Summer 2017

California

VO L . 68 N O. 3 S u m m er 201 7

FAMILY PHYSICIAN st ron g

med i c i n e

in this issue ADDRESSING HEALTH DISPARITIES AND SOCIAL DETERMINANTS OF HEALTH PLUS, 2017 ACADEMY AND FOUNDATION AWARDS

f o r

Ca l i f o r n ia

Leading the future of health care.

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Nos apasiona nuestro trabajo.

En Kaiser Permanente, a nosostros los médicos nos encanta nuestro trabajo. Nuestra misión es servir a nuestros pacientes. Innovar, avanzar, ser inclusivos. Intégrate a nuestro equipo de atención de la salud, en apoyo a la comunidad.

LA SALUD PERMANENTE

At The Permanente Medical Group, Inc., 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.

FAMILY MEDICINE OPPORTUNITIES: Contact Aileen Ludlow at: Aileen.M.Ludlow@kp.org | (800) 777-4912 INTERNAL MEDICINE OPPORTUNITIES: Contact Bianca Davis at: Bianca.X.Davis@kp.org | (800) 777-4912 http://physiciancareers-ncal.kp.org

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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 Michelle Quiogue, MD

Susan Hogeland, CAE

FAMILY PHYSICIAN s tron g

Immediate Past President Lee Ralph, MD 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 AAFP Alternates Carol Havens, MD Jay W. Lee, MD, MPH 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

m e dic in e

for

C a l i f o r ni a

Quarterly publication of the California Academy of Family Physicians

Executive Vice President shogeland@familydocs.org

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

Pamela Mann, MPH

Program Manager pmann@familydocs.org

Sonia Kantak, MPH Manager, Medical Practice Affairs skantak@familydocs.org Elizabeth Lukrich

Manager, Communications and Social Media elukrich@familydocs.org

Shelly Rodrigues, CAE, FACEHP

pcipublishing.com Created by Publishing Concepts, Inc. David Brown, President • dbrown@pcipublishing.com For Advertising info contact Michelle Gilbert • 800.561.4686 ext 120 mgilbert@pcipublishing.com EDITION 23

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

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California Family Physician Summer 2017

California

Summer 2017

FAMILY PHYSICIAN s trong

medi ci ne

for

C al i fo r nia

features 20 Generational Voices

David Trần, MD; Brea Bondi-Boyd, MD

22 The Forum: From My First-time Attendee Eyes

Elizabeth Lukrich

24 Social Determinants of Health Give Rise to an Upstreamist 26 Family Physicians Gain Vital Patient Information by Understanding the Adverse Childhood Experiences (ACEs) Study

Pamela Mann, MPH Wanda D. Filer, MD, MBA, FAAFP

28 Integrating Public Health into Primary Care

Sonia Kantak, MPH

departments 6 Editorial

When America Was Great

Nathan Hitzeman, MD

8 President’s Message

Please Consider “The Parable of the Upstreamist”

10 Political Pulse

CAFP Again Wins Major Budget Battles

12 Legislative News

Health Care Reform in Tumultuous Times

14 Membership News

Extraordinary Students Are Accomplished Beyond Their Years

16 Awards

CAFP and CAFP Foundation Honor Outstanding Family Physicians

30 EVP Forum

Upstream Medicine: Another Form of Hot Spotting?

Michelle Quiogue, MD, FAAFP Carla Kakutani, MD Adam Francis Shannon Goecke

Susan Hogeland

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

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editorial

Nathan Hitzeman, MD

When America Was Great Expressions such as “upstreamism,” “cracks in the system,” and “social determinants of health” flow in this CFP issue like midnight tweets finding a paperbound home. It seems harder and harder to take in all of the complexity inundating health care, let alone our own personal lives. We need to harbor our boats together to weather this through.

I live in a flood plain next to the Sacramento River about 75 miles south of the Oroville Dam. The spillway sustained damage over the stormy winter; Orovillians were evacuated for impending crisis, then the evacuation was lifted, and now, most likely, another lengthy public works project will run over the amount of time and money budgeted to address what the Los Angeles Times called “design flaws, construction shortcomings, and maintenance errors.”

It’s hard not to think of the recently reopened Bay Bridge – outsourced work, allegations of fabricated safety testing, prefabbed sections from China with questionable welding, and corroded cables that weren’t covered in time. Everyone was responsible and no one was responsible.

As family physicians, we are ultimately the ones responsible for our patients’ health. This is not an easy job, and multiple factors work against us. Fragmented care, too much or too little care, tough upbringings, crappy food availability, substance abuse, lack of role models and educational opportunities plague a good many of our patients.

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California Family Physician Summer 2017

We can’t go home with our patients, teach them a trade, or make them a health pita pocket, but we can help them reactively and proactively with their health. We can support our professional organization in addressing the upstream issues of tobacco use, health care access, primary care reimbursement, obesity and social services that align with wellness. We can also mentor medical students to take our places when we have given our last breath for this cause.

My family and I visited the Hoover Dam in 2015.

It has been called one of the greatest public works projects in human history.

Completed two years ahead of schedule in 1936 during the Great Depression, staggered crews of men worked around the clock for five years to make a well-built, quality dam that continues to serve millions of peoples’ water, electricity and flood control needs. To tour the dam and see the pictures and video of the teamwork, coordination and choreography of the many cables and cranes is truly inspiring.

Our future is uncertain. The world has become a mess. Has America’s greatest time passed? Will my children live in a country with opportunity and prosperity? Should we just tune out and buy some legalized marijuana, or should we give a damn (dam?) and keep up the good fight?

Let’s give a damn, and not throw our kids’ future into the raging waters.

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.

“

Participating in CAFP and my local chapter enables me to feel connected to other doctors outside my clinic.

I always come away feeling renewed about our specialty and energized about the current challenges we are facing in Family Medicine.

Monique George, MD Family Physician at Kaiser Permanente Woodland Hills Assistant Secretary-Treasurer of the Los Angeles Chapter AMAM Delegate CAFP Member since 2014

”

in memory of

Randall Eden 11/21/49 - 06/16/17

PCI and CAFP are sorry to share the news of the passing of a true gentleman, valued colleague and friend. Randall has been with Publishing Concepts, Inc. for 18 years and has contributed a great amount to California and dozens of state AFP chapters. He will be greatly missed.

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California Family Physician Summer 2017 MC8000-212A.indd 1

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4/3/17 10:23 AM

p r e s i d e n t ’s m e s s a g e

Michelle Quiogue, MD, FAAFP

Please Consider “The Parable of the Upstreamist” Rishi Manchanda, MD, MPH shared this parable with us in his opening keynote presentation at our Family Medicine Clinical Forum this past April. Dr. Manchanda is president of an organization that provides quality improvement tools to mitigate the social determinants of health. Here is my retelling of the Parable of the Upstreamist: Three family docs are hiking together through a beautiful valley. This is not their first time on this path and they have hiked together for many years. As they approach the nearby stream, they realize the recent rains have turned the once babbling brook into a roaring rapid. And, to their surprise, the angry waters are filled with drowning people. Each doctor jumps into action to help these spontaneously discovered patients.

The first doctor reaches directly into the waters and pulls out victim after victim one at a time. Feeling overwhelmed and nearly hopeless as more and more people come downstream, the doctor looks over for assistance and discovers the second doctor working a short way upstream.

The second doctor is building a raft – a complex and integrated system to bring more than one patient at a time to safety. Thankful that the first doctor is there to rescue those who fall through the holes in the system, the second doctor looks around for the third doctor and cannot find her. After a long time of struggling, the people stop streaming down in overwhelming numbers.

The third doctor finally returns to the exhausted friends.

“Where did you go? What have you been doing while we were here handling this crisis?” they asked.

“I went all the way upstream to find out why all these folks were falling into the water in the first place,” said the third doctor.

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California Family Physician Summer 2017

For me, this parable is a reminder that more good can be done outside of my exam room and health care organization.

Can you relate to these doctors? It is likely you have acted in each of these three roles at some point, depending on the problem.

Perhaps you have experienced each of these roles in various episodes of your career. Perhaps your curiosity is calling on you to choose a new role. Perhaps you have always known it was your purpose in life to become an Upstreamist.

Family medicine is the specialty of context. We are dedicated to providing high quality, evidence-based, person-centered care with attention to the context of our patients’ lives and communities.

In many ways, family physicians are called to be Upstreamists in order to find meaning during our careers. The Parable of the Upstreamist also tells us that, because none of us can be in more than one place at once, we depend on one another to make a difference in the health of our communities.

If our shared goal is to achieve optimal health for all, then we cannot act just as individuals but must also act as a collective.

Through my experiences with the CAFP and AAFP, I have come to appreciate that membership in the Academy is much more than continuing medical education (CME) or advocacy or practice support. The value of the CAFP and AAFP professional staff who work daily to champion family medicine, making it possible for each of us to advocate for our patients beyond the confines of our exam rooms, is immeasurable (yet certainly worth more than $70 a month in member dues). Membership extends our influence to the upstream determinants of health such as public health policy, maintenance of safe environments and fair access to health care.

We know that none of us can avoid the inevitable. In some sense, aren’t we each rowing our boat “gently down the stream merrily, merrily, merrily, merrily; life is but a dream?” While I am not certain how far this river will take me, it brings me hope and peace to know that the next FM generation will join you, Upstreamist family doctors working in every corner of our state, to do the most good for the most people.

HunGER kEEps up On cuRREnT EVEnTs, TOO.

Southern California Permanente Medical Group

The Answer to Health Care in America

Family Medicine & Urgent Care Opportunities in Southern California The future of health care is happening today at Kaiser Permanente Southern California. By pursuing new breakthroughs, promoting proactive care and employing innovative technologies, we’re giving our physicians the tools they need to create a healthier tomorrow for everyone. As part of our practice, you’ll be working in a progressive environment that encourages cross-specialty collaboration, professional autonomy and work-life balance.

Kaiser SCPMG is proud to offer its physicians:

1 in 6 amERicans sTRuGGlEs WiTH HunGER.

• An organization that has served the communities of Southern California for more than 60 years • A physician-led practice that equally emphasizes professional autonomy and cross-specialty collaboration • Comprehensive administrative support • An environment that promotes excellent service to patients • A fully implemented electronic medical record system • An excellent salary, comprehensive benefits and partnership eligibility after 3 years

TOGETHER WE’RE

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

For consideration or to apply, please visit our website at http://scpmgphysiciancareers.com.

For questions or additional

information, please call (800) 541-7946.

We are an AAP/EEO employer.

Visit Feedingamerica.org today.

California Family Physician Summer 2017

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political pulse

Carla Kakutani, MD Chair, Legislative Affairs Committee President, Family Physicians Political Action Committee (FP-PAC)

CAFP Again Wins Major Budget Battles For a second straight year, the California State Budget played a major role in the health of all Californians and family medicine residency programs. CAFP and our advocacy partners won several major achievements, protecting $100 million in primary care residency funding and increasing Medi-Cal provider payment for the first time in decades.

CAFP had tremendous success in 2016 in securing $100 million in the State Budget to support the Song-Brown Physician Training Program, which funds primary care residency programs in underserved areas who provide care for underserved population. CAFP was also successful last year in convincing voters to pass Proposition 56, which increased the tax rate on cigarettes and tobacco products by $2 – from 87 cents to $2.87 per pack of cigarettes – to support both an increase in Medi-Cal provider payment rates and primary care residency programs. Unfortunately, the Governor’s 2017 budget proposal sought to redirect all of this money into the General Fund instead.

Thanks to the incredible grassroots advocacy of the CAFP Residency Network, CAFP Key Contacts, our Government Relations team and advocacy partners in Sacramento, the Legislature rejected the Governor’s proposals on both fronts and passed a State Budget that increased Medi-Cal physician payment and saved last year’s $100 million allocation to the Song-Brown Physician Training Program.

1) $100 Million in Song-Brown Physician Training funds.

When Governor Jerry Brown released his 2017-18 State Budget proposal in January and its revision in May, both included provisions to eliminate nearly $1 billion in not-yet-spent one‑time funds passed as part of last year’s budget agreement. This includes rescinding the $33.4 million appropriation ($100 million total over three years) that was intended to support the Song-Brown Physician program. Family medicine residency programs have already lost more than $55 million in state, federal and private grants. This cut would have caused programs in underserved areas to close, or at the very least, significantly reduce the number of physicians they train. The remarkable grassroots advocacy of our members and Government Relations team in Sacramento convinced the Legislature to reject this cut.

2) $1+ billion in Proposition 56 funds to improve access to care for Medi-Cal patients.

CAFP fought hard to ensure the passage of the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 (Proposition 56) – 10

California Family Physician Summer 2017

drafting language for the initiative, gathering signatures to qualify it for the ballot, raising and contributing money for the campaign and participating in get-out-the-vote efforts. CAFP celebrated its passage in November 2016, knowing that the increased tax rate would decrease smoking rates and raise funds to increase access to care for Medi-Cal patients. The Governor is instead sought to use the funds on “growth in Medi‑Cal expenditures,” or put simply, to augment the General Fund.

After significant pressure for the physician community, the legislature reached a compromise with the Governor that ensures the vast majority of these funds will be used to increase access for Medi-Cal patients and improve the program’s dismal payment rates, including: • $325 million for physician provider payments • $140 million for dental providers payments • $50 million for family planning providers • $27 million for care for the developmentally challenged • $4 million for HIV/AIDS care While CAFP appreciates that the Budget rejects the Governor’s original proposal not to use any of the funds to improve payment rates, we note that the allocation above is less than originally intended under Prop 56. CAFP will closely monitor whether this appropriation adequately encourages physicians to increase their Medi-Cal panels.

3) $40 million in Proposition 56 funds to increase primary care residency funding.

CAFP was instrumental in inserting language into Proposition 56 that transferred revenue from the increased tobacco taxes to support primary care residency funding. Prop 56 stipulates that $40 million annually shall be used to increase “the number of primary care and emergency physicians trained in California.” The funds will be administered by the University of California, but are open to all eligible primary care programs that serve “medically underserved areas and populations.”

We cannot thank enough all the Key Contacts, CAFP members, Family Medicine Residency Programs, residents and students who took action to make your voice heard and push for CAFP’s priorities. Please contact your legislators and thank them for sending the Governor a budget that supports primary care.

And, of course, thank you to all our members who fight on behalf of patients and all family physicians every day!

FOR SOME OF OUR MOST ELITE SOLDIERS, THE EXAMINATION ROOM IS THE FRONT LINE. Becoming a family medicine physician and officer on the U.S. Army health care team is an opportunity like no other. You will provide the highest quality health care to Soldiers, family members, retirees and others, as well as conduct medical research of military importance. With this elite team, you will be a leader – not just of Soldiers, but in family health care.

See the benefits of being an Army medical professional at healthcare.goarmy.com/hb76 To learn more about the U.S. Army health care team, call 310-216-4433.

Š2016. Paid for by the United States Army. All rights reserved.

California Family Physician Summer 2017

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

Adam Francis CAFP Director of Government Relations

Health Care Reform in Tumultuous Times This year has been a roller coaster of health care policy and advocacy. Guided by our policy on how a health care system should operate and policy provisions it should include, as well as requests from the American Academy of Family Physicians (AAFP) for localized help, CAFP has been heavily involved in the national discussion on repealing the Affordable Care Act (ACA) and proposed plans for its replacement.

In fact, a delegation of 12 CAFP members just returned from Washington, DC to assist AAFP in its advocacy efforts as part of the 2017 Family Medicine Advocacy Summit.

Our delegation met with 13 Congressional Representatives’ offices, including Minority Leader Nancy Pelosi’s (D – San Francisco) and Majority Whip Kevin McCarthy’s (R – Bakersfield). We also met with staff for Senators Dianne Feinstein and Kamala Harris.

Since the introduction of the ACA, which CAFP supported, we have acknowledged and worked to address its flaws, and we have worked aggressively in our own state to implement its provisions that directly improve the lives of patients and family physicians, including expanded Medi-Cal eligibility, numerous patient protections, the creation of a health insurance exchange, a more than 10 percent increase in primary care provider payment by Medicare and the nearly 50 percent increase for two years in Medi-Cal.

their coverage canceled based upon a current or pre-existing health care condition, age, family history, disability, race, gender identity, sexual orientation, immigration status, income or place of residence.

Patient protections should be maintained and expanded: Every individual’s insurance should cover (with no out-of-pockets costs) evidence-based essential benefits, including primary and preventive care. Annual and lifetime caps on benefits must be prohibited. Prescription drug and mental health services must be covered equivalent to physical health services. Patients must have access to comprehensive primary, preventative and wellness care services (including diagnosis and treatment of acute and chronic illnesses in a variety of health care settings), as well as ambulatory, laboratory, emergency and hospital services, vaccines, reproductive and women’s health services, disability services, palliative and hospice care.

Increased investment in primary and preventive care must be made: The investment in primary care must be significantly increased, including preventive health services, mental health, public health, health services research, and innovations in health

Though debate on health care reform has now shifted to the Senate, CAFP and AAFP’s message remains clear and consistent: Health insurance coverage should be maintained and expanded: Currently insured individuals must not lose their coverage and access to health care insurance should be universal and continuous.

Individuals should not be denied health care coverage or have

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California Family Physician Summer 2017

CAFPers stormed DC, from left (up and down): Drs James Suchy, Glen Stream, Anne Montgomery, Christie Thomas, FP-PAC President Carla Kakutani, Po-Lin Samuel Huang, Melissa Campos, Rick Gardner, CAFP President Michelle Quiogue, Frank Aliganga, Robert Bourne, medical student Mhy-Lanie Addura, and CAFP’s Adam Francis.

AHF care delivery, including continued support and funding for the Centers for Medicare and Medicaid Services, Center on Medicare and Medicaid Innovation, and the Agency for Healthcare Research and Quality.

The individual insurance market must be stabilized: Premium and cost-sharing subsidies must be sufficient to make coverage affordable and accessible, especially for vulnerable patients like children and adults with special health care needs, people with mental health and substance use disorders, the elderly, and low-income individuals and families. The value of current subsidies should not be eroded.

Safety net programs must be protected: The more than 20 million individuals and families covered in states that have expanded Medicaid or purchased qualified health plans offered in the exchanges should have uninterrupted coverage and benefits.

Potential changes in federal Medicaid funding should not erode benefits, eligibility, or coverage compared to current law. The Children’s Health Insurance Program (CHIP) must be reauthorized and guaranteed sufficient funding.

Unfortunately, health care policy has become an exceedingly partisan issue. Voices of moderation and bipartisanship repeatedly have been shut out of the conversation.

What we are left with is a policy pendulum that swings wildly from side to side, depending on which party is in power. Smart policy provisions are discarded in favor of ideological purity or aggressive political messaging. Instead of widespread support by constituents and organizations, we have bills that pass by fewer than two votes with no organizational support.

CAFP will continue to do its part to inject real policy solutions into the discussion and push for reforms to our health care system that benefit patients and primary care, regardless of the political party in power.

AIDS HEALTHCARE F OU N DAT ION

AIDS Healthcare Foundation (AHF), was founded in 1987 and is the largest specialized provider of HIV/AIDS medical care in the nation. We provide cutting edge medicine & advocacy regardless of ability to pay.

Primary Care Practitioners Needed in California AHF is seeking dedicated full-time Family/Internal Medicine Practitioners (MD/DO/RNP) Hollywood, CA - https://careers-aidshealth.icims.com/jobs/6355/physician--hollywood/job

Experience/Educational Requirements: 1. Must possess a State Medical Board license MD/DO in Internal/Family Medicine.

2.

(without restrictions)

3.

3+ years recent experience treating and diagnosing HIV/AIDS clients in an outpatient Primary Care Setting.

Candidates will be required to obtain DEA furnishing licenses.

4.

5.

Must obtain AAHIVM Certification within 18 months of hire.

Current CPR (Cardio Pulmonary Resuscitation) required.

(without restrictions)

Base Salary with Retention/Productivity Bonus, Relocation Assistance, On-Call Schedule 5 Weeks Per Year, 28 Days PTO Annually, CME Stipend, 401K, Liability Coverage and Comprehensive, Loan Repayment Plan. We sponsor H-1 Visas

Email: Miyoshi.LaFourche@aidshealth.org • Telephone: 310-999-6089

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 Summer 2017

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Shannon Goecke

Director, Membership and Member Services

membership news

Extraordinary Students Are Accomplished Beyond Their Years Earlier this year, I shared inspiring stories of some of our senior members – including a decorated WWII paratrooper who cheated death at Battle of the Bulge and the first African American doctor to open a practice in San Mateo, in a three-story Victorian where he still sees patients today at the age of 94.

In this issue, I want to highlight a few of our youngest members, whose dedication and accomplishments are equally impressive.

Ridwa Abdi UC Davis School of Medicine Class of 2017, begins UCLA Family Medicine Residency Program July 2017 Ridwa Abdi and her twin sister Farah are the youngest of 12 children, born in Somalia in the early days of the Somali Civil War. When the twins were three years old they fled intense violence, crammed into boats for the journey to Kenya.

As young as they were, they had a sense of how lucky they were to get out. Three years later, they made the move to the Bay Area, where one of their older siblings had obtained legal residency.

Ridwa and Farah will be reunited this summer at UCLA, where they matched for residency – Ridwa in family medicine and Farah in internal medicine. Eventually, they both hope to return to Somalia or eastern Africa to open a medical clinic, where patients can learn how to better manage their chronic diseases such as diabetes and hypertension. Though we don’t look forward to her leaving California, we are enormously proud of Ridwa’s achievements and ambition.

Arunima Kohli Stanford University School of Medicine Class of 2017, begins UC Davis Family Medicine Residency Program July 2017

Ridwa and Farah were the first of their siblings to go to college, ending up on similar paths simply because they both like the same things. They completed their undergraduate degrees at UC San Diego – Ridwa in Microbiology and Farah in Human Biology, followed by graduate degrees in African Studies (MA) and Public Health (MPH) from UCLA. It was as a freshman undergrad that Ridwa discovered family medicine after hearing a talk by Doctors without Borders. As she learned more about the various specialties, her commitment to family medicine grew because it would enable her to “do the most good for the most people.”

Before she knew she wanted to practice medicine, soprano Arunima Kohli knew she loved to sing. She was born and raised in New Jersey, where she participated in her schools’ choruses and musical theatre performances. Her family relocated to Palo Alto when she was in high school, where she began her classical training. She sang with several of the award-winning choirs at Palo Alto High School, and excelled academically as well. She even performed the National Anthem (with two other students) at her graduation ceremony before heading to Stanford, where she majored in Biology and minored in English.

Ridwa and Farah separated for medical school; Ridwa headed to UC Davis and Farah went off to UCLA. Ridwa is currently a student codirector on the CAFP Board of Directors, which she joined in part to better develop her advocacy skills. “The biggest challenge is to figure out how we can be advocates for our patients, which is why we went into medicine in the first place.”

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California Family Physician Summer 2017

It was as an undergraduate at Stanford that she began training with renowned mezzo-soprano and voice teacher Wendy Hillhouse, with whom she is still working today. She has performed with a number of ensembles while at Stanford, including the Stanford Chamber Chorale and the Stanford University Singers. She has also been active in theater, notably with the Stanford Savoyards, and more recently with Stanford Light Opera Company (SLoCo), playing the title role in

FAMILY MEDICINE/OB/GYN MEDICINE

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SLoCo’s production of The Ballad of Baby Doe this past February.

Arunima is now in her fourth year of medical school at Stanford, where she is doubleconcentrating in Biomedical Ethics and Medical Humanities and the Molecular Basis of Medicine. As a medical student, she has been an active member of the Stanford Music and Medicine Network (SMMN), which invites musicians and music lovers to come together and share music, as well the medical school’s annual “Medicine and the Muse” event. Founded in 2000 by Audrey Shafer, MD, professor of anesthesiology, perioperative and pain medicine, Medicine and the Muse highlights the artistic talents of medical students through performances of song, dance, music, poetry, and exhibits of artwork, photography, and film.

Earlier this year, Arunima conceived and performed the recital Body Parts: Musical Reflections on Medicine, an original vocal program highlighting various topics in medicine. The diverse program consisted of six sets, each built around a different idea related to medicine, including madness, AIDS and the physician as composer. It included compositions by Russian physician-composer Alexander Borodin, Richard Strauss’s triptych of Ophelia’s songs from Hamlet and selections from The AIDS Quilt Songbook, to name but a few. Her selections not only showcased her singing voice, but also her expansive knowledge of music and literature.

The next step on Arunima’s journey will be in Sacramento, where she’ll complete her residency at UC Davis’s Department of Family and Community Medicine. She was inspired to specialize in family medicine by the example set by her mentors, including Dr. Tracy Rydel, and because she liked the idea of getting to know and take care of everyone in a family long-term. She is particularly drawn to UC Davis family medicine residency program for its emphasis on preparing family physicians for careers in academic and community teaching settings, and hopes to teach in the future.

CAFP has amazing members in their 90s, in their 20s, and every age between. You don’t have to take my word for it, dear reader – just take a look in the mirror.

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California Family Physician Summer 2017

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awards

CAFP and CAFP Foundation Honor Outstanding Family Physicians Each year CAFP and CAFP Foundation honor outstanding members who represent the finest characteristics of the specialty and are directly and effectively involved in public service and activities that enhance the quality of life in their communities This year we are pleased to honor four family physicians who have gone above and beyond. They are shining examples. Congratulations to each of them.

“It is a privilege to be a family physician. We get to share in people’s lives in a way few people do. Our patients tell us things they might not tell anyone else – even if we are not always sure we want to hear it!” said Dr. Havens during the award ceremony.

“I am honored and humbled to receive this award, especially as I look at my colleagues who are here and those who aren’t. All of you are family physicians of the year, every year, to your patients, your family and on behalf of all the work you do through advocacy, education, community involvement in support of family medicine, the family of medicine and the family of mankind.

No one succeeds in this work alone; actually, I believe no one succeeds in life alone, so there are some I must thank.

2017 Family Physician of the Year Carol Havens, MD It has been written of Carol that she masterfully combines the scientific evidence that underpins her subject matter with practical management, diagnostic and therapeutic considerations. She consistently demonstrates enthusiasm, professionalism and initiative.

She leads from the lectern, the board table and in front of the media’s cameras. She is also caring and compassionate. Her message simultaneously challenges and supports physicians, patients, policy makers and the public. These traits allow her to communicate a love of our specialty. The end result is that physicians are inspired and enthusiastic about the messages she teaches and speaks. We have listened to many individuals comment on her skill as a teacher and a leader, but have been most impressed by how she inspires all of us to do and be our very best.

Dr. Havens exemplifies the pivotal leadership needed for crossgenerational and cross-organizational collaboration that is fundamental to the creation of medical homes throughout our state now and into the future.

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First, the Academy, which includes not only all of you, but also the best academy staff anywhere. It is no surprise they are working with family physicians, as they share the same mission-driven spirit of family physicians. I am sure that in another life, they either were, or will be, family physicians. Although I have been a member of the Academy for more than 30 years, I didn’t become active until 20 or so years ago. One of my regrets is that I didn’t get involved sooner. For all you students, residents and new members, don’t just be a member, get involved! You have much to offer the Academy and they have much to offer you.

Second, my Kaiser Permanente physician education team, some of whom are here today. I get to work with such talented, creative, smart, dedicated and passionate people that coming to work is a pleasure.

Finally, the person who has been with me for decades, for most of my career. Who has loved me, supported me, encouraged me and always makes me want to be the best physician and person I can be, and who is willing to tell me when I am not, my wife, Jessica.

Thank you.”

Congratulations, Dr. Havens!

2017 Family Medicine Resident of the Year Laura Doan, MD The CAFP Foundation bestowed its first Resident of the Year Award on a resident who represents the finest characteristics of family medicine, including a commitment to leadership, communication, mentorship and advocacy in 2010. The winner of this award is selected based on nominations presented by the Medical Student and Resident Leadership Councils.

of Ubuntu, which roughly translates to “I am what I am because of who we all are.” You see, what makes me special are the unique interactions and relationships I’ve developed with the people I’ve met along my life journey.

These are the people who shaped me into what I am today.

I have my dad’s work ethic, my mom’s extraverted energy and my brother’s goofiness.

I have a little bit of Adam Francis’ passion for advocacy, a smidgeon of Susan Hogeland’s incredible organizational leadership and a lot of Shelly Rodrigues’ voice for liberalism. I surround myself with passionate people, people who believe insane things can be done and who motivate me to make the impossible possible.

The 2017 award is presented to Laura Doan, MD, Kaiser Los Angeles Family Medicine Residency Program. Laura has served as a student and resident leader at the CAFP, actively engaged in advocacy, planning for the Family Medicine Summits, serving as a delegate at the National Conference for Residents and Students and encouraging her peers to get involved.

“I am deeply humbled to be selected as Resident of the Year and would like to thank the CAFP Foundation for this honor,” said Dr. Doan. “I would also like to thank a few individuals who made this possible, including Dr. Dan Pio, my colleague and friend, and Dr. John Su, my program director and friend, for their nomination. Thanks to Matt Varallo, DO, my resident co-director, for being my partner in crime the past four years. And thank you to my family for supporting me in my many, crazy ambitions.

When I read the letter from the Foundation saying I had been selected, the first thought that came to mind was, ‘Why me?’ I know hundreds of colleagues who have accomplished amazing feats during their time in residency. What makes me, my story, stand out from the crowd? I could chalk it up to Drs. Pio and Su’s letter being so mind-blowing that they sealed the deal, but I think the answer goes deeper.

As some of you may know I was recently in Cape Town, South Africa for a medical service trip. While there, I was introduced to the philosophy

That is the essence of Ubuntu. To paraphrase President Obama at Nelson Mandela’s funeral, ‘Ubuntu captures Mandela’s greatest gift: his recognition that we are all bound together in ways that are invisible to the eye, that despite our unique skills and strengths, there is still oneness to humanity, that we achieve ourselves by sharing ourselves with others, and caring for those around us.’

So, here at the Family Medicine Clinical Forum, let’s learn about the new topics in family medicine to improve our clinical practices, but let’s also learn from one another. Ask your neighbor to share his or her story and be inspired by another’s passion about work, life and the people they love. Let them transform the way you think, give you new ideas and get you fired up. Because if you surround yourself with big dreamers and creators, the results will be exponential. Thank you for this award, and for letting this young millennial ramble a bit about her musings on life.

Ubuntu!”

Congratulations Laura!

2017 Barbara Harris Award for Educational Excellence Lance Fuchs, MD This award recognizes educational excellence in the field of family medicine. The Barbara Harris Award was established in 1984 to honor the late Ms. Harris, a former Executive Director of CAFP. The award was renamed, with an enhanced focus, in 1996. The Award for Educational Excellence in Honor of Barbara Harris highlights achievements in education, a field very important to Ms. Harris.

Our 2017 winner is Lance Fuchs, MD. Lance has all of the qualities of a great educator. He is an outstanding clinical teacher. He works with residents and students in numerous settings. He does scholarly projects and teaches his physician colleagues. He is a community leader and activist. Lance has a long list of accomplishments, but what sets him apart is his amazing skill, passion and enthusiasm as a teacher.

“I am greatly humbled and honored to be receiving this award, and would like to offer my sincerest gratitude to the CAFP Foundation for selecting me and to my home chapter, the San Diego AFP, for nominating me,” said Dr. Fuchs.

“I did not make the journey here alone. Numerous people have supported me Continued on next page >

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along the way. I would like to thank my friends and colleagues at Kaiser Permanente San Diego Family Medicine Residency for allowing me to fulfill my dreams as a teaching physician and as a leader. I would like to thank my wife and children for all the sacrifices that they make when I am working so much.

Role models are critical for all of us to grow and develop. I would like to thank my parents and my high school teacher, Jim Johnson, who taught me to be a community-oriented person And I would like to thank two amazing family physicians, Dennis Gingrich at Penn State and Jimmy Hara, who was my residency program director at Kaiser LA. They showed me the beauty of family medicine.

I would like to use my time with you to celebrate all of OUR accomplishments. This is such an important and exciting time in our history as family physicians. With the introduction of the Affordable Care Act, our entire country recognized the great work of family physicians as never before. You do amazing work. You take care of CEOs and the homeless. You are there for your patients when they are scared, vulnerable and alone. You take care of young and old, men, women and children, and some of you deliver babies. You take care of athletes and students, the disabled and refugees. You care for and about people regardless of race, religion, citizenship or immigration status. You care for and about people regardless of sexual orientation or gender identity. You just care! You treat them with love, patience and respect. These people are our families, our neighbors and our friends. I am so proud to be part

of this family … the family of family physicians.

Our patients’ health and well-being is being threatened by the new administration. Let’s all stand together for what is right, for human rights, for access to food, housing, a safe place to live and access to health care.

We are community leaders; we are advocates. Please stand with me and other family physicians to be the voice of our patients, our communities, and our profession. Please stay involved through community service and involvement in the CAFP. Call your elected representatives to share your views and your needs. Let’s be proactive for the future we desire.

I stand before you today because, like you, I care about people. I love to teach and to learn. I am willing to step forward when an opportunity arises to make a difference. My students and residents help provide me perspective and remind me that all of the sacrifices I make, and you make, are worth it.

I want to again say how grateful I am to receive this award, especially knowing that I work with so many other amazing people every day in my residency and through my involvement at San Diego AFP chapter and CAFP. I am equally grateful for the opportunity to be a physician educator. I consider it an honor to work with bright enthusiastic medical students and residents, who I know will make the world a better and healthier place.”

Congratulations, Dr. Fuchs.

2017 Hero of Family Medicine Tim Munzing, MD This award goes to a CAFP member who has gone above and beyond the call of duty to advocate for patients, colleagues and the family medicine specialty. It is presented during the All Member Advocacy Meeting in March. This year’s winner of the California Academy of Family Physicians “2017 Hero of Family Medicine Award” is Tim Munzing.

Tim Munzing is the Residency Director of the Kaiser Permanente Orange County Family Medicine Residency program.

“Tim is one of the most responsive members I’ve ever encountered at my

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time with CAFP,” said Adam Francis, CAFP Director of Government Relations. “I’ve called him 15 minutes before a committee hearing to shore up talking points or get his unique perspective on residency training, and he always makes himself available to take my call and help in the effort.” As anyone who has attended CAFP Lobby Day knows, Tim makes sure advocacy is both inside and outside the exam room. He is known for making strong, lasting connections with his local politicians. He has attended countless fundraisers and advocacy events in his region, frequently acting as CAFP’s representative at receptions hosted by Californians Allied for Patient Protection, the state’s leading professional liability Medical Injury Compensation Reform Act organization. CAFP’s Executive Vice President Susan Hogeland said, “Personal ideologies and politics obviously vary among our more than 9,800 members, but Tim puts patients and family medicine first in his advocacy.”

Those of us who have worked with Tim for many years have witnessed his efforts to support the specialty and improve the lives of those in his community. His efforts to grow and strengthen the family physician community through education, advocacy and leadership make him a true family medicine champion and our 2017 Hero of Family Medicine.

Congratulations, Tim.

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generational voices

health disparities and social determinates

David Trần, MD; Brea Bondi-Boyd, MD

images confirmed an aggressive cancer far worse than I expected. The news rattled me. I called my attending and we looked at the results together in silence. No words can explain the feeling when you realize a patient has fallen through the cracks. No words can explain when the health care system let someone down.

“There is absolutely no good reason this should have happened.”

We have had this conversation before. I imagine permutations of this scenario playing out in primary care clinics and emergency rooms all over the country. Variations on a theme: A late finding due to inadequate screening, a lack of access to care, financial instability leading to poor health outcomes, the devastation of cancer.

David Trần, MD / Millennial “I have a lump.”

Residency taught me a few principles about health care. One, that our disjointed health care system does not work unless we make it work, both for ourselves and our patients. Two, that our most vulnerable patients are the ones who need us most. Three, those patients do not have a voice in our health care system unless we make them heard.

We have heard these words before. A woman sits on an exam table across from me, the words barely escaping her mouth, muffled as she begins to break down in tears. I stop typing, I sit down, and her story unfolds. The lump has been there for months. She noticed it growing as the shape of her breast changed. She feels pain at night and recently a bruise started to form. She has lost weight.

As a family physician, I see a tremendous opportunity for advocacy as the debate over the American Health Care Act looms. Our core values of family medicine are under attack: The social determinants of health, access to basic medical care, maternity care, the validity of immunizations and many other important preventative services that save lives every single day.

It has been years since she was last seen by a physician and she is listed today as a new patient. In our system, she hasn’t existed until now. She recounts a history of lumps and breast biopsies years ago at another facility and somewhere I imagine another physician wondering what happened to her patient. I cannot help but ask what caused her delay in care.

I want Congress to hear my patients. I need them to understand this is more than partisan politics; for millions of Americans, it is the difference between life and death. We need to speak out, not only for ourselves, but also for our patients and our communities. Whether the Affordable Care Act changed your practice for better or worse, now is the opportunity for us to shape the fabric of health care in our country.

“I didn’t have insurance.”

As I near the end of residency, I remain optimistic about the future.

An entire generation of residents, thousands of newly-minted family physicians, trained during the implementation of the Affordable Care Act. We are a generation prepared for constant change, transformation and innovation. Every year I meet more and more students who express interest in health policy in addition to clinical medicine. Instead of resignation or disappointment, I hear questions like, “How can I make a difference?,” “To whom should I speak?,” and “What do I need to learn?” The message I hear all around is clear: Our patients need us more than ever.

Her insurance lapsed after she lost her job more than a year ago.

Her financial struggles meant having to forego her health in order to find a job, and having only recently gotten back on her feet, it was time to be seen again. Her exam was not reassuring. After ordering a mammogram with plans for biopsy, I called the imaging center to make sure she didn’t have a wait she couldn’t afford.

Days later, I received an urgent message with biopsy results. The

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indicate dengue or risk for dengue-spreading mosquitos. For families with members with chronic disease such as diabetes, we checked on their access to fresh fruits and vegetables. For socially isolated older adults, we encouraged them to join the tai chi groups held in each neighborhood park in the early mornings. We visited patients’ work places to monitor environmental hazards. We visited schools regarding safety for children.

Brea Bondi-Boyd, MD/Generation X Under the warm Caribbean sun, sweat beads forming on my upper lip, my white, short-sleeved bata sticking to my back, I climbed the stairs to another set of apartments clustered together in central Havana. As part of our family medicine rotation, which was longitudinal and part of each rotation during medical school, we were doctors armed with public health tools assessing our community. Tasked with making house calls, we assessed families we had risk-stratified as high need. This day we were looking for cases of fever and free-standing water that might

Back in Contra Costa County, where I completed my family medicine residency and continue to work in primary care, I have been lucky to find an organization (and a safety net health plan) that is not so different from Cuba. We are encouraged to look up stream to solve health problems. We have a department of health equity that directs our improvement efforts to reduce disparities as we aim to improve diabetes and hypertension by changing our approach for more vulnerable groups. We have partnered with organizations like Health Leads to screen for social determinants and direct resources targeted to specific patient needs. As champions for our patients and the biopsycho-social model, the administrative (and political) will to change our patients’ social determinants to improve their lives and health outcomes is highly visible. Even though I rarely go door-to-door these days, I hope I am still opening doors to the resources for those who most need it.

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health disparities and social determinates

Elizabeth Lukrich CAFP Manager of Communications and Social Media

The Forum: From My First-time Attendee Eyes As a first-time attendee at the Family Medicine Clinical Forum in April, I was awed by how presenters and audience members alike opened up to share their personal narratives that embody family medicine. The Forum went beyond the communal sharing of information – it brought physicians together to share what makes family medicine family medicine: the stories, memories, mistakes, best practices and hard work of family physicians. This act of sharing, openly and wholeheartedly, created a unique and enthralling atmosphere that encouraged reflection on how stories of family medicine connect physicians across California.

On the first day of the Forum, our newly elected CAFP President, Michelle Quiogue, MD, FAAFP (below), stood in front of the audience to share the stories of her patients, the stories she has created by practicing family medicine, how our communities and colleagues are stories and that, “there is power in stories; in listening to them, in telling them, in taking them to heart and in learning them.” Dr. Quiogue called on the audience of family physicians to tell their own stories – and the beauty of the Forum is that it gave many physicians a chance to do just that.

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hearted, resonated with me through its power to tell an unfortunate story in a positive light: We all make mistakes, but what’s important is what we do next – do we shy away in disappointment or take a bow for trying? Dr. Fu also shared the story of her own journey through family medicine; the ups, the downs, the mistakes and the triumphs. She conveyed that a story may never be perfect, but it makes us who we are and can be positive if we understand how to learn from it and make the best of our mistakes.

Later that afternoon, Kristy Lamb, MD (above) told a moving story of the everlasting bonds she formed with her patients, the pain of losing them, and the beautiful, tragic power of family medicine to enable her to form those bonds. Her presentation covered suicide, assessing risk factors and creating an effective treatment plan, and didn’t require her to divulge personal, heartfelt stories that were true and significant to her, yet she chose to do so. She realized, as Dr. Quiogue encouraged, the power in her story to share a memory and portray the significance these stories have in our lives and in family medicine. In particular, Dr. Lamb’s story struck me because it showed the raw, emotional and resonating power of family medicine to connect with patients in ways that only family physicians can.

Another physician whose story-telling stood out to me was Belinda Fu, MD, (right) who concluded the Forum with her presentation on the ability to accept, celebrate and find personal solace in the moments when physicians make mistakes. She encouraged, and actually requested, her entire audience to receive a round of applause whenever they made a mistake, as an expression of admission and ownership of their blunders. Her presentation, while humorous and light-

Every family doctor has a story, a story that makes them them; that intertwines their everyday into a life and reaches across years, even generations, to represent themselves. What the Family Medicine Clinical Forum does is give family physicians from across the state and the country the opportunity to come together and share their stories.

Each patient, physician, colleague and stranger, no matter how similar or different, has a story. What it did for me was open a window into the world I joined when I started my job here at the Academy, and it’s given me a great view of the family physicians, residents and students I’m serving.

When will you share your story?

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h e a l t h d i s p a r i t i e s a n d s o c i a l d e t e r m i n a t e s

Pamela Mann, MPH CAFP Program Manager

Social Determinants of Health Give Rise to an Upstreamist It is well known that social factors influence health. For more than a decade, the World Health Organization, Centers for Disease Control and Prevention and Robert Wood Johnson Foundation have provided frameworks to help us conceptualize and understand how social determinants, such as housing, education, employment and food access affect health. The message is a rather simple one: health starts where we live, learn, work, play and age – not at the doctor’s office.

During the opening session of the 2017 CAFP Family Medicine Clinical Forum, keynote speaker, Dr. Rishi Manchanda began his address with the common public health parable, “The River – Upstream,” a powerful narrative that emphasizes the need to address root causes of health problems and not just symptoms. He urged the family physicians in the room to look beyond managing

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and treating conditions, and to move further upstream to see the source and factors influencing them. Social factors account for 60 percent of premature deaths, and while more than 80 percent of clinicians understand this, only 20 percent feel confident addressing these issues.

Upstream medicine calls on clinicians to understand and address the social context of disease in order to improve health outcomes.

Physicians must use robust needs assessment tools and build nonmedical partnerships with community-based organizations so patients can access appropriate resources. The most important questions during an exam can be the “whys” and the “wheres,” and with this different way of looking at health care, Dr. Manchanda says, “Get ready, get set, and go upstream!”

For Victoria Boggiano, her journey upstream began after college during a trip to Hanoi, Vietnam with Save the Children. She was working on a HIV stigma reduction project, and she describes the experience as one in which she got more than she was able to give.

While her expertise was limited at the time, it was here that she realized the power of asking questions. Before this trip, she knew she wanted to become a doctor. As a volunteer at a Federally Qualified Health Center and the daughter of two physicians, she was already in love with primary care medicine.

At Stanford University, Victoria enrolled in the Scholarly Concentration in Community Health and completed a Master of Public Health degree after her third year in medical school. This 11-month interdisciplinary public health training included courses in social and behavioral health, environmental health, health policy and research methodologies.

When asked about her reasons for doing a dual MD/MPH, she said, “In primary care, you are constantly confronted with issues of social disparity, stark inequality and injustice.

I wanted a bigger lens to look through when thinking about patient care. It goes beyond the clinic visit and the pathology. The diagnosis can be about the patient’s built environment.”

As a rising fourth year student, Victoria is exploring how to integrate her public health training into her clinical training, “I feel more prepared to ask better questions; to read the literature critically; and to connect patients to outside resources. Where the patient lives, where they work, their access to nutritious foods – their overall built environment is equally, if not more impactful on their health than medicine. It’s thought provoking. Social problems that affect care are hard to solve. But right now, I’m feeling particularly optimistic.

This past year made me hopeful of what could be done – things seem more solvable, and I’m now aware of resources that I wasn’t before.”

Victoria also has a lot of questions, and as an upstreamist, there’s a lot of power in asking why.

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Hello humankindness California Family Physician Summer 2017

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Wanda D. Filer, MD, MBA, FAAFP Board Chair, American Academy of Family Physicians

health disparities and social determinates

Family Physicians Gain Vital Patient Information by Understanding the Adverse Childhood Experiences (ACEs) Study More than 25 years ago, my professional career was affected dramatically when a family of my patients was murdered. I had just seen the newborn in the nursery, spoken to mom about car seats, breastfeeding and immunizations. I was not taught about family violence in residency and could not know that the new father, a few weeks later, would kill his wife, other children (not the newborn), his mother-in-law and two-year-old nephew with a ball peen hammer.

I watched my colleague crying as she dictated closing notes in each of the charts and then turned to me and said “I thought this was a family who could make a difference.” For me, that moment was transformational. What could I have known, asked, or done differently? I went on a professional journey to learn about family violence/domestic violence/interpersonal violence. Along the way I learned that homicide is the leading cause of death for women within one year of childbirth – not infection, not hemorrhage, not embolism. I learned that one in four women and one in five-to-six men are sexually assaulted, 60 percent before the age of 18; that

violence can be physical, sexual, emotional and even financial.

I learned that these are heinous crimes but that society spends a lot of time blaming victims rather than holding perpetrators accountable. Back then even some insurance companies would stop covering clients who had domestic violence (DV) or sexual assault in their medical histories. Fortunately, that element has changed, at least for now.

In the mid-1990s, a critical study was done in California involving 17,000 patients, roughly one-half male and one-half female, mostly middle-class, many with at least some college education.

These individuals were asked to self-report if they experienced any of eight “adverse events” in their childhoods; things such as experiencing serious physical abuse, emotional neglect, sexual assault, living with only one parent, substance abuse in the family, witnessing a mother being treated violently, someone institutionalized/incarcerated were standard questions. For each “yes” answer, a point was given and the total tabulated to obtain each patient’s ACE score. The study authors, Felitti and Anda, then followed these patients for many years and saw direct correlations between increased disease states, high-risk health behaviors, shortened lifespans and higher ACE scores. Most participants had a total of at least one and a huge swath had scores of four and

The art on our cover and in this article has been provided by The Anna Institute. The Institute celebrates and honors the life of Anna Caroline Jennings, by using her artwork and life experience to educate others on the hidden epidemic of childhood, trauma and their horrific lifelong impacts on society, and paths to prevention and healing. The Institute also provides resources on the prevalence and impacts of trauma, trauma packages for schools and details on the ACE Study. For more information or to support the Anna Institute: https://www.theannainstitute.org/.

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California Family Physician Summer 2017

higher. Patients with an Adverse Childhood Experience (ACE) score of six or higher often had their lifespans shortened by almost 20 years!

Cardiac disease, depression/anxiety, substance abuse, teen pregnancy, autoimmune disease, COPD and liver disease are just a few of the adverse consequences seen more commonly in high ACE score patients. Many offshoots of the original study have been spawned as a result of the original ACE study. A clearer picture has emerged about the neurobiological, and often lifelong, impact of trauma in childhood.

The Centers for Disease Control (CDC) and others continue to expand on this work and its implications.

As a family physician caring for the whole person in the context of their family and community, my eyes were opened and my approach has changed for the better. I recognize that a person who won’t go to the dentist, have a colonoscopy or pelvic exam is not necessarily “non-compliant.” These procedures can cause flashbacks and retraumatization. The patient needs to remain in control as much as possible and I am not here to re-victimize them, or endanger their sense of bodily integrity. The person who doesn’t take their meds, doesn’t follow through on care, may see themselves as unworthy. One survivor, through her graphic art therapy descriptions, saw herself as despicable, evil and that no one would ever understand. Many of these individuals feel that they are alone, isolated, and that no one will believe them.

I ask patients “Are you safe at home? Have you ever been sexually assaulted? Tell me about your childhood.” Frequently they only disclose several visits later, after they find trust in our physician-patient relationship.

Behavioral health colleagues to whom I refer have been trained in trauma-informed care, and the approach can be very different. My office teams have learned about traumainformed care and many have disclosed their own experiences, as have fellow physicians, as I have traveled around the country.

occurring countrywide, learn about resilience and much more. Dr. Felitti was quoted saying that the ACE score may be the biggest determinant of the health of this nation. I completely agree. As family physicians, knowing more about ACES helps us to modify our approach to patient care, to strengthen our teams and to be more effective in our day-to-day work.

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h e a l t h d i s p a r i t i e s a n d s o c i a l d e t e r m i n a t e s

Sonia Kantak, MPH Manager, Medical Practice Affairs

Integrating Public Health Into Primary Care It once was common practice to emphasize health care delivery and payment to improve an individual patient’s health. The rigid fee-for-service payment structure promoted a culture of paying for the volume of services rather than for the quality of care.

Despite this, research has shown that the United States ranks consistently lower on most health indicators and is plagued by greater health disparities compared to other industrialized nations. The push to understand the underlying reasons for such disparities and the role social determinants play in creating them has never been stronger. Social determinants are defined by the World Health Organization (WHO) as the conditions in which people are born, grow, live, work and age that are strongly linked with mortality, general health status, disability, birth outcomes, chronic conditions, health behaviors and other risk factors for chronic disease By definition, social determinants affect a population’s health and can influence the way primary care should be delivered. As family physicians play a large role in their respective communities and watch their patients’ health evolve over time, they are naturally suited to observe, track, understand and influence the social and environmental causes of illness.

Weaving Social Determinants of Health into Practice A wealth of research exists to support the significant effect social determinants can have on health and general well-being.

The Let’s Get Healthy California Task Force has accumulated a number of state-specific statistics outlining some disparities in health due to social determinants: ● Forty percent of low-income adults in California are food insecure. Food insecurity refers to the limited ability to attain nutritionally adequate food and/or not having enough for household members, which can be affected by the availability of locally-sourced, healthy food in a community; the price of food and where it can be purchased; and the capacity to store and prepare food. ● Research has shown that strong social networks, whether that means a “close knit community” or familiar structure, correspond with significantly lower rates of homicide and alcohol and drug use. Additionally, exposure to violence influences health and mental health outcomes both directly, by affecting an individual’s ability to adopt healthy behaviors and manage stress and chronic diseases, and indirectly, by weakening a community’s social ties and lessening economic investment. ● Exposure to violence has been linked to increased incidence or worsening of many chronic health conditions including asthma, heart disease, hypertension and diabetes.

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California Family Physician Summer 2017

The challenge in incorporating these statistics into everyday practice, however, lies in the data collection. Until recently, collecting data about and addressing these determinants of health have largely been done in the public health sector.

Family physicians often are challenged by the lack of consistent and reliable data about their communities because of the wide variety of agencies and nonprofit organizations active in their areas and the lack of a systematic or standardized approach to developing and sharing information. Family medicine, however, is working to mitigate these challenges. To help family physicians attain the data about community resources, the American Academy of Family Physicians (AAFP) has developed the Community Health Resource Navigator (CHRN). The CHRN is an interactive mapping tool for AAFP members to generate customized reports that may be downloaded, printed and shared during patient visits. According to the AAFP:

“The purpose of the CHRN is to help family physicians personalize care by assessing patients’ environments and barriers to healthy living. The tool provides resources in communities that can assist patients in achieving a healthy lifestyle. This may help shape counseling options and shared decision-making discussions.”

The CHRN tool currently can be used as a resource that helps patients with healthy eating and active living, mental health services and substance abuse services.

The Changing Landscape Although silos between public health and clinical care still exist, the situation is improving. In recent years, governments, insurers and health plans have increasingly begun to incorporate incentives for physicians and other clinicians to address the social determinants of health during patient care. This focus gained momentum in 2010 with the introduction of the Affordable Care Act (ACA), which recognizes comprehensive models of care such as the patient centered medical home (PCMH). In 2015, the

Centers for Medicare and Medicaid (CMS) continued to show movement toward value-based care with its decision to migrate 30 percent of Medicare payments into alternative payment models by the end of 2016, and 50 percent by the end of 2018. Most recently, CMS published regulations for the Medicare Access and CHIP Reauthorization Act (MACRA) with built-in incentives to move toward alternative payment models. These initiatives, and many others emerging at all policy levels, are designed to create opportunities for family physicians to integrate social determinants into decision-making.

• • • • •

http://www.oecd-ilibrary.org/social- issues-migrationhealth/health-at- a-glance_19991312 http://www.who.int/social_determinants/sdh_definition/ en/ https://letsgethealthy.ca.gov/sdoh/ http://www.rwjf.org/content/dam/farm/reports/ reports/2016/rwjf428872 https://www.cms.gov/newsroom/mediareleasedatabase/ fact-sheets/2015-fact-sheets-items/2015-01-26-3.html

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California Family Physician Summer 2017

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evp forum

Susan Hogeland, CAE

Upstream Medicine: Another Form of Hot Spotting?

No, as family medicine physicians know well, what ails most people isn’t just the physical manifestations of their health status, but their “life” status as well. How we live encompasses a lot – some of us with economic independence don’t take as good care of ourselves as we should, but we have options. For us, it’s more a matter of not eating as we should rather than having too little to eat. It’s a matter of being short on self-discipline to get in those 150 minutes of walking weekly rather than being too dangerous to step outside to take that walk.

Poor health caused by social determinants disproportionately affects minorities and the underserved – and often they are the same folks. This likely isn’t the first time you’ve heard the term “upstream medicine” – attendees were treated to a keynote address at CAFP’s recent Family Medicine Clinical Forum by Rishi Manchanda, MD, who spoke eloquently about the health impacts of social and environmental determinants of health, looking “upstream” for the significant sources of health problems and working with resources in the community to address them. Dr. Manchanda noted that social factors account for 60 percent of premature deaths and affect the Quadruple Aim, but only one in five physicians indicate they have confidence to address them.

Physician and medical writer Atul Gawande wrote of the program developed by family physician Jeffrey Brenner in Camden, NJ, who intervened aggressively in the primary care of the sickest individuals in that city – “hot spotting” – in an issue of New Yorker magazine in 2011.

Hot spotting shares many characteristics with “upstream medicine.”

But, writing in Forbes magazine, Larry Van Horn says: “The efforts described in the (New Yorker) article, while seemingly laudatory, reflect an unsustainable expansion of the medical establishment to address growing social ills that historically have fallen outside the scope of health care.”

I can see his point – we don’t have enough resources to properly address the health problems of the patients family physicians see every day; and, now, expanded access created by the Affordable Care Act is under threat. Yet, if we never address these upstream problems, the outcomes are predictable. I have attended several meetings of late at 30

California Family Physician Summer 2017

which family physician leaders in Accountable Care Organizations have discussed the value of going beyond clinics’ and hospitals’ walls to get at the root problems behind patients’ frequent trips to the emergency room. From toilets that have fallen through a rotten mobile home’s floor to living without lights or water, from having too little to eat and no safe place to exercise to suffering from domestic abuse, such contributory factors explain why patients may be less than adherent to self-care recommendations.

It seems we have to start somewhere … and who better to instigate such changes than family physicians? Naturally, “Who’s going to pay for it” is the first question that comes up, and, it is valid. The move to global payment provides greater incentive for addressing these upstream issues. That’s where I’ve heard about creative solutions such as training returning military medics to do patient outreach/ home visits, organizing special care teams to address the gamut of patients’ issues, including the upstream ones, using Electronic Health Record and registry data to identify those who need the most services and connecting patients to community resources (happy to say AAFP is working on gathering such information and also supports Health Landscape, an online tool that can help turn statistics into intervention and action). Dr. Manchanda says the US has a lopsided health to social services ratio, and I would have to agree. He offered an “Upstream Readiness Assessment for Health Care Systems” to help determine an organization’s likelihood of success, recommendations on reviewing upstream data collection to optimize segmentation and risk stratification and creating quality improvement projects to address specific upstream issues, in addition to offering an Upstream Risks Screening Tool and proposing Community Health Detailing. It can be done – if we have the will. Contact CAFP and we can provide more information.

“

How we live encompasses a lot – some of us with economic independence don’t take as good care of ourselves as we should, but we have options.

“

It’s been a long time coming, but recognition finally is being given to the very commonsense notion that what ails most people can’t be fixed in a few 20-minute visits with their physicians over the course of a year, 10 years or sometimes a lifetime.

A D VA DEVRE RTT II S S EE MM E N TE N T How ‘Food as Medicine’ Transformed My Life and Clinical Practice

by Steve Lawenda, MD, Family Physician, Kaiser Permanente, Southern California Late in 2012 I hit a rock bottom both personally and professionally. I had just turned 38, the same age my paternal grandfather had his first heart attack and only seven years away from the age my father suffered his first heart attack. I was so worried that I would suffer their same fate myself. I knew that one third of heart attack victims didn’t survive, and I was deathly afraid that I might not be as lucky as my father and grandfather. I was obese with a BMI of 33 and already had prediabetes, fatty liver, acid reflux, and symptoms of sleep apnea. Our first child was only three years old at that time, and I could not imagine leaving her without her daddy.

Steve (right) with Michael Greger, MD, FACLM at the Int’l Plant-based Nutrition Healthcare Conference

On top of this overwhelming concern and weighing on my mind like an extra ton of bricks was the memory of two years prior when I had witnessed one of the most tragic and horrible events that have ever happened to my family.

My father, fortunate to have survived his first heart attack and coronary artery bypass surgery a few years later, underwent bilateral leg amputations (below the knee) as a result of his type II diabetes. He went from being a fully functional, working, and joyful new grandpa enjoying his first infant grandchild (our daughter), to being a disabled, unemployed, and depressed man confined to a wheelchair.

On top of all this, professionally I was burning out. I was so dejected and so frustrated not knowing what to do as I witnessed more and more of my patients gaining weight, getting sicker and sicker, taking more and more medications, all the while becoming more and more miserable and depressed. They would ask me for help and I felt I had nothing to offer them other than more pills.

One particular patient of mine, that in hindsight epitomized what was wrong with modern medicine, was a local popular clergyman in his mid 50s. I always enjoyed seeing him – I’ll never forget we had such meaningful conversations with plenty of laughter as he had such a great sense of humor. He was obese with type II diabetes, yet was a model patient – he took his long list of medications diligently and his hemoglobin A1c, LDL, and blood pressure were always at target.

Yet one day I received the most dreaded call of my career: The local ER called to inform me that this most pleasant and delightful patient of mine collapsed suddenly at home of a suspected heart attack and was taken by ambulance to the ER in full cardiac arrest. Unfortunately the staff in the ER were unable to resuscitate him. Like that, he was gone. In spite of all his medications and his diligence in doing precisely what I asked him to do, with all his numbers at target, he died far too soon. He left behind a young family, a loving wife, and a community that cherished him. I knew at that time that something was seriously wrong with modern medicine, but I didn’t know what the answer was. Now I do.

Fortunately, four years ago, at this age of 38, worried deeply about my personal and professional future, I had discovered the incredible power of food as medicine. I was blown away by what I was learning: I was amazed to learn that there existed a way of eating, namely a whole food, plant-based diet, where one can eat until they are full, without counting calories or measuring or restricting portion size—all while losing significant amounts of weight, regardless of the amount of exercise. This same way of eating, I learned, also REVERSES our most common chronic diseases, including our number one killer, heart disease, and our most costly and complicated disease, diabetes. I was very skeptical learning all of this, especially as it was not part of my years of training. Yet soon I began to realize how much solid scientific evidence existed that more than substantiated these incredible benefits.

Before long I challenged myself to eat and live this way. Within eight months, I lost 75 pounds, and my BMI went from an obese 33 down to a normal 23. My prediabetes, fatty liver, acid reflux, and symptoms of sleep apnea went away. My blood pressure dropped twenty points. I felt amazing. Most importantly, I felt as if the huge monkey on my back was gone. I was no longer depressed or worried about my health and my future.

It was obvious my next step was to implement this into my clinical practice. Doing so has brought me from burnout to now feeling a true sense of joy and deep satisfaction in my career. Before I felt as if I wasn’t really helping

people. I rarely if ever saw a patient’s health turn around completely from a prescription I wrote. Yet now I often see patients have such dramatic and meaningful improvements in their lives and health.

I have seen many patients lose significant amounts of weight, in some cases as much as what we see with bariatric surgery.

So many patients have reversed their chronic diseases such as diabetes; even diabetic neuropathy and erectile dysfunction, which we are taught are non-reversible. One patient in particular was able to discontinue a total of 160 units of daily insulin in just two weeks after starting a whole foods, plant-based diet. Another patient was facing a below the knee amputation like my father and was able to heal his diabetic foot ulcer and avoid amputation by changing to a plant-based diet. I have seen numerous patients discontinue the majority and in some cases all of their medications within a matter of just days to weeks.

I have become so passionate about plantbased nutrition that I discuss it with nearly every patient at almost every visit. I realize that not all patients are ready for change, but I have been pleasantly surprised by the effectiveness of planting the seed sooner rather than later. I have also found that my patients are more receptive and encouraged by the fact that their doctor is practicing what he preaches. I now supplement my practice by teaching healthful eating classes, and I help run group-based lifestyle medicine programs. This change in my practice has given me such pleasure and joy; there is nothing more satisfying for me than to see what this can do for my patients and for the practice of medicine.

When I had my paradigm-shift, I began seeking out CME accredited education opportunities that would enable me to learn what I had not been taught in medical school.

I’ve had the opportunity to attend the International Plant-based Nutrition Healthcare Conference each of the past three years: The experience has been nothing short of transformative, personally and professionally. I urge my family physician colleagues to join me in taking back your health and regaining the joy and satisfaction of putting health back into healthcare.

Empowering patients to use food as medicine!

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