Autumn 2022

VOL . 73 N O.4 Au tu mn 2 0 2 2

Celebrating Independent Physicians

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Officers and Board

Staff

President Lauren Simon, MD, MPH, FAAFP

Lisa Folberg, MPP Chief Executive Officer lfolberg@familydocs.org

Immediate Past President Shannon Connolly, MD, FAAFP President-elect Raul Ayala, MD, MHCM Speaker Alex McDonald, MD, FAAFP Vice-Speaker Anthony "Fatch" Chong, MD Secretary/Treasurer Brent Sugimoto, MD, MPH, FAAFP Chief Executive Officer Lisa Folberg, MPP Foundation President Ron Labuguen, MD, FAAFP

Karen Alvarado Advocacy Assistant kalvarado@familydocs.org Anita Charles Program Assistant acharles@familydocs.org Morgan Cleveland Manager of Operations & Governance mcleveland@familydocs.org Jerri Davis, CHCP Vice President, Professional Development, CME/CPD jdavis@familydocs.org Christine Lauryn Manager, Member Communications clauryn@familydocs.org

AAFP Delegates Jay Won Lee, MD, MPH, FAAFP Lee Ralph, MD

Josh Lunsford Vice President, Membership & Communications jlunsford@familydocs.org

AAFP Alternates Michelle Quiogue, MD Lisa Ward, MD, MPH, FAAFP

Pamela Mann, MPH Executive Director, CAFP Foundation pmann@familydocs.org

CMA Delegates Kimberly Buss, MD Felix Nunez, MD Sumana Reddy, MD, FAAFP Kevin Rossi, MD, FAAFP CMA Alternate Delegates Raul Ayala, MD, MCMH Noemi Doohan, MD, PhD Adia Scrubb, MD, MPP David Tran, MD

Catrina Reyes, Esq. Vice President, Policy and Advocacy creyes@familydocs.org Jonathan Rudolph Manager, Finance jrudolph@familydocs.org Tiyesha Watts Legislative & Policy Advocate trwatts@familydocs.org

Brent Sugimoto, MD, Editor Josh Lunsford, Managing Editor The California Family Physician is published quarterly by the California Academy of Family Physicians. Opinions

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EDITION 44 4

California Family Physician Autumn 2022

Au tu mn 2 0 2 2

features ELDER CARE 8 President’s Message

Holding Hands Throughout Life: The Sacred Moments Shared by Family Physicians

Lauren Simon, MD, MPH, FAAFP

20 Elder Care: A Prescription for Loneliness

Jeff Luther, MD, FAAFP

21 Can We Prescribe Social Media to Combat Loneliness and Social Isolation?

24 CAFP Looks Back at 2022 Congress of Delegates

Lee Ralph, MD

28 Putting a Family Physician in the CA Assembly

Jasmeet Bains, MD

departments 6 Editorial

Vote Like Our Patients' Lives Depend on It

Brent K. Sugimoto, MD, MPH, AAHIVS, FAAFP

10 Political Pulse

It's the Final Countdown

14 Legislative Update

Under the Dome - Vote Early and Vote Often

16 CAFP Foundation

CAFP Foundation Welcomes Student-Resident Council & Co-Chairs

19 CEO's Message

Time Well Spent

22 Trauma-informed Care

Trauma-informed Care for Every Body (Part 1)

Jeff Luther, MD, FAAFP Bryce Docherty, CAFP Lobbyist Pamela Mann, MPH Lisa Folberg, CEO Erika Roshanravan, MD, FAAFP

Your Online Resource for Continuing Medical Education. Visit education.familydocs.org

editorial

Brent K. Sugimoto, MD, MPH, AAHIVS, FAAFP

Vote Like Our Patients’ Lives Depend on It We family physicians would do anything for our patients.

We leverage the breadth of our training to ensure our most vulnerable patients get access to the services they need.

We take the time to build relationships with our patients and their families so that our care is personal and patientcentered. Family physicians are right there at the moment of birth, and many times are there to ease the end of life. Can we assume that we do everything in our power to assure the best outcomes for those we provide health care?

If you analyze the data, we fall short in two important regards. Not enough of us vote, and not enough of our patients vote.

Electing our representatives is a basic way to influence policy priorities that impact our patients’ health, such as pandemic preparedness, vaccine funding, residency funding, and health care programs like Medi-Cal. Voting is vital to protecting patient rights, especially those under assault like access to abortion and gender-affirming care. Exercising the right to vote may be the most direct means many of us have to protect our communities from gun violence.

Without exercising our franchise and encouraging our patients to do the same, we are neglecting a powerful tool in our family medicine arsenal.

Even though voting is a health care issue, it has long been observed that physicians have a poor track record when it comes to voting. Consistent with past studies, Ahmed and Chouairi (2022) found in the 2020 U.S. Census data that physicians were less likely to vote compared to the general population. In general, the likelihood a physician will vote is correlated with age, with Millennials being the least likely to exercise their franchise.

The most commonly cited reasons for failing to vote included not being registered and being too busy or having a conflicting work schedule. The most common reasons for not registering were missing the registration deadline and a professed uninterest in politics, (Ibid, 2022).

I believe that an “uninterest” in politics is an unstated part of medical culture, rooted in the well-meaning intent to be unbiased fiduciaries to our patients. However, this attitude conflates political engagement with partisanship, which many of us would hesitate to bring even to Thanksgiving dinner, let alone the exam room.

Political engagement, however, allows family physicians 6

California Family Physician Autumn 2022

to educate legislators about the needs of our patients.

At its most basic level, it begins by electing those lawmakers who understand our patients’ health needs.

Voting is the first step in crafting sound health policy.

Beyond our own voting habits, exercising the right the vote should be a regular part of health education to patients.

Our counsel to vote is one way patients can get their representatives to address shortcomings in our health care system. Dr. Manisha Sharma, a California family physician and co-founder of Civic Health Alliance, has been one of the leading voices championing voter registration drives in health systems because of the recognition that those communities with the worst health disparities also happen to be the communities that vote the least. (Voter registration is legal in public and private non-profit health systems—and even required in FQHCs with government employees—when done in a non-partisan manner) Because of voices like Dr. Sharma’s, the house of medicine is finally starting to recognize the importance of helping our patients vote. In June, the American Medical Association updated its policy to declare that “voting is a social determinant of health and significantly contributes to the analyses of other social determinants of health as a key metric.” At the 2022 Congress of Delegates, the AAFP resolved to support mail-in voting options for any reason in elections at all levels in order to reduce health disparities, because those with the poorest outcomes are the least likely to vote.

Medicine still has a ways to go (for example, a group of us continues to advocate that the AAFP support voter registration in health systems to improve health equity), but I am encouraged by recent progress that we can go further.

As the midterms approach, register to vote if you haven’t already and please encourage your patients (and peers) to do the same.

We must vote like our patients’ lives depended on it.

For resources to help you get your patients (and colleagues) registered to vote, Civic Health Alliance has guidance and materials to help you get started: https://www.civichealthalliance.org/resources

SCREEN FOR HIV

Ending the HIV Epidemic Starts With Routine HIV Screening.

The Centers for Disease Control and Prevention (CDC) recommends that everyone between the ages of 13 and 64 get tested for HIV at least once and that those with ongoing risk be screened at least annually. Yet 1 out of every 8 people in the United States are unaware of their HIV status.

You can play a critical role in ending the HIV epidemic by offering HIV screening to all your patients. Routine HIV screening helps to: • Reduce HIV transmission by empowering your patients to know their status.

• Improve your patients’ health outcomes by linking them to prevention or care services.

• Eliminate stigma associated with HIV testing by making it the standard of care.

Access new CDC resources on integrating routine HIV screening into your practice at: cdc.gov/ScreenForHIV.

p r e s i d e n t ’s m e s s a g e

Lauren Simon, MD, MPH, FAAFP, CAFP President

Holding Hands Throughout Life: The Sacred Moments Shared by Family Physicians

As I enter one exam room in the Family Medicine clinic, I see the weathered hands of my patients gently entwined as they have been so often in their 50-year marriage. They release their hands to shake mine and I feel the strong hand grip of the husband, from years of working in the Citrus groves and the knotted joints on the wife’s hand, damaged from years of rheumatoid arthritis before she had insurance to cover her medications. I feel so fortunate to hold their hands in-person after almost 2 years of video visits due to the COVID-19 pandemic, when we could only mimic an “air-handshake”. I hold their hands and share their joy as I listen to their “Golden Anniversary” plans.

In the next clinic room, I give a “high-five” to my teen patient who made his varsity sports team after working for months to raise his grades to become eligible to play. I listen closely as the normally quiet teen shares dreams about his future.

Sometimes , touching our patient’s hand reveals vulnerabilities that help direct our care, and potentially send us to the supply cabinet for cast supplies, such as when I see a patient in clinic and reach out to give a handshake and feel the patient’s swollen hand in the “boxer’s fracture” location (not listed as a reason for the clinic visit), which leads us to explore the anger and hurt in the patient’s life, underlying their decision to punch a wall the weekend prior to their visit. As we hold their hand, and reduce the fracture, we concurrently provide the patient hope to address the turmoil behind the injury and move forward.

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California Family Physician Autumn 2022

As family physicians, we have the incredible privilege to walk through both the positive and negative life experiences with our patients, holding their hands along the way. I think of times when I have held the tremulous hands of my patients as I told them of biopsies revealing they have cancer and exchanged a reassuring grip that I stand with them through this challenge.

In addition to medical care, we also offer the patient and family spiritual support, sometimes denoted with images of hands held in prayer. Sometimes in the months that follow the diagnosis, I am fortunate to feel the patients’ excited hand grip when their cancer is cleared. Sadly, I have also had to say goodbye to some of my patients while I held their hands, once so firm a grip-now weakened by terminal illness, as they took their final breaths.

Although we sometimes have to say goodbye to our patients, as family physicians we also have the amazing opportunity to say the “hello” as we welcome our newest patients, our newborns, into the world. We have the wonderful privilege to hold a laboring mother’s hand and then deliver the baby or be one of the first people to hold the baby’s tiny hand. I am incredibly thankful that family physicians can share the sacred moments in our patient’s lives: births, deaths, triumphs, tragedies, health and health challenges, celebrations and stresses and continue to hold our patients’ hands through each step of their life’s journey. Enjoy the journey!

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9

political pulse

Jeff Luther, MD, FAAFP Chair, Legislative Affairs Committee

It’s the Final Countdown California’s legislative session concluded September 1st with lawmakers rushing to pass hundreds of remaining bills before the clock struck midnight on August 31st. After both houses approve a bill, it goes to the Governor. The Governor has three choices - sign the bill into law, allow it to become law without his or her signature, or veto it.

Most bills go into effect on the first day of January the following year. Urgency measures take effect immediately after they are signed or allowed to become law without signature.

At the time of drafting this article, the Governor had already signed into law the following CAFP-supported bills. All bills on which CAFP has taken a position fit under one of CAFP’s strategic goals – advance payment reform and system transformation; raise the profile of family medicine; prioritize justice through diversity, equity, and inclusion; and alleviate burnout and support member wellness and joy in medicine.

• AB 35 (Reyes D) Civil damages: medical malpractice. AB 35 keeps California’s Medical Injury Compensation Reform Act’s (MICRA) essential guardrails solidly in place for patients and providers alike while implementing a predictable increase to limits on non-economic damages in medical negligence cases starting January 1, 2023, with gradual increases thereafter. AB 35 also establishes new protections for all pre-litigation expressions of sympathy, regret, or benevolence, including statements of fault. AB 35 precluded a costly ballot initiative – the so-called “Fairness for Injured Patients Act” – which would have effectively eliminated MICRA’s cap on non-economic damages and at least doubled malpractice premiums overnight.

• AB 2176 (Wood D) Live birth registration. This bill relates to CAFP’s strategic goal of justice, equity, diversity, and inclusion. Many Native tribes hold a sacred ceremony to name a child on the tenth day of life, and some Rancherias and tribes hold the naming ceremony later than that, but current law requires a hospital to submit a baby’s birth certificate to the local registrar/health department within ten days, which places undue pressure on Native families to provide 10

California Family Physician Autumn 2022

information to the hospital on the very day they are holding a naming ceremony for their new child. This bill addresses this issue by extending the time, from ten days to 21 days, by which live births are required to be registered with the local registrar.

• AB 2585 (McCarty D) Health care coverage: nonpharmacological pain management treatment.

This bill encourages the use of evidence-based nonpharmacological therapies for pain management.

• SB 245 (Gonzalez D) Health care coverage: abortion services: cost sharing. This bill prohibits cost-sharing, restrictions, delays, prior authorization, and annual or lifetime limits on all abortion services, including follow-up services.

• SB 872 (Dodd D) Pharmacies: mobile units. This bill authorizes a county, city and county, or special hospital authority to operate a licensed mobile unit to provide prescription medication to individuals, including those individuals without fixed addresses, within the county’s jurisdiction and specifies certain criteria that a mobile unit must meet.

We are still awaiting action on several more CAFPsupported bills listed below.

Access and Equity • AB 32 (Aguiar-Curry D) Telehealth.

• AB 498 (Quirk-Silva D) Medi-Cal: county organized health system: Orange County Health Authority.

• AB 2352 (Nazarian D) Prescription drug coverage.

• AB 1930 (Arambula D) Medi-Cal: comprehensive perinatal services.

• SB 838 (Pan D) Insulin Manufacturing.

• SB 944 (Pan D) California Health Benefit Exchange: affordability assistance.

• SB 974 (Portantino D) Health Care Coverage: Diagnostic Imaging • SB 1234 (Pan D) Family Planning, Access, Care, and Treatment Program. continued on page 12

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continued from page 10

Justice, Equity, Diversity, Inclusion • AB 2761 (McCarty D) Death certificates: death while in law enforcement custody.

Reproductive Health • AB 2091 (Bonta, Mia D) Reproductive health and privacy.

• AB 2134 (Weber, Akilah D) Reproductive health care.

• AB 2320 (Garcia, Cristina D) Reproductive health care pilot program.

• AB 2626 (Calderon D) Medical Board of California: licensee discipline: abortion.

• SB 523 (Leyva D) Health care coverage: contraceptives.

• SB 1245 (Kamlager D) Los Angeles County Abortion Access Safe Haven Pilot Program.

Behavioral Health • SB 1238 (Eggman D) Behavioral health services: existing and projected needs.

COVID-19 and Vaccines • AB 1797 (Weber, Akilah D) Immunization registry.

• SB 1296 (Pan D) Viral surveillance program.

• SB 1479 (Pan D) COVID-19 testing in schools: COVID-19 testing plans.

Administrative Burdens • AB 1880 (Arambula D) Prior authorization and step therapy.

Licensing • AB 1636 (Weber, Akilah D) Physician’s and surgeon’s certificate: registered sex offenders.

Workforce • AB 1918 (Petrie-Norris D) California Reproductive Health Service Corps.

For links to the bill language and an up-todate status of these bills, scan the following QR code: Aside from legislation, CAFP may also take positions on ballot propositions, however, there is a higher threshold for taking positions on propositions.

Generally, the initiative should clearly be within CAFP’s strategic goals and policies, have a direct impact on family medicine, and/or is an issue we have engaged 12

California Family Physician Autumn 2022

on in the past. The CAFP Board adopted a support position on two of the initiatives on the November 2022 ballot.

Proposition 1 SCA 10 (Resolution Chapter 97, Statutes of 2022) Atkins.

Reproductive Freedom.

The California Constitution declares that defending life and liberty, acquiring, possessing, and protecting property, and pursuing and obtaining safety, happiness, and privacy are inalienable rights, and that a person may not be deprived of life, liberty, or property without due process of law or equal protection of the laws. Existing law, the Reproductive Privacy Act, declares that every individual possesses a fundamental right of privacy with respect to personal reproductive decisions and prohibits the state from denying or interfering with a person’s right to choose or obtain an abortion before viability of the fetus, or when the abortion is necessary to protect the life or health of the person.

This measure would amend the California Constitution to prohibit the state from denying or interfering with an individual's reproductive freedom in their most intimate decisions, which includes their fundamental right to choose to have an abortion and their fundamental right to choose or refuse contraceptives.

A “YES” vote on this measure means: The California Constitution would be changed to expressly include existing rights to reproductive freedom—such as the right to choose whether or not to have an abortion and use contraceptives.

A “NO” vote on this measure means: The California Constitution would not be changed to expressly include existing rights to reproductive freedom.

Proposition 31 Referendum on a 2020 Law Prohibiting Retail Sale of Certain Flavored Tobacco Products.

This referendum challenges a 2020 law that prohibits the retail sale of certain flavored tobacco products and tobacco flavor enhancers. The referendum would require a majority of voters to approve the 2020 state law before it can take effect. CAFP supported the passage of SB 793 (Hill-D), the legislation prohibiting the sale of flavored tobacco products in California and signed onto an amicus brief opposing tobacco company efforts to prevent enforcement of SB 793.

A “YES” vote on this measure means: SB 793 goes into effect so in-person stores and vending machines could NOT sell most flavored tobacco products and tobacco product flavor enhancers.

A “NO” vote on this measure means: In-person stores and vending machines could continue to sell flavored tobacco products and tobacco product flavor enhancers. https://elections.cdn.sos.ca.gov/ballot-measures/pdf/sca-10.pdf https://oag.ca.gov/system/files/initiatives/pdfs/20-0003 %28Tobacco Products %29.pdf

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legislative update

Bryce Docherty CAFP Lobbyist

Under the Dome: Vote Early and Vote Often Elections are all about the numbers. Voter turnout.

Voter registration. Polling. Campaign war chest. Political contributions. In close races the candidate matters. After the November 2022 General Election there will be 33 new members of the State Legislature. This represents nearly a 30% turnover with 10 new Senators and 23 new Assemblymembers. Hopefully, family physician Jasmeet Bains, MD (D-Bakersfield) will be one of them!

This turnover is a function of legislative term limits, but also the “Great Resignation.” Just this year alone 11 legislators have decided not to seek reelection in November 2022.

Additionally, 10 legislators are running for another office from County Sheriff to State Senate to Congress. Four Assemblymembers have already resigned this year and have been replaced in Special Elections. These new Assemblymembers include Lori Wilson (D-Fairfield) in AD 11, Tina McKinnor (D-Inglewood) in AD 62, David Alvarez (D-San Diego) in AD 80, and Matt Haney (D-San Francisco) in AD 17. CAFP strongly supports Assemblymember Haney.

The political makeup of the Legislature is not expected to change drastically. Turnout in a mid-term (Presidential) election is typically lower as well. CAFP can anticipate Democrats maintaining their “gigamajority” in the Legislature with 61 seats out of 80 in the Assembly and 30 out of 40 seats in the Senate.

CAFP under the leadership and direction of FP-PAC are engaged in some of these open seats in the Legislature by supporting Eric Guerra (D-Sacramento) in AD 10, Dave Jones (D-Sacramento) in SD 8, and Dr. Bains in AD 35. Dr. Bains would be the third physician in the State Legislature joining Assemblymember Akilah Weber, M.D. (D-La Mesa) an OB-GYN elected and sworn-in to the State Assembly in April 2021 and Assemblymember Joaquin Arambula, M.D. (D-Fresno) an ER physician. Unfortunately, Senator Richard Pan, M.D (D-Sacramento) a pediatrician terms out in 2022.

The General Election excitement has been shrouded in controversy over who will become the next Assembly Speaker. On May 27, 2022, Assemblymember Robert Rivas (D-Salinas) announced that he has secured enough votes 14

California Family Physician Autumn 2022

from his Democratic Caucus to become the next Assembly Speaker. Assemblymember Rivas is not termed out until 2030, while current Assembly Speaker Anthony Rendon (D-Lakewood) terms out in 2024. Assemblymember Rivas would be the first Assembly Speaker in modern history to represent a predominantly rural district. He currently serves as Chair of the Assembly Agriculture Committee and is Vice Chair of the power California Latino Legislative Caucus.

However, Speaker Rendon is not giving up without a fight.

He has refused to step-down and was able to push off a vote on electing the next Assembly Speaker until after the Legislative Session ended, which was on September 1, 2022. Rendon has been Assembly Speaker since 2016.

This all makes for riveting Capitol intrigue, as the Assembly Speaker has the sole discretion to appoint policy committee chairs and members of those committees, as well as selecting other Assembly leadership and singlehandedly decides the fate of thousands of legislative bills every year. Although powerful, Rendon has also been characterized as vindictive, indignant, and out-of-touch.

He was also blasted by the SacBee in June 2022 for his “hubris” and unrelenting desire to hold onto his power as long as possible.

What happens in the November 2022 General Election matters to CAFP. What happens with the Assembly Speakership matters to CAFP. Getting Dr. Bains elected to the State Assembly matters to CAFP. Family physicians cannot afford to take their eyes off the proverbial political ball for one second. The only thing consistent in Sacramento is inconsistency.

“If you miss a day ‘Under the Dome’ – you miss a lot!”

www.drjasmeetbains.com https://calmatters.org/politics/2022/01/california-legislature-greatresignation https://a11.asmdc.org/biography • https://a62.asmdc.org/biography https://a80.asmdc.org/about/biography • https://a17.asmdc.org/biography https://www.electericguerra.com • https://www.davejonesforsenate.com https://a79.asmdc.org/biography • https://a31.asmdc.org/biography https://sd06.senate.ca.gov/biography • https://a30.asmdc.org/biography https://speaker.asmdc.org/biography https://www.sacbee.com/opinion/article262094552.html

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15

CAFP Foundation

CAFP Foundation Welcomes Student On behalf of the CAFP Foundation, I am thrilled to announce the new leaders of the 2022-2023 StudentResident Council. Dr. Nadine Grace-Abraham, a third-year resident at Emanate Health Family Medicine Residency Program, will be returning as a co-chair in her final year of residency. Dr. Juliana Jones, a third-year resident at Dignity Health California Hospital Medical Center, and Dr. Zachary Pope, a second-year resident at the University of California Davis Family and Community Medicine Residency Program, will be joining as peer co-chairs. Benjamin Slobodnik, a third-year medical student at California Northstate University will serve as the new student cochair.

a community of like-minded individuals. Within CAFP, I am connected with hundreds of people who are passionate about family medicine, want to make positive change, and advocate for their patients.

Their unique perspectives on medical student and family medicine resident advocacy, leadership, mentorship, and networking will help us sharpen our strategies to best serve the next generation of family physicians in California. All co-chairs share a deep commitment to the Foundation’s mission, and we are grateful they will be part of shaping the organization’s future.

We are pleased to introduce you to these rising leaders.

They have shared why the joined Council and what they are looking for to during their service:

I have been inspired by the CAFP members that I have had the opportunity to meet and work with since I joined as a medical student. Being a co-chair of the Student-Resident Council gives me the opportunity to develop my leadership skills and learn from those around me.

As a member, I hope to create opportunities for medical students to learn more about family medicine and why it is the best specialty! Throughout my time in residency, I have gained awareness of how important it is for family physicians to advocate for meaningful policies and be a driver of change for the betterment of our patients and communities. I am looking forward to attending the All Member Advocacy Meeting this upcoming year to expand my knowledge about advocacy and continue to build connections with other motivated physicians, residents, and students.

Nadine Grace-Abraham, MD

Zachary Pope, MD

I have served on the Council since I was a third-year medical student, and this is my second year serving as a resident cochair. The reason I chose to be part of CAFP and the Council is to feel a sense of connection to

I joined the CAFP StudentResident Council because I'm deeply aligned with the vision of the organization - to transform health care to achieve optimal health for everyone. I'm enlivened when working with

The Student-Resident Co-Chairs serve as key members of the California Academy of Family Physicians (CAFP) Board of Directors and the California Academy of Family Physicians Foundation (CAFP-F) Board of Trustees.

Co-Chairs demonstrate a broad understanding of CAFP and CAFP-F key content areas and possess exemplary academic achievements, strategic leadership ability, strong interpersonal and communication skills, and an entrepreneurial spirit.

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California Family Physician Autumn 2022

My favorite accomplishment while being on the Council is hosting the Procedures Workshop. I enjoy it because I feel that it shines a light on all the amazing things a family medicine doctor can do in clinic and brings students/ residents/faculty together. This year on the Council, I’m looking forward to having more in-person events and connecting with people.

Juliana Jones, MD

Pamela Mann, MPH,

Executive Director, CAFP Foundation

t-Resident Council & Co-Chairs a community of people with shared values to work towards a common vision. I’m excited to connect with like-minded, patient-centered innovators and find ways to make the future of family medicine even brighter. Our specialty has focused on delivering effective, equitable, and scalable healthcare since its creation, and I believe that starts with providing direction and stoking the passion of future family physicians.

Benjamin Slobodnik, MS3 I joined the CAFP Student-Resident Council because I saw an opportunity to further develop my own leadership skills, learn about the many ways a physician can advocate for their patients, and to create strong relationships with other family medicine physicians across the state.

I strongly believe that the Council can foster the growth of promising new ideas and promote inclusivity within the field. I also believe that increased cooperation between residents and medical students can only help bring ideas to fruition, and I am more than excited to be part of that process! continued on page 18

JOIN OUR TEAM! Now Hiring Primary Care Chair and Faculty • Make an impact on the Central Valley by serving the health care needs of our underserved and rural populations • Develop curriculum with whole-person approach to treatment and care, utilizing cutting-edge technology and hands-on experiences • Enjoy living in Central California’s diverse community culture with over 70 distinct ethnic groups • Find a family-friendly community with highly ranked educational institutions

See current openings at

chsu.edu/careers

California Family Physician Autumn 2022

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continued from page 17

CAFP and the CAFP Foundation welcome all of the Student-Resident Council members.

Uyi Aisueni, MS3 (Ross University School of Medicine) Andrea Banuelos Mota, MS4 (USC-Keck School of Medicine) Buranee (B) Bockman, MS4 (Ross University School of Medicine) Jodie Guller, MS4 (USC-Keck School of Medicine) Susan Wang, MS4 (UC San Francisco School of Medicine) Angie Zhang, MS4 (California Northstate University College of Medicine) Hannah Dragomanovich, MS4 (Touro University College of Osteopathic Medicine) Haris Rana, MS4 (Ross University School of Medicine) Lydia Nelson, MS4 (USC-Keck School of Medicine) Michelle Do, MS4 (California Northstate University College of Medicine) Tamer Tamer, MS4 (Ross University School of Medicine) Grace Firestone, PGY1 (Stanford-O'Connor Hospital FMRP) Lutetia Li, PGY1 (Long Beach Memorial FMRP) Nadine Grace-Abraham, PGY1 (Emanate Health FMRP) Tara Filsuf, PGY1 (Stanford-O'Connor Hospital FMRP) Juliana Jones, PGY1 (California Hospital FMRP) Jennifer Perdomo, PGY1 (Long Beach Memorial FMRP) Joel Solis, PGY1 (Kaiser Permanente Los Angeles FMRP) Karen Antwiler, PGY1 (Eisenhower Health FMRP) Samuel Chang, PGY1 (Stanford-O'Connor Hospital FMRP) Christina Spandler, PGY2 (UC Davis Family and Community MRP) Neel Kotrappa, PGY2 (Eisenhower Medical Center FMRP) Fari Valji, PGY2 (Long Beach Memorial FMRP) Khoa Nguyen, PGY2 (Kaiser Permanente Fontana FM Training Program) Pallavi Bhat, PGY2 (Eisenhower Medical Center FMRP) Yoon-kyu Sung, PGY2 (Stanford-O'Connor Hospital FMRP)

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California Family Physician Autumn 2022

c e o ’s m e s s a g e

Lisa Folberg CEO

Time Well Spent Time is our greatest commodity. We can’t buy it and we can’t make more; we can only figure out how to make the most of it.

I have always thought that making the most of my time was about getting things done. I come from a long line of people who know how to keep busy. I don’t remember my Finnish grandmother ever sitting down, and my mom, at 81 years old, remains a “land shark” who requires constant movement to keep the oxygen flowing through her gills.

Keeping busy is good, but like all things, best in moderation.

Being solidly in middle-age and starting to realize there is more life behind me than in front, I have been considering how I spend my time, where I place my efforts, and aspects of my time management that I might want to reframe. For most of my life I have employed magical thinking, that by working harder I will somehow create more time. I have also been infected with the idea that if I work harder, I will get through my to-do list. The antidote to this thinking has been to accept the reality that I won’t ever complete my to-do list, but I can put thought into addressing activities/ tasks that lead to a more meaningful and rich experience.

Framing my availability for work tasks and personal activities into a narrow, “I don’t have time” has been limiting and has added to my stress. Understanding that no matter how hard I work or for how many hours, my to-do list will never be done has been freeing. I have tried to replace “I don’t have the time” with “I am not prioritizing it.” It feels empowering to take back my schedule. A reframing has also forced me to focus more on prioritizing and being better about limiting the less important or meaningless activities.

Our family physician members are some of the most time committed people I know. I sometimes feel conflicted when asking you to serve on committees, do media interviews, send advocacy letters, or serve in leadership, because I know how busy you are. At its heart, CAFP is a volunteer organization. We depend on the participation of our physician members to make CAFP work well. We know most of you are struggling with how to “make the time” to go to work, care for friends and family and take care of yourselves (often in that order). While CAFP participation is not a requirement for a well-functioning personal and professional life, it is time well spent and may be one of your more enriching commitments.

Doing the things you love may not actually create more time, but it can expand our capacity and energy. We saw this during COVID-19. CAFP had some of the highest virtual event participation rates we have ever had during what was likely the busiest time for many of you. I see this every time we have a CAFP event, as tired as you may be, you leave feeling more energized and motivated than when you arrived.

Rather than draining you, you have told us that being involved in CAFP is additive and can help protect against burnout. Being involved in CAFP may look different at different times during your life. CAFP involvement does not have to involve a long-term commitment or take a huge amount of time. Your CAFP is here for you when and how it makes sense for you. The right CAFP connections can help you connect with your family physician community, learn new skills, and even advance your career.

1. Serve on a CAFP Committee 2. Run for local or state CAFP leadership position 3. Attend the All Member Advocacy Meeting to shape CAFP policy and learn more about advocacy 4. Connect with colleagues and get fantastic CME at POP Prism of Practice 5. Help get a family physician in the State Legislature 6. Become a key contact 7. Attend local chapter events I was recently listening to a song by CarolinaStory called "Time Well Spent." The lyrics recount very ordinary moments; a call from a friend or someone you love sleeping beside you as “time well spent.” The song is a reminder that it is the things that provide life meaning that should be included as time well spent, whether it is getting caught in a rainstorm with colleagues as you try and find the AAFP after-party or walking districts knocking on doors to support your family physician colleague in her bid for the legislature. We know that your time with CAFP is time well spent. https://www.youtube.com/watch?v=Gwhm3Ku9Ycs California Family Physician Autumn 2022

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Elder Care

Jeff Luther, MD, FAAFP

Elder Care: A Prescription for Loneliness If, like me, you’ve been in practice for a while you’ve probably seen your patient population age with or ahead of you. And on those days (I call them weekdays) when I feel like a de facto geriatrician, I am often faced with some of the social – in addition to physical - challenges my patients face. Chief and most subtle among these may be the quiet epidemic of loneliness.

Even before the pandemic the winter and the holiday season tended to bring with them more of a sense of loneliness and isolation for many seniors. Fewer daylight hours and longer nights; weather-related hindrances to travel; a societal focus on ‘togetherness’ at the holidays; and even the holidays themselves, reminding us of absent friends and loved ones – all of these and more can make the coming months tough for our elders. Other factors they may face include: • Social circles shrinking. Friends move away and lose connection, or they pass away.

• Changes in mobility or transportation make it difficult to meet others in person.

• Volunteering: think school, tutoring program, hospital, library, or museum.

• Picking up an old hobby or pastime, or taking a class to learn something new.

• Scheduling regular time to connect with friends or loved ones (whether by phone, in person, via email or even FaceTime).

• Checking out the local senior center for any interesting programs.

• Finding out if their health system or local hospital has any senior wellness groups or activities.

I am often faced with some of the social - in addition to physical challenges my patients face. Chief and most subtle among these may be the quiet epidemic of loneliness.

• Connecting with others virtually may be technologically challenging.

• Age-related hearing and vision loss may make it too difficult to meet up or communicate with friends and family.

• Other chronic medical conditions can lead to other impediments to social interaction (incontinence; need for use of mobility aids or oxygen; etc.).

As family physicians we are clearly concerned with the effect of all of this on our patients’ emotional well-being, but we must also recognize the potential impact on other aspects of their health. There are varying degrees of evidence associating loneliness and isolation with anxiety and depression, cardiovascular disease, obesity, cognitive decline and altered immune function.

20

So, what are we do to? Well, a gentle inquiry into a patient’s social connection or sense of community is a good place to start. Even bringing up the subject can start a helpful conversation and will certainly deepen a doctor-patient relationship. Beyond that, there may be steps we can suggest to relieve a bit of the loneliness.

California Family Physician Autumn 2022

Last week, I saw an 83-year-old patient of mine in the office. She was a volunteer at our hospital for decades until the pandemic put an end to that program. Then, early this year, she fell and fractured three lumbar vertebrae. Her recovery has gone fairly well, with physical therapy and time getting her to the point where her pain seems to be manageable. But her physical limitations and wish not to impose on her daughters’ time has shrunken her life, and one daughter shared with me that she stopped going to the art class she has attended for over 20 years. (She paints lovely watercolors.)

By the end of this visit I had (for the first time ever) written a prescription that read “Go to art class.” As importantly, I hope her experience has made me more sensitive to the fragile interplay between age, isolation and health.

I can’t wait to find out if she’s gone back to class!

Can we prescribe social media to combat loneliness and social isolation?

The world increasingly interacts online, and older adults are no exception. Can social media be a tool family physicians use to help our patients feels connected with others?

Key Points Internet use can strengthen social networks in older adults - Several studies show reduction of social isolation and loneliness compared to baseline

Policy; Committee on the Health and Medical Dimensions of Social Isolation and Loneliness in Older Adults. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. Washington (DC): National Academies Press (US); 2020 Feb 27. 9, Interventions. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557966/ % of U.S. adults 65 and who say they ever use …

- Frequency of contact with friends, frequency of contact with family, and attendance at organizational meetings is positively associated with internet use

(Source: Survey of U.S. adults conducted Jan. 25-Feb. 8, 2021. Pew Research Center. https://www.pewresearch.org/internet/fact-sheet/social-media)

- May be especially beneficial for those who are homebound

• Instagram 13%

• Facebook 50%

However

• Twitter 22%

- As more people go online, the inability to use internet platforms by older adults may actually exacerbate social isolation

• YouTube 49%

- Internet use to find new people may be a risk factor for loneliness and social isolation. It may benefit primarily those with existing social network by maintaining close ties in existing relationships. Those who are already isolated may not benefit by internet use alone Source: National Academies of Sciences, Engineering, and Medicine; Division of Behavioral and Social Sciences and Education; Health and Medicine Division; Board on Behavioral, Cognitive, and Sensory Sciences; Board on Health Sciences

• TikTok 4% • NextDoor 8% If you are looking to be more engaged on social media, download the CAFP Social Media Toolkit for Family Physicians.

The CAFP communications team and Membership Engagement Committee (MEC) have created a Social Media Toolkit. This toolkit provides best practices, including the top 10 things to maximize your impact on social media. Resources include two CAFP webinars available in Homeroom any time: Social Media Basics for Family Physicians and Social Media as an Advocacy Tool: A Look at #ThisIsOurShot, Using Your Voice to Build Vaccine Trust.

The toolkit also includes examples of how to respond to misinformation, and a list of family medicine thought leaders to follow.

Figure 1. Social Media use by age. Surveys of U.S. adults conducted 2005-2021.

Pew Research Center.

California Family Physician Autumn 2022

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Trauma-Informed Family Medicine Erika Roshanravan, MD, FAAFP

Trauma-informed Care for Every Body (Part 1) This is the first installment of a two-part discussion on weight stigma, and how using trauma-informed care will improve care experience and engagement for patients of increased weight. Stay tuned for Part 2 in the Winter 2023 issue, where Dr. Roshanravan will discuss disordered eating, the relationship between trauma and weight, and what family physicians can!

“Why would I go to the doctor? I really don’t want to hear again that I should lose weight.”

“I bet the only thing they’d have to say about my symptoms is lose weight anyway.”

“They say to lose weight, but nothing ever works anyway.”

“I don’t want to get weighed all the time, so I just don’t go to the doctor.”

When we talk about trauma-informed care, we talk about creating safety, trustworthiness, empowerment for patients and staff. It is interesting and frankly alarming to realize that as a healthcare system, we seem to have a blind spot for this when it comes to patients with increased weight.

Although well-intentioned, common workflows such as unasked weight checks at every visit or checking the box on “counseled about diet and exercise,” can create unease, and even make patients with increased weight feel unsafe, untrustworthy, and disempowered. What we were taught is the “right thing” is stigmatizing, and evidence shows our part in weight stigma encourages and increases disordered eating, low self-esteem and stress, and the likelihood that stigmatized patients avoid healthcare altogether (Alberga et al, 2019).

Weight stigma is defined as “discriminatory acts and ideologies targeted towards individuals because of their weight and size.” Like other types of stigma, weight stigma is a form of trauma and can have devastating psychological and social effects for affected individuals.

Unlike other types of stigma, much of weight stigma is socially acceptable because of the common assumption— including by physicians—that increased weight is largely a choice. This assumption ignores that weight results from the complex interplay of heredity, epigenetics (remember 22

California Family Physician Autumn 2022

how trauma changes epigenetics?), mental health, social determinants of health, and the prenatal and postnatal environment.

The thing is this: I don’t think we in the medical community have made a sweeping commitment to combatting weight stigma and its harms, and we do not acknowledge our role in it. Most of medicine still believe that “thinness” is objectively “better,” despite evidence that it is not necessarily healthier.

Many of us may also feel some unease with supporting patients of all sizes and shapes. We may feel that allowing patients to “love their bodies just the way they are” ignores the risk we see in their weight, and so we impress the need to change and telegraph our disapproval of our patients’ bodies. Studies in adolescents at higher weights actually show our error: there is an association between better body image and lower future weight gain, improved mental wellness and much lower rates of disordered eating (Sonneville et al, 2012; Sonneville et al, 2015).

To make matters worse, the traumatization of patients with weight stigma is pointless, because the advice we give day in and day out—"diet and exercise”—has proven largely ineffective. Very few people successfully lose weight, and many of those who do gain it right back (Fildes et al, 2015).

Now to Body Mass Index (BMI). First of all, BMI is a terrible proxy for health. Besides its problematic roots in an entirely white European population, it also entirely ignores important indicators of health like cardiorespiratory/ cardiometabolic fitness, muscle mass and others. In fact, the AMA House of Delegates acknowledged this as an issue at their 2022 Annual Meeting and referred it to their Board of Trustees for further consideration.

Even accepting the conventional thinking about BMI, physicians tend to forget that the association of BMI and mortality is J shaped: lower BMI and higher BMI are both associated with an increase in mortality. In fact, a large study

by Bhaskaran et al. (2018) in the Lancet showed that the mortality curve rises more sharply towards lower BMIs than towards higher BMIs, especially in women and the elderly.

In women, for example, a BMI of 20 had about the same

mortality as a BMI of about 32.

I have a BMI of 20, and despite these findings, my doctor has never told me that I should gain weight. Moreover, I am generally met with the assumption that I am fit without knowledge of my lifestyle habits or risk factors. Meanwhile, my patient with a BMI of 40 exercises at high intensity daily, eats a plant-based diet, has a hemoglobin A1c one percent lower than mine, and an enviable unmedicated LDL, yet she is routinely met with the assumption that she is lazy, non-compliant, and “just needs to start doing the right thing.”

Unfortunately, this weight bias is all too common.

I know this is complicated, but I also know we can do better.

We will talk about how to do better for all patients of any size in next issue’s edition.

References Alberga AS, Edache IY, Forhan M, Russell-Mayhew S. Weight bias and health care utilization: a scoping review.

Prim Health Care Res Dev. 2019 Jul 22;20:e116. doi: 10.1017/S1463423619000227. PMID: 32800008; PMCID: PMC6650789.

Bhaskaran K, Dos-Santos-Silva I,9/28/22 Leon DA, Douglas IJ, A1106printad4ParadigmOut.pdf 1 7:06 PM Smeeth L. Association of BMI with overall and cause-

specific mortality: a population-based cohort study of 3·6 million adults in the UK. Lancet Diabetes Endocrinol. 2018 Dec;6(12):944-953. doi: 10.1016/S2213-8587(18)30288-2.

Epub 2018 Oct 30. PMID: 30389323; PMCID: PMC6249991.

Fildes A, Charlton J, Rudisill C, Littlejohns P, Prevost AT, Gulliford MC. Probability of an Obese Person Attaining Normal Body Weight: Cohort Study Using Electronic Health Records. Am J Public Health. 2015 Sep;105(9):e54-9. doi: 10.2105/AJPH.2015.302773. Epub 2015 Jul 16. PMID: 26180980; PMCID: PMC4539812.

Sonneville KR, Calzo JP, Horton NJ, Haines J, Austin SB, Field AE. Body satisfaction, weight gain and binge eating among overweight adolescent girls. Int J Obes (Lond). 2012 Jul;36(7):944-9. doi: 10.1038/ijo.2012.68. Epub 2012 May 8.

PMID: 22565419; PMCID: PMC3394875 Report of Reference Committee D. June 2022 Meeting of the AMA House of Delegates. https://www.ama-assn.org/system/files/a22-resolutions.pdf.

Accessed October 5, 2022.

Sonneville KR, Thurston IB, Milliren CE, Kamody RC, Gooding HC, Richmond TK. Helpful or harmful? Prospective association between weight misperception and weight gain among overweight and obese adolescents and young adults. Int J Obes (Lond). 2016 Feb;40(2):328-32. doi: 10.1038/ijo.2015.166. Epub 2015 Aug 25. PMID: 26303350.

continued on page 24 California Family Physician Autumn 2022

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Lee Ralph, MD

AAFP COD Recap

CAFP Delegate to the AAFP

CAFP Looks Back at 2022 Congress of Delegates

The Friends of Jay team at the AAFP Candidate Hospitality Event

For the first time in three years, the AAFP Congress of Delegates was held in-person in the nation’s capital of Washington, DC from September 18-21, 2022. The California delegation arrived in force to try to push forward resolutions presented by its members through the All Member Advocacy Meeting previously held in Sacramento. First on the agenda was pushing forward the campaign for AAFP Board of Directors of Dr. Jay W. Lee, from Orange County. Jay was successfully elected on the final day, becoming the first Korean American AAFP Director. He also is the first Californian elected

Drs. Lee and Simon at the Candidate Hospitality Event

at the AAFP Board level in the past decade. His candidate speech was heartfelt and brought out an emotional response from the delegates and attendees. His theme focused on Family Medicine Rising (#FMRising) and the important role family physicians will play in the future of our health care system.

Additional elections were held for President-Elect, Speaker and Vice Speaker of the Congress and other Board of Directors.

Dr. Steven Furr (Alabama) was elected President-Elect. Dr. Russell Kohl (Oklahoma) was elected Speaker, and Dr. Daron

Drs. Ralph and Lee at AAFP's 2022 Congress of Delegates

continued on page 26 24

California Family Physician Autumn 2022

Join a team that’s been helping to redefine what it means to be a community clinic for 50 years.

Vista Community Clinic has outstanding opportunities for Full-Time and Part-Time Physicians. We are looking for dedicated, motivated and enthusiastic team players who want to make a difference in the community.

Vista Community Clinic is a federally qualified, not-for-profit healthcare clinic with more than 800 employees and nine state-of-the-art clinics treating more than 69,000 patients every year. We provide healthcare throughout the Southern California regions of North San Diego, Orange and Riverside Counties.

Our compensation and benefits program includes: C ompetitive compensation, sign-on bonus, relocation bonus, health, dental, vision, company-paid life, long-term disability, flexible spending accounts, 403(b) retirement plan, malpractice coverage, NHSC loan repayment eligible organization, CME allowance, and no on-call hours For more information visit www.vcc.org or email hr@vcc.org EEO/AA/M/F/Vet/Disabled

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25

continued from page 24

Gersch (Minnesota) was elected Vice Speaker. Dr. Jay W. Lee was joined by Dr. Kisha Davis (Maryland) and Dr. Teresa Lovins (Indiana) as the newest members of the Board.

The majority of the time in the Congress was spent reviewing resolutions from each of the state chapters. Numerous resolutions were introduced on topics related to administrative burden, reproductive health rights, continuation and expansion of telehealth, global health, and climate awareness. California introduced resolutions on training in transgender education, equitable distribution of COVID vaccines, reproductive healthcare accessibility, reparations for Black Americans, surgical rights of intersex children, fire prevention, and

Drs. Ward and Quiogue alternate delegates

preparation and working toward zero waste. Most of the California resolutions were adopted or referred to the Board for further refinement.

The California Delegation to the AAFP Congress of Delegates

Overall, it was a pleasure to finally get to meet in person with our colleagues from around the country for the first in person meeting in the past three years. The entire delegation agreed that more fruitful discussions and testimony transpired, and the ability to reconnect with fellow family physicians led to a highly successful Congress.

Next year’s Congress will be held in Chicago, IL on October 25-27th, 2023, so start thinking about any issues you would like to be brought forward as a resolution.

Save a life. Don’t Drive HoMe buzzeD. BUZZED DRIVING IS DRUNK DRIVING.

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California Family Physician Autumn 2022

VA Northern California Health Care System

WE ARE HIRING! Primary Care Physicians

Supervisory: Modesto, CA - Yuba City, CA - Chico, CA - Redding, CA Staff Physicians: Modesto, CA - Stockton, CA - Chico, CA - Redding, CA Clinical Deployment Team (CDT) PC Physicians: Sacramento, CA

To apply, email current CV to: Crystal.Keeler@ @va.gov The Department of Veterans Affairs (VA) needs primary care professionals who possess the energy, compassion, and commitment to serve those who served our country. Eligible applicants must be able to provide comprehensive general primary care and comprehensive women’s health care.

Whether your a new graduate or an experienced professional, physicians are always needed at the VA. These locations have a lot to offer to those seeking good weather and an abundance of outdoor activities such as hiking, snow skiing, boating, hunting and fishing. Enjoy the area’s beautiful rural settings with access to many national parks, rivers, and lakes at your fingertips. Whether you’re interested in work/life balance, research or academics you will find that working for the VA offers many benefits not to mention the great honor we have in serving our nation's heroes.

Available benefits: • Insurance for Medical, Dental, Vision and Long • Term Care Sick and Annual Leave accrual starting on day one Education Debt Reduction Program • Recruitment/Relocation Incentives • Some positions offer partial tele-work opportunities, but are not virtual assignments

Candidates must: 1) be US Citizen or Green Card Holder; 2) BE/BC Family Medicine or Internal Medicine; 3) have a medical license in any State; and 4) confirm vaccination for seasonal influenza and Coronavirus Disease 2019 (COVID-19), which are both requirements for all Health Care Personnel (HCP) employed by Department of Veterans Affairs.

Supervisory candidates should: have demonstrated leadership experience or demonstrate informal leadership training, experience and skills.

Jasmeet Bains’ Campaign:

Putting a Family Physician in the CA Assembly Running on a platform to address the challenges facing Central Valley families, Dr. Bains aims to improve access to healthcare to build strong communities, expand quality education, and more.

CAFP is providing updates on Dr. Bains’s campaign and ways you can get to know the candidate. If you would like to get involved with the campaign, please consider volunteer opportunities. Visit

familydocs.org for more information. To donate to Dr. Bains’s campaign please scan the QR code.

About Dr. Bains

Dr. Bains is a family physician providing primary healthcare to families throughout the Central Valley. She is a champion for children, fighting to improve health outcomes for vulnerable communities while increasing opportunities for all who call the Central Valley home. Dr. Bains is running for State Assembly to make an even bigger difference and address the challenges facing Valley families, from improving access to healthcare to building strong communities, expanding quality education and more.

About District 35 District 35 is a newly redrawn district that now covers parts of Kern County including Delano, Shafter, and Arvin. It used to be part of District 32 prior to redistricting due to population change reflected in the 2020 census. The new boundary lines took effect at the start of this year’s legislative races.

POP 2023: Prism of Practice CAFP and CAFP Foundation are very excited about joining forces (and conferences) in 2023 to bring you POP: Prism of Practice - Celebrating the Spectrum of Family Medicine.

Expect the same great content, networking, keynotes, and community service opportunities that the Family Medicine Clinical Forum brings. Combine that with the enthusiasm and excellent student/resident hands on workshops, residency fair, and keynotes the Family Medicine Summit brings to make POP 2023 one conference you won't want to miss next year!

Save the date: August 25-27, 2023 in Orange County!

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California Family Physician Autumn 2022

JOIN OUR TEAM! NECC HAS OPPORTUNITIES FOR FAMILY MEDICINE PHYSICIANS who are dedicated to our mission of providing primary and preventative healthcare services to our underserved communities. Connect with our recruiters at providerrecruiter@necc.net.

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California Family Physician Autumn 2022

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CALIFORNIA ACADEMY OF FAMILY PHYSICIANS 816 21st Street Sacramento, California 95811

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provide policyholders timely resources and expert advice to improve patient safety and reduce risk. To learn more about the benefits of being an MIEC policyholder, or to apply, visit miec.com or call 800.227.4527.

Get a quote today.

Medical Malpractice coverage for individuals, groups and facilities.

Acupuncture, Psychiatry, and other specialty coverages available.

miec.com | 800.227.4527

Insurance by physicians, for physicians.™