamic, 8-8-8 unopposed, community-based program that is attentive to underserved patient populations. The successful candidate must be a board-certified family physician who is committed to educating future family physicians and passionate about excellence in education and clinical services. The selected individual will be responsible for administrative leadership support, direct clinical care and precepting. Contact: Lynn Eddleman, Residency Program Coordinator p: (925) 941-2674 f: (925) 296-9015 lynn.eddleman@johnmuirhealth.com

If interested, forward C.V. to Tony Mottalei M.D. mottalei@gmail.com

California Family Physician Winter 2017

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winter 2017 / generational voices

With this issue, CAFP launches a new feature: Generational Voices. Four generations are currently represented in CAFP’s membership and these generations have both vast differences and amazing similarities. This feature gives members of The Silent Generation (1925-1945), Boomers (1946-1964), Generation X (1965-1984) and Millennials (1985-2000) a place to offer their thoughts on the theme of the magazine or topics of interest to family physicians. For this issue, we asked about wellness, joy and resilience and received three wonderful reflections. Want to be part of our Generational Voices Project? Send your reflections on this topic or on our Spring topic of leadership, to cafp@familydocs.org. Watch www.familydocs.org for more Generational Voices.

Carol Havens, MD

As a boomer, I do suffer from what my millennial friends call “vacation deficit disorder.” We have not been able to take long vacations for several years because of our special needs child, Stella (a 90-pound black lab/great Dane rescue who loves to go in the car but is very anxious around new places or people). We have tried to add vacations onto work travel when I go to places we want to visit. Alas, I also have trouble playing when I am working (we Boomers work so we can have time to play, but work and play are separate entities). So, we are trying something new: short trips away, completely unrelated to work. We can often arrange brief child care for Stella, and I can be totally away from work (OK, we haven’t tried it yet, but I think I can) for a short time, and if we do it often enough, the hope is it will restore some balance and support joy. Our goal is to take the respites every few months and our first one was in December. For a variety of reasons, this has been a stressful time recently so I was really looking forward to getting away. We had three days filled with friends, great food, art and conversation. It was special and we can’t wait to do it again! We did miss our child, however, and were happy to get back to our very happy lap dog. So, while I get joy from doing challenging work that makes a difference, at my core, my strength comes from friends and family, including the furry ones.

Will Woo, MD

Karen Muchowski, MD “Stop and breathe Laugh as often as you can Be playful every day” 20

California Family Physician Winter 2017

2016 has been a year of big change, bringing both victories but also uncertainty. Nationally, this meant a change in political climate and uncertainty regarding the future of the Affordable Care Act. In the State of California, the year brought victories in funding for primary care graduate medical education and a lot of legislation for tobacco cessation. 2016 also brought the enactment of the End-ofLife Options act. For me, the year brought new patients and new administrative responsibilities. With many competing priorities in my life, time management and prioritization have become vital. As the year progressed, I realized that my work was consuming more and more of my life and I had to pay more attention to my own personal wellness. To some, wellness means having a sweet schedule or taking big vacations. While these ideas are great, I had to look for other options over the past year. I heard many talks on wellness, including talks from “The Happy MD,” local medical group experts and teachings from Brene Brown. I learned innumerable wellness techniques exist and it is up to each physician to choose what will work best for him or her. Many of the teachings felt like performing cognitive behavioral therapy on myself; the two themes that really spoke to me were setting boundaries and finding joy in the activities that keep you grounded. Setting boundaries meant reigning in some of the runaway patient relationships that were taking disproportionate amounts of time. It also meant setting boundaries with


my colleagues and my superiors. By setting boundaries with patients, colleagues, and superiors, I can reclaim some of my own time and allocate more of my focus to higher acuity cases and important projects, allowing for better outcomes all around. Making time for the things that keep me grounded was by far my favorite wellness technique this year. Free time, unfortunately, has not come in large chunks recently, but blocking off time on my schedule to go to the park with my young kids or cooking a delicious meal for my family brought me great joy. Professionally, volunteering to provide sideline medicine at local high school football games, giving talks to the “At Risk Youth” high school student summer program and teaching medical students and residents has kept me going. I have had a relatively busy year which has brought successes as well as challenges for me. I am so thankful for the support that I receive from my friends and family and I am looking forward to a more balanced 2017.

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Rev. Nicole Reilley

Wellness, Joy and Resilience Embracing a Tool or Practice As the wife of a physician leader and as a pastoral leader, I see the unique stresses physicians shoulder. The intensity of the work, the needs of people, the demands of medicine, as well as the long hours physicians keep, can make their well-meaning advice to ‘eat right and exercise’ void in their own lives, and wellness, joy and resilience can feel far away. I remember a visit to my own physician years ago; as I left the exam room I saw her standing in a doorway, looking out at the busy street. Her face revealed exhaustion and grief brought on by the demands of her work and her personal life. I will never forget her face and the concern I felt for her, as both a person and as a professional. Spiritual leaders share some of the same stresses as physicians. We work long hours and deal with people in times of need, all the while finding the new complexities of ministry draining our own wellness, joy and resilience. My own work as a senior pastor, a house church planter and a denominational leader has taught me the need for joy (a very faith-familiar word), wellness and resilience. And I believe these ways are rooted in a spirituality of life that is available to all, regardless of your spiritual belief system. What is a spiritual life? I believe that a spiritual life is a life in which we no longer expect, or are disappointed by a lack of, perfection. Spiritual people are people who see challenge, pain and change not as circumstances to rebuff or deny but as an essential part of the human condition. They are not the antitheses of this issue’s theme of wellness, joy and resilience but partners in bringing it forward, in all its messiness and failings. Tools and practices (on which I will touch later) encourage the development of resilience, which I believe grows both joy and wellness. Resilience is more in the news these days. Some use the term “grit;” others speak of “bounce back;” but it is all about responding to what life brings, adapting and thriving. Thankfully, we have moved from telling people to “just relax” and to “be less stressed” and recognize that life is stressful and, at times, crushing. People have to deal with a host of challenges that cannot be avoided. As those who care for others and ourselves, we do better when we realize this and embrace tools and practices that ground us in wellness while we live complicated lives. 22

California Family Physician Winter 2017

In a terribly difficult time in my own work, I visited a specialist who told me all my health issues were stress-related and that I should give up my work (this five minutes into our first visit). Horrified, I left her office knowing that she didn’t recognize something important – giving up my work wasn’t going to solve my stress. Illness, the loss of love, issues in the economy, and other everyday situations wouldn’t go away if I had other work. We live life in all its glory and challenge not by running away but by embracing it. I have become more able to respond to what life brings me, which is what I understand resilience to be, through embracing two things – a useful tool and some simple life practices. The tool is deepening my self-understanding. The tool I used, StrengthsFinder, was a simple online survey (and book) that didn’t tell me anything startling but did remind me how I am wired. It is an easier pathway to wellness when we build on who we are and not who others want us to be or whom we wish we were. I learned through StrengthsFinder that I am an Achiever. As an Achiever, I find life more exciting when I can check off boxes in my planner


as I work toward my goals of exercise and movement. (I hate to admit it, but it brings me a lot of pleasure to see those checkmarks!) And when I think I don’t need those little boxes (or that Fitbit), I falter. My practices have changed throughout my life and are adjusted seasonally, but the practices I faithfully use include:

FP Opportunities in A Coastal Community With University Culture!

Mindfulness Meditation – I simply sit for 2030 minutes each morning and focus on my breath. What has strengthened my practice is setting a timer that rings every five minutes; this helps my wandering mind return to my breath. And while there are many variations, I find keeping it simple works best. This simple practice has grounded me better than anything I have tried. I am more resilient and more joyful because of it.

If you like fresh air, good schools, an outdoorsman’s paradise and affordable housing, then you belong here!

Daily Happy Hour with my Husband – This isn’t about going out or even drinking, but spending time together. When I arrive home from work, Jeff and I usually have a drink (sparkling water, martini, whatever) and catch up on our day. We learned about this from a family friend as I was preparing his wife’s memorial service. Don and Dorothy’s daily happy hour has worked for us and, in a time when many physicians (and pastors) are experiencing burnout, this daily time of checking in stops us from isolating and gives us an opportunity to strengthen our connection. One last practice I’d like to share, and one into which I’m growing is self-compassion. Self-compassion connects to my spiritual tradition through the term grace. Grace is the belief that life has been gifted to us freely and without our need to earn it. Grace reminds us of our worth outside of what we can accomplish. Grace feels comfortable to me when I offer to others, but offering grace to myself has been harder. That’s why I have added it to my daily to-do list as selfcompassion. And honestly, I look forward to placing a check mark beside it. Blog: www.lightweightlowmaintenance.com

Sign-on Bonus, relocation assistance, income guarantee

Contact: Connie Cartwright, Physician Recruiter Mad River Community Hospital ccartwright@madriverhospital.com

UCSF FRESNO FAMILY MEDICINE FACULTY OPPORTUNITY The UCSF Fresno Medical Education Program and Central California Faculty Medical Group (CCFMG) are recruiting for a physician to join the teaching faculty. The successful applicant must be board certified in Family Medicine, have a license to practice medicine in the United States, and be eligible to obtain a California medical license at the time of hire. This position provides an opportunity for teaching, clinical research, and community practice. Proficiency in OB optional. Administrative/leadership opportunities are available. A competitive salary is offered. The program is based in Fresno, California, which offers a high standard of living combined with a low cost of living. The result is a quality of life uniquely Californian, yet surprisingly affordable. Fresno is a vibrant, growing city located in Central California. There is much to see and do in Fresno and the city is ideally located for fast, convenient getaways to the scenic Central Coast as well as the majestic Sierra Nevada mountains. Fresno is the only major city in the country with close proximity to three national parks, including renowned Yosemite National Park.

PLEASE APPLY ONLINE AT: https://aprecruit.ucsf.edu/apply/JPF01168 Visit our websites: www.fresno.ucsf.edu | www.communitymedical.org

UC San Francisco seeks candidates whose experience, teaching, research, or community service that has prepared them to contribute to our commitment to diversity and excellence. The University of California is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, age or protected veteran status.

California Family Physician Winter 2017

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Catherine Sonquist Forest, MD MPH

Rx: Choosing Wisely I very nearly could not write this piece. Like many, I have endured big physical challenges, the deaths of near and dears, disappointments and failures – more than some, less than many. I was not sure I had anything to offer in the days and weeks after an election that will leave so many of our patients, colleagues, friends and families even more vulnerable than before. I am still not sure about the value of my contribution on this subject, but here goes. Do you believe that one can cultivate resilience and joy? If so … Let’s choose resilience. Let’s choose joy. When I was three-years-old, I touched the wrinkled, contorted burn on my grandfather’s leg and asked him what happened. He responded, “It reminds me that people heal and just how precious life and you all are.” Then he wrapped me in his arms and tussled me about, laughing and making animal noises. I later found out he had been badly wounded in combat in WWI. Like me, my grandfather was a professor of medicine. Mid-career at the University of Vienna, he recognized the deadly seriousness of the unfolding Nazi crisis in Europe. He struggled in vain to convince his family, friends and colleagues and after months of organizing and talking with his friends and peers, he decided to leave everything behind to try to save his family. One midnight, hoping to go unnoticed, he and his family quietly boarded a train, leaving their entire life behind. My grandfather’s mother, sister, aunts, uncles and cousins, along with many of their friends, died in the camps. My grandparents and their two children were very fortunate to be able to make a new life in the US.

dissatisfaction lies in ourselves. That does not resonate with my life experience, however. I believe our relationships to the health care system are more like dysfunctional marriages that we stay in for the children (our patients now and in the future). We try with love to improve the dysfunctional system, until we run out of life, strength, patience or trust. I fear for my country and my patients at the thought of President Trump. I know from world history and from my own family history that a “wait-and-see” attitude can sometimes lead to terrible outcomes. One “wellness” component for me is direct political action. I also learned from my family, however, the importance of self-care, immersion in art, music, outdoor exploration and family connections. In the weeks after my mother died, I invented a mindfulness exercise that combined art, the outdoors, poetry and connection. I take a nature photo, compose a haiku and text it to a loved one. I named it Textku (combining text and haiku). I do this most days. It helps me bathe in the beauty of the earth, be present in the moment and be grateful for connections. This is the one I wrote on November 9th.

No time in my life have I not been aware that the worst could, and does, happen. My grandfather fought in the trenches in WWI. He suffered terrible physical pain through most of his life, and most of his family died in Auschwitz. Yet somehow, my grandfather and the rest of my family are a joyful and hopeful people. How? I believe the answer lies in love. Loving ourselves, and loving others enough to try to leave the world better than you found it for those to come. When physicians talk about how to maintain wellness, joy and resilience, we almost invariably use the phrase “physician burnout” – implying that the problem of

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California Family Physician Winter 2017

Sinking orb winking She knows tomorrow will come On my side of fence


After the election, I began to think about what it will take to maintain our resilience in the years to come. In health care, as in an abusive relationship, sometimes we must have the conviction to stand for what we know is right. A recent TED talk by Elizabeth Lesser reminded me of lessons I learned from obstetrics and pediatrics. Pain in labor is inevitable and indicates that things are progressing, as they should be. Staying open, not resisting the pain, allows us to move through it. Step into deep time – the most important issues are not always those that clamor for your attention. Lastly, never forget to be in deep awe.

This is the Textku I wrote on my noon walk last Friday, inspired by a café threshold:

Glancing down briefly Glimpsing etched words at my feet Grateful it is so.

In the last few weeks, the meaning of my grandfather’s words and how they fit into the “wellness” piece of the picture became clearer. We do not have to wait for life and death situations to speak truths and listen for the truths from others to mend the rents in the fabric of society and our lives. For me, this means engaging in political action. So – I am trying to be braver about speaking truth (and also listening). I am unafraid of pain, I step into deep time, and I remain in awe. I believe we are in dangerous times. For now, I am trying to take courageous steps. I hope others are willing to engage. I guess I am ever hopeful, that we can choose resilience and joy. Who knows if this will change anyone’s practice pattern. It turns out – we do not yet know what does. I love the range of what people call on to renew themselves: exercise, meditation, bodywork, pets, art, music, travel, every hobby imaginable, nature, you name it. I find joy in music, hiking, art, poetry, and making people laugh. Each day I try to give myself time outdoors and a dip into the arts. Hearing or making music, being in the open air, being with my loved ones – this is what keeps me ready to go back to work on Monday with full presence.

Primary Care Opportunities in Southern California Loma Linda University Faculty Medical Group, is seeking candidates for the following positions: • Inpatient Hospitalist • Outpatient Clinics in Loma Linda and outlying areas • Federally Qualified Health Center • Community-Based Outpatient Clinics/VA We are looking for applicants that BE/BC in Family Medicine or Internal Medicine, with a commitment to developing comprehensive quality primary care services. Includes opportunities for onsite teaching and metoring Loma Linda University students and residents. Loma Linda University is located East of Los Angeles, in an area known as the Inland Empire. The beaches of Newport, Laguna, and Malibu are only 60-90 minutes to the West, with superb swimming, sunbathing, surfing, and sailing. Also 60 minutes to the West is downtown Los Angeles, with its top-quality restaurants, world-renowed museums, opera, and other cultural opportunities. The Big Bear Mountain Ski resort is about an hour drive from LLU. The golf courses, shopping, and spas of Palm Springs are an hour drive to the East and the World-class Mammoth Mountain resort is a 6 hour drive to the North. These opportunities are not eligible for a J1 Waiver.

Interested candidates, please send your CV to:

Mike Unterseher Director of Physician Recruitment recruitmd@llu.edu 800-328-1163

California Family Physician Winter 2017

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from sacramento

Jodi Hicks

New Laws May Affect Your Practice and Your Patients Hundreds of bills were signed by Governor Jerry Brown in 2016, many of them affecting health care. Because of resource constraints, CAFP can take action only on a portion of them, but it is important that family physicians are aware of changes that may be on the way as a result of new laws. While CAFP may not have had an official position on these bills when they were signed, we took aggressive action on some of them as they moved through the legislative process and worked with the authors and sponsors to remove or amend harmful provisions before they made it to the Governor. • AB 72 (Bonta) allows patients to pay the in-network rate (or 125 percent of Medicare, whichever is greater) for an out-of-network physician practicing in an in-network hospital. Insurance companies would have to pay doctors the rest, and the bill allows an independent process for doctors to challenge that payment. CAFP did not have a position on the bill, but the California Medical Association (CMA) adopted a neutral stance after amendments gave more options for the level at which out-of-network physicians are paid and fleshed out the process to dispute charges. • AB 1668 (Calderon) allows patients with an immediately life-threatening disease or condition to use an investigational drug, biological product or device if he or she has written informed consent from his or her primary physician and a consulting physician. The law prohibits disciplinary action against the license of a physician based on the physician’s recommendation to an eligible patient if the recommendation is consistent with protocol approved by the physician’s institutional review board or an accredited institutional review board. • SB 482 (Lara), sponsored by the Consumer Attorneys of California and influenced by the Department of Justice (DoJ), requires a health care practitioner to check the CURES database to review a patient’s controlled substance history before prescribing a Schedule II, III or IV drug for the first time and at least once every four months thereafter if the substance remains part of the patient’s treatment. The practitioner must check CURES no earlier than 24 hours, or the previous business day, before he or she prescribes the controlled substance to ensure the most up-to-date information. CAFP originally

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opposed this bill, but moved to a neutral position after we and CMA secured several exemptions to mandatory checking based on website/Internet outages, emergency care, instances when the system cannot be accessed in a timely manner, etc., as well as an amendment that stipulates the DoJ cannot implement the bill until six months after it certifies that the CURES database is ready for statewide use and that the department has adequate staff, user support and education. • SB 586 (Hernandez) establishes a Whole Child Model for children enrolled in both Medi-Cal and the California Children’s Services (CCS) Program, instead of the existing arrangement in most counties where CCS services are “carved out” from the Medi-Cal managed care plan. This law also contains a number of provisions to ensure the expertise and quality of care in CCS is preserved, including requirements for plan readiness; time-limited continuity of care; requiring Medi-Cal managed care plans to facilitate timely access to services by CCS providers and facilities with clinical expertise in treating the enrollee’s specific CCS condition; requiring a “rate floor” for CCS providers; and requiring an independent evaluation that compares CCS services before and after they are incorporated into the plan. • SB 908 (Hernandez) requires health plans to notify purchasers in the individual and small group market if premium rates have been determined unreasonable or unjustified. • SB 1135 (Monning) requires health plans (including Medi-Cal managed care plans) to notify enrollees and contracted providers about information on timely access to care standards and information about interpreter services, at least annually. Thank you to all the CAFP members who took grassroots action to ensure these bills were amended to better reflect the priorities of family medicine and patients. As the new laws are implemented, it is important that we hear from you to ensure we can address any unintended consequences that affect you or your patients. Please email us at CAFP@familydocs.org. Jodi Hicks, DeMare, Brown, Hicks and Kessler, is CAFP’s legislative advocate in Sacramento.


Department of Family

and Community Medicine Academic Recruitment The University of California, Davis, Department of Family and Community Medicine seeks a Health Sciences Assistant Clinical Professor. The position will be expected to contribute with distinction in the areas of clinical care, teaching, mentoring of trainees, and University and public service. Positioned in the heart of Northern California, Sacramento is a diverse farm-to-fork foodie and coffee town with a vibrant art scene, and is an easy drive from San Francisco, the Napa Valley, Tahoe, and Yosemite. We have everything—but you! Candidates wishing to learn more about this academic opportunity should review the full recruitment description at https:// recruit.ucdavis.edu/apply/JPF01151 If interested, candidates should submit their application, including a current CV and a cover letter with full contact information, and they should apply online using the above URL. Inquiries regarding this position may be directed to Search Committee Chair, Dr. Sarah Marshall at smarshall@ucdavis.edu or by calling (916) 734-6226. The position opens on August 1, 2016. For full consideration, applications should be received by December 1, 2016. The position will remain open until filled through June 30, 2018. The University of California is an Affirmative Action/Equal Opportunity Employer with a strong institutional commitment to the achievement of diversity among its faculty, staff, and students.

Explore new possibilities Adventist Health offers a variety of employment opportunities with full- and part-time physician careers throughout the West Coast in California, Washington, Oregon and Hawaii .

phyjobs@ah.org • 800-847-9840 • physiciancareers.ah.org


Shannon Goecke

membership news

For Senior CAFP Members, Age Is Just a Number The theme of this issue is wellness, so it seems appropriate to highlight some of our elder members who clearly know something about the topic. James Hutchinson, MD, arrived in San Mateo after finishing his residency in Sacramento, hoping to set up practice on a tree-lined street of doctors’ offices near what is now Mills-Peninsula. But the young family doctor and his wife, pregnant with the first of their three children, could not catch a break. The Hutchinsons are African-American, and some neighbors and realtors simply didn’t want them in the neighborhood. Fortunately, many community members did support the Hutchinsons. Fellow physician Norton Benner allowed Dr. Hutchinson the use of his office to see patients in the afternoons. San Mateo Postmaster Jim Kehoe sold the Hutchinson’s his threestory Victorian home, and community members lobbied the San Mateo City Council for a zoning change to allow Dr. Hutchinson to practice out of his home. “A lot of good people in the community, both blacks and whites, spoke up and made it happen; otherwise we would have had to leave San Mateo,” says Dr. Hutchinson. On his first day in practice, on March 5, 1953, the front page of the local newspaper read “Negro MD Gets Permit in Mateo.” He and wife Evelyn were married for more than 60 years, until her death in late 2014. These days, Dr. Hutchinson, now 93, still sees patients in that Victorian on San Mateo Drive. Dean McCandless, MD, had already lived a full life before he even started medical school. Dr. McCandless was a seasoned paratrooper during World War II, and participated in four campaigns – Sicily, Italy, Normandy and Holland – without serious injury. But his luck ran out during the Battle of the

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Bulge. Or did it? He was shot in the shoulder and two more bullets strafed his helmet. If he hadn’t been looking down at the trail in the snow at the time he was shot, he would have been killed. After the war, Dr. McCandless graduated from Duke University School of Medicine in 1950 and served in the US Army Medical Corps from 1950 to 1952. He spent the bulk of his career at Kaiser Permanente, from 1952 to 1980. He spent the remainder of his career in solo practice before retiring in 1989. Dr. McCandless and wife Polly, a retired nurse he originally met at Fort Sam Houston in 1941, have been married for more than 70 years and currently reside in La Quinta. Dr. McCandless and other veterans were honored at the City of La Quinta’s Veterans’ Day Celebration in 2016. Charles Wildenman, MD, has the distinction of being CAFP’s last surviving charter member, having joined at the end of 1947. Dr. Wideman, 102, of Fairfield, was recently honored at the annual Solano County Centenarian Celebration. When asked for the secret to his longevity, Dr. Widenmann replied, “Everything in moderation and make friends with your enemies.” Whether you’re in your ‘20s or in your ‘90s, CAFP is your family medicine home. We look forward to hearing your stories and serving you and your patients for years to come. Shannon Goecke is CAFP’s Director of Membership and Marketing For Further Reading San Mateo Doctor, 93, Has Simple Prescription: Keep On Working, bit.ly/2fLNSmX La Quinta Honors Its Veterans with a Ceremony at City Hall, desert.sn/2fXJhN2 Two Long Lives Shared by Dr. Dean McCandless, amzn.to/2fLL7SS Solano Centenarians Celebrated for Longevity, bit.ly/2fXX99V


Excellent Physician Opportunities

HunGER kEEps up On cuRREnT EVEnTs, TOO.

Enjoy Work - Life Balance in the Gateway to the Sierras

• Short distance to hiking in 2 National Parks • Numerous lakes • Biking, Fishing, Hunting, Golf, as well as other outdoor activities available

• Close to International airport • Excellent schools • Low cost of living • High Quality Medical Care

Now Seeking: Family Medicine • Internal Medicine Competitive compensation, signing bonus, annual physician bonus, malpractice coverage.

Please send CV to CVIH HR: 2740 Herndon Ave., Clovis, CA 93611 or email to hr@cvih.org

Central Valley Indian Health, Inc.

Hiring in accordance with Indian Pref. Act.

Voted one of the “Best Places to Work in LA & Orange County”

1 in 6 amERicans sTRuGGlEs WiTH HunGER.

HealthCare Partners has immediate fulltime and part-time opportunities for Family Medicine Physicians throughout Los Angeles and North Orange County. Ideal candidates will have at least one year of Family Medicine experience. H1B candidates are encouraged to apply. We offer organizational stability, career growth, excellent compensation and benefits for a truly balanced professional/personal lifestyle.

TOGETHER WE’RE

Hunger is closer than you think. Reach out to your local food bank for ways to do your part. Visit Feedingamerica.org today.

To see a full list of available positions and to apply online visit us at: www.joindavitamedicalgroup.com or email your CV to: ClinicianApplicants@healthcarepartners.com


evp forum

Susan Hogeland, CAE

If ever there was a time… If ever there was a time for an issue of California Family Physician on the topic of wellness and joy, this is it. Prior to the recent election, CAFP leadership and staff heard most about the struggles our members face in addressing administrative hassle and work-life balance. Hardly a medical publication has come out that doesn’t address burn-out or restoring joy in practice. It’s certainly been a topic at our own Family Medicine Clinical Forum and at the AAFP’s Family Medicine Experience (FMX), as well as at many of our county chapter meetings. Our North Bay Chapter has even undertaken an entire project around restoring joy – way to go North Bay! Since the election, those struggles have been compounded by uncertainty about the future of health care in America (and California, especially) as our leaders, members and staff prepare for the potential dismantling of six years of implementation of an imperfect-but-certainly-better-than-what-we-had-before Affordable Care Act (ACA). Once the ACA was signed into law, then-Governor Arnold Schwarzenegger (R) made California the first state to adopt enabling legislation. The ACA significantly increased primary care payment for both Medicare and Medicaid, and CAFP helped inform our members and their staffs about how patients and their families could obtain coverage through Covered California, our insurance benefit exchange. CAFP and AAFP share strong policy supporting access to care for all and are concerned about the sustainability of the work we have done toward that goal. Let me acknowledge again, the ACA is by no means perfect, but it has helped cover millions of Californians who previously were uninsured and began to move our health care system to one that recognizes the value family physician bring to health care, instead of the volume of care provided. All of us are subject to historical revisionism. In my case, maybe it’s just a bad memory. The 13 percent projected premium increase this year for some plans offered through Covered California came as a shock to many; around the country, even higher increases set off a hue and cry. It wasn’t long ago, however, that CAFP’s staff health insurance plan increased by 18 percent in one year. That was well before enactment of the ACA. Last year, our (non-public) plan premiums went up 10 percent. The trend line for premium increases before the ACA

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was even steeper than since its passage. That fact seems to have been lost in the shuffle. As we prepare for what might come, CAFP’s committees and Board will evaluate the ACA in its entirety to determine which provisions CAFP will fight to include in any health care reform proposal moving forward, whether the ACA is retained, repealed or amended. President-elect Trump has indicated he might keep some of the more popular provisions such as allowing children to remain on their parents’ insurance until they’re 26-years-old, a ban on denial of coverage because of pre-existing conditions and a ban on lifetime limits. The provisions that seem to cause the most upset about the ACA among its opponents are the individual and employer mandates. Without the mandates, however, the “popular” provisions will doom health plans to failure – why buy a health policy now if you’re not sick and can buy it the minute something bad happens to you? Without broad premium support from the healthy and the non-healthy, plans either collapse because they are top heavy with the very ill, or prices become unaffordable for all. Medical societies that sponsored health plans for members have experienced that in the past – only the least healthy, who could not migrate to other plans because of their pre-existing conditions, stayed in the plans while premiums went up and up until the plan either went out of existence or it was no longer affordable. Meanwhile, as we monitor the situation with the ACA and prepare to engage, we are looking for specific ways family physicians can spend more time with patients and less on useless administrative tasks, based on the belief that it is patient time that brings FPs joy. Your Board has approved the recommendation of the Legislative Affairs Committee that CAFP “… introduce legislation to improve access to care for patients by reducing unnecessary administrative roadblocks to care.” We are eager to hear from you on specific administrative burdens you believe could be relieved by legislative action – please let us know your specific recommendations at cafp@familydocs.org. In the meantime, the staff and I at CAFP wish you joy and good health in the New Year.


Leading the future of health care.

FAMILY MEDICINE PHYSICIAN OPPORTUNITIES Northern & Central California Many organizations have a mission statement; we have a calling: to lead the way to a better future for health care. Through our leadership in the use of advanced technology, our creation of innovative solutions and our influence on health policy and reform efforts, we are shaping the future of health care in the nation. Currently, we have opportunities available for Family Medicine Physicians in Northern and Central California.

FORGIVABLE LOAN PROGRAM - $150,000-$200,000 (based on experience) To demonstrate how much we value the role our Primary Care Physicians play, we’ve created a special incentive just for you. Available exclusively to Internal Medicine and Family Medicine Physicians, the Forgivable Loan Program is just one of many incentives we offer in exchange for your dedication and expertise.

LA SALUD PERMANENTE At The Permanente Medical Group, Inc. (TPMG), we practice a multi-lingual, culturally inclusive approach to care that celebrates the diversity of our patients and physicians. By developing medical programs that are in tune with every aspect of our patients’ lives—from the language they speak to the heritage they embrace—we are actively investing in initiatives and services that reflect the diversity of our member community. Here, our bilingual physicians can act as true advocates for their patients, delivering care that’s as medically advanced as it is culturally sensitive. Si su vocación y avocación son una y la misma, please join us today. TPMG is the largest multi-specialty group practice in the nation with over 9,000 physicians and an over 65-year tradition of providing quality medical care. We offer competitive salaries and a generous benefits package. For further details, please contact Gretchen Miles at Gretchen.H.Miles@kp.org or Aileen Ludlow at Aileen.M.Ludlow@kp.org. You may also call (800) 777-4912. Please visit our website at: http://physiciancareers-ncal.kp.org. We are an EOE/AA/M/F/D/V Employer. VEVRAA Federal Contractor.

http://physiciancareers-ncal.kp.org


CALIFORNIA ACADEMY OF FAMILY PHYSICIANS FOUNDATION 1520 PACIFIC AVE SAN FRANCISCO, CA  94109 -2627

Presorted Standard U.S. POSTAGE PAID

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Toni Brayer, MD Board of Governors

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Winter 2017