Fall 2015

California

FAMILY PHYSICIAN Vol . 66 No. 4 Fall 2015

A Focus on Alternative Medicine, Mindfulness and Physician Well-Being

Incorporating an Integrative Approach: One Family Doc’s Experience

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CAFP Scholarship Recipient Reflects on AAFP National Conference

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How to Stop Worrying and Learn to Love Your Clinical Questions

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Woven Program Provides Women Support Circle

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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

Officers and Board President Jay W. Lee, MD, MPH President-Elect Lee Ralph, MD

Susan Hogeland, CAE

Cynthia Kear, MDiv, cHCP

shogeland@familydocs.org

ckear@familydocs.org

Executive Vice President

Allison Bauer

Immediate Past President Del Morris, MD

Associate Director, Communications and Publications

Speaker Michelle Quiogue, MD

Jerri Davis, CHCP

Vice-Speaker Lisa Ward, MD Secretary/Treasurer Walter Mills, MD

California FAMILY PHYSICIAN

Staff

abauer@familydocs.org

Senior Vice President

Quarterly publication of the California Academy of Family Physicians

Cody Mitcheltree

Nathan Hitzeman, MD, Editor Allison Bauer, Managing Editor

cmitcheltree@familydocs.org

Communications Committee:

Nathan Hitzeman, MD, Chair

Manager, Information, Technology and Foundation Programs

Abhinaya Narayanan

Workforce Development Manager

Director, CME/CPD

jdavis@familydocs.org Brian Devine

Manager, Finance

bdevine@familydocs.org

anarayanan@familydocs.org Leah Newkirk Vice President, Health Policy lnewkirk@familydocs.org

Shelly Rodrigues, CAE, FACEHP

Executive Vice President Susan Hogeland, cae

Adam Francis

Foundation President Anthony Chong, MD

afrancis@familydocs.org

Richa Saraswat

Maria Jennings

rsaraswat@familydocs.org

AAFP Delegates Jeff Luther, MD Carla Kakutani, MD AAFP Alternates Carol Havens, MD Jay W. Lee, MD, MPH

Deputy Director, Government Affairs

Manager, Membership

Deputy Executive Vice President

srodrigues@familydocs.org Program Support Coordinator

mjennings@familydocs.org Sonia Kantak

• Julia Blank, MD • Nathan Hitzeman, MD • Jeffrey Luther, MD • Jay Mongiardo, MD • Michelle Quiogue, MD • Albert Ray, MD 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.

Manager, Medical Practice Affairs

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CMA Delegation Ashby Wolfe, MD, MPP, MPH Nathan Hitzeman, MD Michelle Quiogue, MD Suman Reddy, MD Kevin Rossi, MD Patricia Samuleson, MD

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California Family Physician Fall 2015

12 Incorporating an Integrative Approach: One Family Doc’s Experience

Ronald Cotterel, MD, MS

16 CAFP Scholarship Recipient Reflects on AAFP National Conference

Jenna Diggs

20 How to Stop Worrying and Learn to Love Your Clinical Questions 24 Woven Program Provides Women Support Circle

Kimberly Duir, MD Rachel Abrams, MD, MHS, ABIHM

28 Integrative Medicine Allows Focus on Core Areas of Family Medicine

Robert Bonakdar, MD

6 Editorial

CAM I AM?

Nathan Hitzeman, MD

8 President’s Message

Mindfulness: The Importance of Preventing Physician Burnout

Jay W. Lee, MD, MPH

9 PCMH Corner

Physicians’ Perception of Change Affects Satisfaction

10 Political Pulse

Rough and Tumble Politics Just Got Rougher

30 EVP’s Forum

CAFP Strategic Planning Focuses on Doctor’s “Pain Points”

Leah Newkirk Carla Kakutani, MD Susan Hogeland, CAE

For upcoming CME activities visit family docs.org/cme California Family Physician Fall 2014

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editorial

Nathan Hitzeman, MD

CAM I AM? I’m still trying to get a grip on complementary and alternative medicine (CAM). Some days it feels like a wet snout, other days a floppy ear and still others, a solid leg to stand on. In mechanical terms, a cam is a rotating wheel that strikes a lever or rod and produces action and linear motion. I’m all for patients becoming more active in their health, whether it be through mindfulness, wellness classes, exercise, tissue mobilization (massage, acupuncture, acupressure) or plantbased remedies.

If Chinese healers were doing something for thousands of years and it seemed to work, there is probably something to it.

Many Western medications come from plants (think aspirin/willow bark, digoxin/ digitalis), so it is not a far stretch that herbal remedies may sometimes help.

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replacement, epidurals for back pain, chemotherapies that prolong life less than good hospice care would, cough and cold medications. How can that cough syrup be both a cough suppressant and expectorant at the same time? Tell me that, modern science!

But sometimes surprises happen. Leeches are medicinal in some contexts (skin grafts). Being treated with another person’s poop can now be lifesaving. I have a patient who was a former athlete, became severely depressed a decade ago, was zombified and gained a bunch of weight on a cocktail of antipsychotics, and now had a near miraculous response to Transcranial Magnetic Stimulation (TMS). Things like TMS may seem like TMI at times, but we need to know about what’s out there.

It’s good to keep an open mind and heart, and I think family docs do that best.

We are pragmatic.

It’s good to keep an open mind and heart, and I think family docs do that best. We are pragmatic.

We work with our patients where they are at and, given the options, that would seem to appeal to them. We can whiz against the wind, but what’s the point?

I’m wary of CAM being something other, or even taboo, that thing “that your doctor doesn’t want you to know about.” I’m wary of all things internet. I’m wary of overinflated promises – “this berry extract will help you lose 20 pounds in one week.” I’m wary of cleanses, chelation, toxin theories, thyroid conspiracies, casual marijuana prescribing. I’m wary when there are large amounts of money to be made (Ah-hem, Dr. Oz). And some things just sound bad – like when my patient with MS said she was getting “bee sting therapy.” The cure should not be worse than the disease!

Sometimes it is good to return to basics and CAM has a good way of doing that. It reminds us to take time out from our overstimulated lives and meditate. It reminds us how to touch people physically and find where it hurts. It makes us mindful of what we ingest into our bodies and where it came from. It reminds us how to properly take a breath and fill our lungs. Is it a sad commentary on our society when we’ve forgotten how to breathe?

It’s easy to wag a gouty finger at CAM. Forcefields, crystals, energy beams, magnetism. But one can just as easily say pshaw to many Western medicine practices: arthroscopic knee surgery for arthritis, vertebroplasty, hormone

Well, take a deep breath, fill those lungs. Heck, make it two breaths! Check out our issue on CAM. Avoid SPAM or anything in a can. Listen to WHAM, but don’t watch Van Damme. In a house or with a mouse, CAM I AM!

California Family Physician Fall 2015

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California Family Physician Fall 2015

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president’s message

Jay W. Lee, MD, MPH

Mindfulness: The Importance of Preventing Physician Burnout Late last year, I received an urgent message from a medical school classmate from whom I had not heard in some time.

Although I’m usually happy to hear from old friends, the urgent tone of her message suggested that the news she wanted to share wasn’t good.

I was right. One of our classmates had taken his own life.

Physician burnout is a serious yet underreported issue. About half of family physicians in the United States suffer from symptoms of burnout and physicians have a higher suicide rate than the general population.

In fact, our nation loses the equivalent of an entire medical school class to suicide each year.

In this issue of California Family Physician, you will read stories about integrative medicine and mindfulness. I believe it comes at a strategic time in our story as family physicians.

In the wake of my friend’s death, I took a personal timeout and assessed where I am in my life and career. The good news is I’m quite blessed. I have an amazing wife –who also is a physician – and we have three beautiful kids. I have a good job where I get to see patients, teach residents and help lead our group. And this year, I have the privilege to serve as your president.

Piece by piece, life is pretty good. But taken as a whole, it can be overwhelming at times. Should I strive for life-work balance or merely survive each day’s frantic schedule? I do my best to be mindful of and intentional with all my responsibilities, and I try to contribute meaningfully in all of these areas.

What is painfully obvious is we need to do more to prevent physician burnout.

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California Family Physician Fall 2015

A critical part of the solution is creating a physician culture of mindfulness. This cannot happen if we allow the continued piling on to our daily grind. We must begin unpacking how we got so far away from what we envisioned becoming the physicians we wrote about in our personal statements and begin activating ourselves to move toward making health primary for our patients and ourselves. We must become the physician leaders our health care system needs us to be. That means we need to lead change beyond achieving the Triple Aim: better health, better patient experience and better value. We must understand how to bring joy back to our practice of medicine.

Without joy, the Triple Aim cannot be achieved. Joy in practice is a prerequisite and we must be intentional about calling it out and building capacity for achieving it.

This must be a core value for why we transform our practices.

In this issue of California Family Physician, you will read stories about integrative medicine and mindfulness. I believe it comes at a strategic time in our story as family physicians. As more and more of the newly insured enter our practices, there is a potential for more and more work and little focus on physician well-being as it becomes painfully evident how severe our state’s primary care workforce shortage is.

I encourage you to become the strong voice for change, to become the physician leaders our health care system and our primary care colleagues need us to be. We deserve to have an integrative and mindful approach to our work (just as our patients deserve the best primary care we can deliver). And if we deserve it, we must act to make it so.

If you’d like to share your story about mindfulness or physician burnout, please contact the CAFP via email (cafp@ familydoc.org) or post a comment on our Facebook page (facebook.com/familydocs).

PCMH Corner

Leah Newkirk

Physicians’ Perception of Change Affects Satisfaction In August, The Commonwealth Fund and The Kaiser Family Foundation released a report (the Commonwealth Report) describing primary care providers’ views of recent trends in health care delivery and payment, including health information technology (HIT), Patient Centered Medical Home (PCMH) and Accountable Care Organizations (ACOs).1 The physicians, physician assistants and nurse practitioners surveyed describe a varied experience with new care models and tools and, perhaps most troubling, a high level of discontent.

The Commonwealth Report describes a changed practice environment. Approximately one-third of the 1,624 primary care physicians surveyed described themselves as qualifying as a PCMH or advanced primary care practice. A similar portion described themselves as participating or preparing to participate in an ACO. These results match AAFP’s practice survey data. Another important data point from the Commonwealth Report suggests upheaval in primary care practice: 17 percent of physicians report that their practice has consolidated with or been acquired by a group practice, a hospital or another type of organization in the past two years.

The Commonwealth Report describes providers’ mixed perceptions of new models of care and tools. Half of physicians described HIT’s positive effect on the quality of care patients receive. One-third of physicians described PCMH as having a positive effect on quality of care, while 40 percent described the model as having a negative or no effect on quality. Those physicians who received incentives or payments for qualifying as a PCMH or advanced primary care practice viewed the model more positively. Only 14 percent of physicians describe ACOs as having a positive effect on quality of care, while 47 percent describe a negative or no effect on quality.

Other results in the Commonwealth Report are disheartening. Only 22 percent of physicians feel the increased use of quality metrics to assess provider performance is having a positive effect on quality of care. And then there is the data assessing overall satisfaction with practice change. Nearly half of physicians said that recent trends in health care are causing them to consider retiring earlier than they originally thought they would.

Perceptions of quality do not exactly match research on quality.

When it comes to research on PCMH, for example, results generally show a positive effect on quality. A study published in the same month as the Commonwealth Report shows a medical home intervention led to improvements in quality, increased primary care utilization and lower use of emergency department, hospital and specialty care.2 Physicians’ perceptions are significant, however, particularly to organizations such as CAFP that are dedicated to our members’ well-being. What leads to the discouraging data in the

Commonwealth Report? And what should we do about it?

Here are a few CAFP hypotheses: The Affordable Care Act greatly accelerated the pace of change in health care delivery and that change continues apace. The old adage “change is hard” is important to remember; perhaps physicians’ perceptions reflect the difficultly of transformation.

Financial incentives also play an important role. Primary care physicians are expected to do a lot of work that goes uncompensated.

CAFP certainly hears from members who describe their frustration with the uncompensated time and effort associated with quality improvement programs. It is again worth noting that physicians who participate in a PCMH for which they receive incentives or payments view the model more positively, and it is CAFP’s goal to see that all family physicians receive incentives or payments for PCMH work.

Finally, transformation work may detract from what physicians find satisfying about their jobs and what they are likely to view as improving the quality of care delivered: direct patient care.

Medscape’s Family Physician Compensation Report for 2015 reports a decrease in hours per week that family physicians actually see patients and an increase in hours spent on non-clinical paperwork.3 Medscape also reports that family physicians view their relationships with patients as, by far, the greatest source of satisfaction in their work. If a PCMH, ACO and other programs that measure quality are associated with more paperwork and less time with patients, how could family physicians view this as improving quality?

CAFP will continue to investigate. We are an association – your association – and we invite you to participate in this conversation.

How are changes in health care delivery and payment affecting your practice and your satisfaction with your work? What can we do to increase your satisfaction and improve the quality of care you deliver to patients? Let CAFP know your thoughts by contacting me at lnewkirk@familydocs.org or (415) 345-8667.

References: 1. Available at https://kaiserfamilyfoundation.files.wordpress. com/2015/08/1831_commonwealth_kaiser_primary_ care_survey_final1.pdf.

2. Friedberg, MW, Rosenthal, MB, Werner, RM, Volpp, KG, Schneider, EC. “Effects of a Medical Home and Shared Savings Intervention on Quality and Utilization of Care.”

JAMA Intern Med. 2015;175(8):1362-1368.

3. Available at http://www.medscape.com/features/ slideshow/compensation/2015/familymedicine#page=1 Leah Newkirk is CAFP’s Vice President of Health Policy.

California Family Physician Fall 2015

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POLITICAL PULSE

Carla Kakutani, MD

Rough and Tumble Politics Just Got Rougher CAFP does not often take controversial positions on legislation or policy matters. With the guiding mantra of advocating on behalf of family physicians and their patients, almost all bills CAFP supports are common sense efforts, such as ensuring underserved populations have access to primary care and expanding oral health coverage, among others. That is why it was so surprising that CAFP, and particularly our stalwart Legislative Advocate in Sacramento, Jodi Hicks, became public enemy number one for a group of “anti-vaxxers” in a debate over a bill that saw five-hour long legislative hearings, shouting matches, stalking and even death threats.

Spurred by the measles outbreak that started at Disneyland, Senator and pediatrician Richard Pan, MD authored SB 277, a bill to allow only physician-ordered medical exemptions to the childhood vaccine requirements for admittance into any public or private day care, elementary school or secondary school. This effectively removes the religious and personal belief exemptions to vaccinations. The bill allows unvaccinated children to enroll in private home-schooling programs that serve multiple families and permits such children to participate in independent study projects that are overseen by school districts but do not include classroom time. The bill includes a provision that gives unvaccinated children with existing non-medical exemptions more time to comply with the rule by requiring vaccine checks only at preschool, kindergarten and seventh grade. In addition, the bill allows, but does not require, physicians to consider family histories when determining medical exemptions.

CAFP’s Legislative Affairs Committee adopted an early Support position on the bill, citing the mountains of evidence that vaccines are essential to creating herd immunity, preventing serious illness and protecting public health. In the committee’s view, passing this legislation would help to ensure herd immunity in every corner of California and protect individuals who are too young or, for medical reasons, cannot be vaccinated.

Although numerous groups and organizations were in support of the bill, CAFP, and Jodi Hicks in particular, became a target of the “anti-vaxxers’” ire. While debate in the public sphere is the sign of a healthy democracy, opposition to this bill took an ugly turn. First, conspiracies pedaled by opponents gained traction on social media. Anti-vaxxers posted purposefully misleading material claiming Ms. Hicks was a pharmaceutical lobbyist (she is not) and that she was a puppet master, controlling what legislators were saying and doing (the world might be a better 10

California Family Physician Fall 2015

place with family physicians running the show, but CAFP always respects the democratic process!).

While conspiracy theories may have been bothersome, what came next was downright frightening. Opponents were aggressive as the bill proceeded in the legislative process. CAFP leaders were quoted numerous times in news publications across the state, including the L.A. Times, KQED, California HealthLine, Oakland Tribune and more than a dozen others.

Despite our physicians’ presence, the anti-vaxxers continued to focus on Ms. Hicks, to the point of openly stalking her in the streets of the capital. Ms. Hicks refused to give in to their intimidation tactics and continued to testify in support of the bill on behalf of CAFP. While opponents warned of the next Holocaust, CAFP focused on the facts: vaccines save lives and do not cause autism.

As a result of the strong work of Senator Pan, Ms. Hicks, CAFP Key Contacts and dozens of other supportive organizations, legislators stood tall and voted in support of the bill and the Governor signed it. CAFP especially would like to thank CAFP member Catherine Sonquist Forest, MD, MPH, whose heartbreaking patient story was read as part of the bill’s closing argument.

While everyone hoped the Governor’s signature might put an end to the ugliness of the opposition, it seemed only to enrage them further. In Los Angeles, graffiti was found on a wall reading: “4 Every Kid Afflicted A Public FiguRE WILL Die – SB 277.” These threats were taken very seriously. Extra security precautions were taken for those involved.

It is clear that the opposition wants to continue the fight. At the time of this writing, opponents are gathering signatures to place a referendum to overturn the law on the November 2016 ballot. Additionally, opponents have begun a campaign to recall Senator Pan and have until December 2015 to gather signatures. We hope that the tactics used by the opposition will be civil this time, but make no mistake: CAFP will continue to support the new law and Senator Pan. We need your help.

Please consider contributing to the Family Physicians Political Action Committee (FP-PAC) by visiting us at www.familydocs. org/advocacy/fp-pac to help us combat efforts like these and support candidates who fight for primary and preventive health.

Dr. Kakutani is Chair, CAFP Legislative Affairs Committee.

Chronic Kidney Disease: Delaying Disease Progression in Your Patients

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Your practice will focus on one of these evidence based project aims:

By committing to improving CKD care processes through this improvement project you will:

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patients with annual micoralbuminuria and serum creatinine testing • Addressing elevated blood pressure

2. Review data from a minimum of 25 patients in your practice. You can use either EHR queries, chart pulls or gather data as you treat your patients. Using your patient data you will select

• Recording CKD on the patient’s problem list

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• Prescribing an ACE/ARB

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• Addressing NSAID use with your patients

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improvement plan to test in your practice.

3. Your team will improve the delivery of care. Practical tools will allow you to measure and assess the result of your improvement efforts.

4. Upon completion of two improvement cycles you will reflect on the changes implemented so that you can sustain and spread your improvement efforts.

Upon completion of your project you will be awarded 20 credits from your board for meeting the MOC Part IV requirements for Performance in Practice. You and your team will receive CME/CE credit as well as the satisfaction of knowing that you have improved care for your patients.

Register Today: http://www.ckdmoc.org Questions? cme-cpd@familydocs.org

California Family Physician Fall 2015

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Ronald Cotterel, MD, MS

Incorporating an Integrative Approach: One Family Doc’s Experience Tom S. was a 58-year-old patient in my practice for years. He was climbing the ladder at his corporate law firm and had the elevated blood pressure and cholesterol to show for it. We had reviewed lifestyle changes at several visits, and he was just not ready to take medication. “Isn’t there something else we can do?”

We agreed upon Hawthorne extract for its mild antihypertensive effect, and fish oil capsules in an effort to improve his lipid profile. He agreed to begin a regular exercise program, and to enroll in a mindfulness-based stress reduction class. I did some dietary counseling. We kept the door open to medications if in the future if these measures did not prove effective.

For two decades, I have had the good fortune to offer not only the breadth and continuity of family medicine, but also the myriad of options offered by complementary/alternative medicine (CAM). Family doctors are well suited to using CAM techniques as we espouse “whole-patient” care and like to engage patients in their own care.

Perhaps my penchant for including “a little something extra” stems from the fact that I came to family medicine through the back door. I had a graduate degree in nutrition. I enjoyed people, and I enjoy helping them stay healthy. I soon realized that a career in dietetics had limitations in both employment opportunities and to the extent in which I could have a personal impact on the lives of others.

As I looked at the world around me during medical school and residency, I found that patients were using therapies not being taught to me and my colleagues. So I sought out elective rotations, professional meetings, extra reading and botanical/herbal therapy. I began to hone skills that have become as intrinsic to my practice as writing prescriptions and doing minor surgical procedures.

I can offer patients visits focused on lifestyle improvement that include the core basics of diet and exercise, as well as stress management options including yoga, breathing, meditation and mindfulness. If patients are reticent to take pharmaceuticals (as many are in my progressive university community), I can offer a trial of herbal therapy or nutritional

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California Family Physician Fall 2015

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supplements. How refreshing for patients to include them in the decision making process with an expansive menu of options! I am also honest with my advice, based upon both evidence of scientific literature and my own years of practice experience.

Just as every primary care physician relies upon the support of specialist physicians, I have called upon the help of complementary therapists in my community on a regular basis.

These modalities include massage, chiropractic, acupuncture, yoga, psychotherapy, chi gong and mindfulness meditation.

Through the years we have learned from one another and supported one another in our mutual belief in an integrative and holistic approach to healing and health.

For family physicians looking to incorporate an integrative approach, many options are available. The University of Arizona offers fellowships in Integrative Medicine, some of them online.

Many excellent scientific meetings covering various facets of Integrative Medicine and complementary therapies, such as those offered by the Scripps Center for Integrative Medicine and UC San Francisco Osher Center for Integrative Medicine, are available as well. For references in the office, I highly recommend David Rakel’s text “Integrative Medicine,” or one of the many online resources such as those offered by the

National Centers for Complementary and Alternative Medicine, or Natural Medicines Database.

A small amount of effort in building upon traditional Family Medicine training to include complementary therapies can pay off in a big way. Not only are patients more satisfied, but I am, too. What a true pleasure as a family physician to be able to offer “something extra” to our patients.

References: • https://integrativemedicine.arizona.edu/education/ fellowship/ • https://www.scripps.org/for-health-careprofessionals__continuing-medical-education-cme • http://www.osher.ucsf.edu/education/ • Rakel, David, et al. Integrative Medicine, Third Edition, Elsevier 2012 • http://health.nih.gov • https://naturalmedicines.therapeuticresearch.com Ronald Cotterel, MD, MS is a practicing family physician at Sutter Health in Davis, CA. He specializes in alternative medicine, health maintenance, mind-body wellness and preventative care.

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California Family Physician Fall 2015

THE STRENGTH TO HEAL and stand by those who stand up for me.

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California Family Physician Fall 2015

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STUDENTS AND RESIDENTS

Jenna Diggs

CAFP Scholarship Recipient Reflects on AAFP National Conference

Each year, the CAFP Foundation sponsors California medical students to attend the conference. This year, the Foundation was pleased to offer eight $750 scholarships. Scholarship recipients were recognized at the California Reception on Friday, July 31 at the Hotel Phillips and also submitted a written reflection of their experiences. One of this year’s scholarship recipients, Jenna Diggs, reflects on her experience:

I aimed to balance attendance at workshops with my goal to meet with individuals in every residency program on my interest list. Needless to say, I was quite busy. The opening and closing speeches were wonderful avenues for me to ponder the vastness and depth of Family Medicine and to learn firsthand what it takes to excel in this specialty. Dr. Beeson’s speech on “Practicing Excellence” particularly spoke to me. He reminded me about the importance of ‘quality’ – in my work, in my interactions, in my documentation and in myself. Sometimes, the pressures of medical school make it easy for me to forget how important it is to simply be a kind human to others and to myself. I appreciated that he highlighted the core of what medicine is all about – working well with others to provide compassionate care to those in need.

Since the time I started vocalizing my desire to go into family medicine, students and physicians involved in the field strong encouraged me to attend the National Conference. They told me it would be an incredible experience as a medical student – and one that I would regret missing. Fortunately, I heeded their advice. I am so grateful that I had the opportunity to attend without the worry of the financial burden since I received the CAFP Foundation scholarship.

Inspired by Dr. Beeson’s speech, I braved the exhibit hall.

With more than 20 programs on my interest list, I got down to business right away. From a practical standpoint, I felt so lucky to learn about so many programs directly and talk to both residents and program directors all under one roof. From a career standpoint, I enjoyed networking with individuals who may play a role in deciding my future. From a personal standpoint, my conversations with so many

CAFP President, Dr. Jay W. Lee, speaks at the California Reception held for all California attendees.

Conference attendees mingle at the AAFPNC Exhibit Hall.

AAFP’s National Conference for Family Medicine Residents and Medical Students is an annual student- and residentfocused event in Kansas City, MO. Thousands of students and residents travel to Kansas City to explore family medicine through workshops, main stage sessions and networking with peers and potential employers.

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California Family Physician Fall 2015

Continued on page 18 >

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different people helped me to create new goals and solidify old ones as I continue my journey as a budding physician. I managed to see almost every program on my list, except for two, in the day-and-a-half that I spent at the conference.

Despite the hustle and bustle of the exhibit hall, I also attended a few workshops. The talk featuring residency applications, “Applying to Residency: From Before Application to After the Interview,” was exceptional. It answered most of my questions about the entire process and made it seem less daunting than I had originally imagined. My other favorite workshop was the “Small-town Doc” session. I do not plan to apply to rural residencies, but I would like to practice rural medicine at some point in my life. This talk highlighted the joys and hardships of working in a remote setting.

I headed home to San Diego feeling rejuvenated and knowledgeable. This conference reminded me again why family medicine is such a perfect specialty for me. It also helped me create a definitive list of programs to which I plan to apply this fall. I cannot wait for the possibilities before me and I appreciate that the CAFP Foundation funded my attendance.

...I felt so lucky to learn about so many programs directly and talk to both residents and program directors all under one roof.

Jenna Diggs is a fourth-year medical student and University of California, San Diego School of Medicine. She is also one of this year’s CAFP Foundation Scholarship winners.

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California Family Physician Fall 2015

Kimberly Duir, MD

How to Stop Worrying and Learn to Love Your Clinical Questions My own journey toward learning to love my clinical questions began about 15 years ago when I attended a course called “Information Mastery,” which was put on by a family doctor named David Slauson and a clinical pharmacologist named Alan Shaughnessy. They taught us the mysteries of evidencebased medicine, but I came away with much more than that. I felt empowered to seek answers to my own questions through the use of a few common sense principles.

Since then, I have also realized that the secret to lifelong learning is the willingness and ability to recognize and seek answers to those pesky questions that come up every day in the practice of medicine. Studies have shown that as primary care physicians we encounter an average of 25 questions per day for which we do not have answers. Even more interestingly, the researchers found that if they asked physicians at the end of the day how many questions they encountered, they could only remember one or two of them.

I am curious about how, and even more intriguingly, why we forget those questions so quickly.

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When asked, physicians respond that they do not seek answers to their own questions because of lack of time and the belief that they will not be able to find answers.

I wonder if some of it has to do with suppressing our awareness of all those questions because of some deep emotional discomfort with not knowing the answers. I think as physicians we have at best an ambivalent relationship with not knowing the answers. Throughout our educational lives, shame has been associated with not knowing the answers. Our value was judged mostly on what we could memorize or carry in our heads. I experienced considerable dread as I approached my fifth board recertification exam this April, because I knew that if the answers were not in my head, they would not count!

When we were in medical school our heads were crammed full of memorized facts. Other than the vague exhortation that we should “read more” as we were sent out into the world to be doctors, there was no warning that five years later much of what we had so painstakingly memorized would be out of date and we would have to figure out what

Continued on page 22 >

“The Academy is a way that I can stay connected, be a voice and be inspired as a family physician. It provides a community of like-minded individuals who are passionate not only about their field, but also about service to society.”

WHY EARLY CAREER PHYSICIANS SHOULD BE CAFP MEMBERS 1. Enjoy opportunities to grow your professional network with like-minded family physicians and healthcare leaders at local chapter and statewide events such as the All Member Advocacy Meeting and Family Medicine Clinical Forum.

2. Use our career development resources, including information on entering practice and contract negotiation, through the CAFP’s online Practice Resource Center.

3. Stay up to date on vital health care issues, on vital health care issues affecting California family physicians and their patients with such publications California Family Physician, Academy in Action, Practice Management News and the Legislative Update.

4. Protect patients’ through such public health advocacy efforts in Sacramento and Washington as the recent effort CAFP spearheaded to eliminate the personal and religious exemptions for childhood immunizations in California – a major public health victory.

5. Take advantage of leadership development opportunities by joining CAFP committees, legislative training, our CME Leaders’ Institute and more.

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Marie-Elizabeth Ramas, MD Medical Director, Mercy Mount Shasta Community Clinic Member, CAFP Medi-Cal Taskforce, Legislative Affairs Committee Member, AAFP Commission on Membership and Member Services

The UCSF Fresno Medical Education Program and the Central California Faculty Medical Group (CCFMG) are recruiting for a physician to join the teaching faculty. The successful applicant should be board certified in Family Medicine. California licensed or eligible to obtain a California license. This position provides an opportunity for teaching, clinical research, and community practice. Proficiency in OB optional.

Administrative/leadership opportunities are available. A competitive salary sala is offered. The program is based in Fresno, California, where residents enjoy a high standard of living combined with a low cost of living. The result is a quality of life uniquely Californian, yet surprisingly affordable. Limitless recreational opportunities and spectacular scenery is all accessible in a community with abundant affordable housing.

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was stale and how and when to replace it. And the world of medical literature is vast and more than a little intimidating.

I would like to offer you Slauson and Shaughnessy’s brilliantly simple guide to what they call the “medical information jungle.”

I invite you to use this guide to feel both empowered as you reckon with all those clinical questions. The usefulness of any source of medical information can be best assessed by looking at only three factors: 1.

2.

3.

How relevant is this information to my patients?

How likely is this information to be true?

How much work does it take to get this information?

The advent of online sources of medical information has been a real game changer in terms of the work of getting medical information. The convenience of having a smart phone in my pocket – allowing me to look something up while seeing patients – cannot be beaten by walking down the hall to look for a textbook of dubious currency.

But I still have to assess the validity of my medical information online! We are blessed with new tools to overcome the

insecurity of assessing statistical validity. Make sure your source of medical information uses one of the objective systems for evaluating the strength of a clinical recommendation. Our academy journal uses SORT but familiarize yourself with the others and beware of sources that do not provide graded evidence.

Albert Einstein said “I have no particular talent; I am merely inquisitive.” We may feel sometimes that we have no particular talent, but in the face of what we don’t know, we can learn to move from reflexive shame to curiosity. “Gosh, I don’t know, let’s look it up!” It may feel hard to say that to a patient or a student the first few times, but it gets easier with practice.

Let’s commit to one another today to take the next step in honoring our questions, whatever that step may be. Let’s take that next step together through the secret portal to lifelong learning!

Kimberly Duir, MD is a practicing family physician at the ContraCosta Regional Med Center. She presented this topic at CAFP’s 2015 Family Medicine Clinical Forum and it can now be viewed online at familydocs.org/cme.

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California Family Physician Fall 2015

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Rachel Abrams, MD, MHS

Woven Program Provides Women Support Circle In my last two decades of practice as a family doc, I have been amazed, and sometimes astounded, by the ability of my patients to heal themselves. So much so, that I find myself searching for “clues” while listening to my patients tell the stories of their health challenges. What are the experiences or findings that will help us “unlock” their ability to heal? The clues are varied: a previous history of trauma that has never been addressed, closet alcoholism, unrecognized depression, signs of vitamin deficiencies, or un-treated sleep apnea, as small examples. These stumbling blocks suppress the body’s ability to heal itself or impair the patient’s ability to make healing choices in his or her life. My dual board certification in integrative medicine has been invaluable in helping me discover ways to support patients to help themselves and avoid unnecessary medications or interventions. I love the deep detective work that I get to do with patients and families in my practice. It is endlessly fascinating and enormously satisfying.

One of the more challenging areas that I find myself exploring in my detective work with patients, however, is their sometimes desperate lack of love and community.

It has been touching and inspiring to hear what happens when women truly feel heard.

They make life-changing decisions, which, of course, positively affect their mental and physical health.

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Now, you may say that this is really not my job—that I should call in a social worker or a therapist—but as I know you know…these folks are hard to come by on the spot when you need them. And as a doc who is really concerned about health prevention, the statistics on the health benefits of love and community are staggering.

More important than cigarettes. More important than exercise. More important than a healthy diet. Or even stress.

According to the famed Alameda study, the risk of death among people with the fewest social ties is more than twice as high as the risk for adults with the most social ties, independent of socioeconomic status or health behaviors. In another study of 3,000 nurses with breast cancer, women who are socially-isolated are twice as likely to die from breast cancer and have a 66 percent increased risk of dying from any cause. The nurses in this study who had the most friends, ten or more, were four times more likely to survive their cancer.

In many ways, this health crisis of isolation is a modern phenomenon. None of us would have survived alone throughout our human evolution—until relatively recently. We needed one another for food, protection and childrearing. And in my study of traditional cultures (I’m a closet medical anthropologist), I can think of no example of a thriving culture in which women did not gather together on a regular basis for socializing, childcare, food preparation, weaving, agriculture or a multitude of other tasks that the community needed. We are genetically and neurologically built for community and affection. As a physician seeking to help my patients heal individually, but also to heal our world, I felt compelled to do something to re-build community, and, being female, started with women. Also, let’s be honest, women are easier to gather.

I co-founded Woven, a collaboration of face-to-face and heart-to-heart circles of women who gather in communities all over the world to share wisdom, stories and support, with the intention of addressing isolation in women’s lives. Woven circles are particular to the place and the people who start them. We provide a structure

Continued on page 26 >

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for how to run a circle, including some basic training in listening and reflection, but women, unsurprisingly, are “naturals” at gathering together for support and transformation. It has been touching and inspiring to hear what happens when women truly feel heard. They make life-changing decisions, which, of course, positively affect their mental and physical health.

WHEN IS A CHILD’S BRUISE FROM AN ACCIDENT OR SOMETHING MORE?

Woven is a simple intervention, but addresses one of the most profound risks to health that we encounter. I have been writing prescriptions for massages, romantic dates, obtaining a pet and other behavioral changes for years. Now I can prescribe love and community. It’s a powerful healer.

References: • Berkman Lisa F., Syme Leonard.

1979. Social Networks, Host Resistance, and Mortality: A NineYear Follow-up Study of Alameda County Residents. American Journal of Epidemiology 117:1003-1009 • C. H. Kroenke et al., “Social Networks, Social Support, and Survival After Breast Cancer Diagnosis,” Journal of Clinical Oncology 24, no. 7 (March 1, 2006); 1105–11.

Dr. Rachel Carlton Abrams runs the Santa Cruz Integrative Medicine Clinic in Santa Cruz, California, is the co-founder of Woven (www.wovenweb.com) and is the coauthor of four books. She helps lead two committees for the Academy of Integrative Health and Medicine on membership and diversity and reconciliation.

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California Family Physician Fall 2015

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Family Medicine Residency Faculty

Department of Family Medicine seeks family medicine physician as residency faculty for the CHMC/USC Residency program.

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Physician – Full-time position for the Clovis facility. Current CA MD or DO license required; Board Certified/Board Eligible Family Practice or Internal Medicine; Current DEA; ACLS required; EMR exp. pref.; Excellent benefits package; Hiring in accord. with Indian Pref. Act. Please send CV to CVIH HR, 2740 Herndon Ave., Clovis, CA 93611 or email to hr@cvih.org Central Valley Indian Health, Inc.

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We currently have the following opportunities with our different medical groups throughout Northern & Central California:

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Join Us in Caring for Our Community Clinica Sierra Vista is seeking dedicated physicians who are passionate about our mission. We are proud to provide high quality and comprehensive primary and prevention health care services to the underserved populations of Kern, Fresno, and Inyo counties. Become part of our team and play an important role in improving the health of our patients and community.

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Qualified applicants must be board certified or eligible in Family Practice, Pediatrics, Internal Medicine, or Obstetrics and Gynecology, and have an unrestricted CA medical license.

www.clinicasierravista.org | Jason Bailey - 559-832-0013 California Family Physician Fall 2015

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Robert Bonakdar, MD

Integrative Medicine Allows Focus on Core Areas of Family Medicine Most family physicians become interested in integrative medicine (IM) through a few predictable routes. Some are exposed out of personal interest or health issues that utilized an integrative therapy; some become frustrated at the limitation on current options for certain conditions and find IM as they search outside the conventional toolbox. Others learn from patients over time and begin to incorporate various approaches based on the populations they serve. For me it was a combination of these factors. In 1992, while in pre-medical training, I received a Richter International Fellowship to study Southeast Asian Healthcare Practices. This was a combination of personal interest in Eastern approaches as well as a desire to learn techniques for pain management that I knew would be a part of my future practice. I had already seen in my family as well as in clinical shadowing how quickly the toolbox can seem empty in the setting of chronic pain. During my travels I was stunned when I toured various clinics and hospitals to find techniques, such as guided imagery and acupuncture, being deployed along side state-of-the-art “Western” care prior to surgery. Could these worlds really get along?

During residency in San Diego, I completed additional training in acupuncture at the University of California, Los Angeles and began a half-day acupuncture clinic. Once word got out, the clinic became popular, especially among clinic staff, and expanded to fielding questions regarding diet, supplements, hypnosis and beyond. After residency I joined Scripps Clinic as there was a desire to expand pain management offerings for those who had failed conventional care.

In this scenario, I find that my family medicine training is excellent for delving into the biopsychosocial underpinnings of my patients’ presenting complaints. I also find that IM allows me the time and doorway to dive deeper into areas, such as diet, mood and activity that are core areas of family medicine.

Unfortunately these area are often sidelined for reasons such as time and the need to arrive at more immediate solutions.

Beyond this, IM allows me to connect patients with therapies such as acupuncture; biofeedback, mindfulness, nutrition and evidence-based dietary supplements that may be both areas of treatment preference as well as therapies with evidence for clinical benefit.

I am fortunate to be working in a supportive environment in which my patients can consider the “best of all worlds,” especially when approaching refractory issues such as pain, depression or cancer. I also see myself as a protector in this 28

California Family Physician Fall 2015

scenario – helping patients steer clear of “too good to be true” hype and focusing on therapies such as biofeedback that can be transformative, cost effective and patient-driven.

I am fortunate to be working in a supportive environment in which my patients can consider the “best of all worlds.”

After more than 15 years of practicing integrative medicine, I realize three important points. In the world of high-tech medicine, I continue to be pleasantly reminded that “simple” suggestion, whether a dietary shift, a stress management strategy or a well chosen supplement, can bring relief even when other therapies have not. Second, patients use IM far more often than we realize and family physicians are best positioned at asking “what else are you considering” to open the doorway and provide initial discussion for patients who are often confused in this arena. Finally, I realize that I practice IM for my personal health as much as I do it to help patients find expanded solutions. As we “healers” get ready to go into room 6 to see that patient with a fibromyalgia flare, it is many times the IM techniques I have learned that help me be the most present with patients. Often this is the most valuable tool I “integrate” in a hectic clinic day.

Considering Integrative Medicine?

Suggestions from Dr. Bonakdar: • Start with areas of interest and find online materials you can review to see if it’s right for you.

• Attend CME courses to dive deeper.

• Take additional trainings or fellowships, many can be done without losing much practice time.

Dr. Bonakdar is the Director of Pain Management at the Scripps Center for Integrative Medicine in San Diego, CA.

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Faculty Family Medicine Residency Rancho Mirage, California

Argyros Health Center, La Quinta, CA

Become an integral part of an exciting new residency program! We recently welcomed our third class of residents and have full 10-year ACGME accreditation.. Eisenhower Medical Center in Rancho Mirage, California seeks to hire two physician leaders to serve as Family Medicine Residency faculty members. You will have in-patient and out-patient care responsibilities as well as precepting FM residents in the Center for Family Medicine. You will have protected time for curriculum management, advising residents, and scholarly work.

Board certification in Family Medicine is required. An academic appointment will be confirmed from the Keck School of Medicine, University of Southern California and rank will depend upon experience and qualifications.

Eisenhower Medical Center seeks candidates whose experience, teaching, research, or community service has prepared them to contribute to our commitment to serving the Coachella Valley. EMC is an EO/M employer. Qualified applicants, including recent residency graduates, are encouraged to apply. Candidates should submit an electronic CV and statement of interest to Anne Montgomery, MD, MBA, Program Director, at amontgomery@emc.org . For questions or inquiry, please contact Fran DeYoung, FM Residency Program Manager at fdeyoung@emc.org or 760-773-4504.

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Susan Hogeland, CAE

Executive Vice President’s Forum

CAFP Strategic Planning Focuses on Doctor’s “Pain Points” This column has nothing to do with alternative medicine. I’ve taken the wise advice of folks I trust and pulled the column I wrote originally in favor of something less controversial.

Darn it.

This magazine will carry more articles in the future about the results of the strategic planning meeting CAFP held in Oakland July 18-19, but it should be known that your leaders and your staff are well in touch with the pain points in members’ practice lives. Without doubt, at the top of the pain point list is the need for payment reform now. Both practice transformation and our workforce pipeline depend on payment reform. But, much as your leaders and staff wish a magic wand could be waved to institute fair payment for primary care services now, that isn’t going to happen. And, of course, no payment reform ever is going to make everyone happy.

the hoped for future payment environment in which family physicians and other primary care health professionals are fairly compensated for the comprehensive, coordinated care they give their patients without bringing the Chevy to a complete stop. So in addition to the monograph on payment reform we produced in April, CAFP will try to address how family medicine is valued, offer trainings on negotiation skills, address sustaining your practice, help you choose which new Medicare payment system will work better for you and more.

When the AAFP or CAFP achieve a victory with regard to payment, such as fixing the Medicare Sustainable Growth Rate, some still are unhappy because all the problems haven’t been fixed; sadly, we and AAFP have to work with what’s possible, not what’s perfect. The challenge to get more family physicians to have a better understanding of the legislative process is huge, to say nothing of engaging them in politics such as by contributing to FP-PAC or FamMedPAC. But we never quit trying.

The photo shown to the right may give us a little perspective on payment. It is my long-deceased grandmother’s hospital receipt from 1960 (pre-Medicare) for an “original history & physical” ($7.50) and 17 days of in-patient care at $4/day (!) for a grand total of $75.50, which she paid in cash. In 55 years, the cost of care increased from $4/day to nearly $2,000/day (in Nebraska, per Becker’s Hospital Review for 2014). Interestingly, the physician charge represented about 11 percent of the hospital bill, so some things haven’t changed!

But to go back to the planning retreat, participants (your Board members, committee chairs and staff) agreed that achieving payment reform is similar to the well-known analogy of changing the tires on a Chevy traveling 60 miles an hour down the highway. One has to survive in the current payment environment long enough to get to and thrive in

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California Family Physician Fall 2015

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