SUMMER 2019
M I N D I N G T H E H E A LT H C A R E
Graduate Medical Education Grant Awards Challenges of Cultural Diversity in Healthcare Employed Physicians Outnumber Self-Employed Summer 2019
CENTRAL COAST PHYSICIANS
1
UPCOMING COTTAGE HEALTH
Clinical Education Events 9TH ONCOLOGY NURSING SYMPOSIUM Friday, September 13, 2019 Hilton Santa Barbara Beachfront Resort
Oncology Nursing Symposium
SAVING THE BRAIN THE 12TH ANNUAL NEUROSCIENCE SYMPOSIUM OF THE CENTRAL COAST Friday, November 8, 2019 Hilton Santa Barbara Beachfront Resort
HEALING THE HEART SECOND ANNUAL CARDIOLOGY SYMPOSIUM Friday, February 7, 2020 Hilton Santa Barbara Beachfront Resort
saving the brain
Healing the Heart
For more information and to register, visit cottagehealth.org/symposium
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CENTRAL COAST PHYSICIANS
Summer 2019
VOLUME 4, NUMBER 3 • SUMMER 2019
{FEATURES}
6 8 12 16 28 Summer 2019
{DEPARTMENTS}
CALMEDFORCE GME GRANTS AWARDED
14 CENCAL HEALTH NEWS HUB
EMPLOYED PHYSICIANS OUTNUMBER SELF-EMPLOYED
24 CLASSIFIEDS
SIERRA VISTA LAUNCHES 24-HOUR HOSPITALIST PROGRAM
30 NEW MEMBERS
22 MEN’S HEALTH 26 PUBLIC HEALTH 31 IN MEMORIAM
MINDING THE HEALTH CARE GAP CHALLENGES OF CULTURAL DIVERSITY IN HEALTHCARE
CENTRAL COAST PHYSICIANS
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Letter from the CEO
IMPROVING ACCESS
Congratulations to local physicians who received funding through CalHealthForce and CalHealthCares.
PRESIDENT Jennifer Hone, MD PRESIDENT ELECT Kevin Casey, MD SECRETARY Ali Javanbakht, MD TREASURER Samira Kayumi-Rashti, MD
DANA GOBA
Marian Regional Medical Center’s new residency program in obstetrics and gynecology was one of 73 residency programs awarded a CalHealthForce grant, which is supporting the sustaining, retaining, and expansion of graduate medical education.
DIRECTORS Bindu Kamal, MD; Daniel Berger, MD; Joseph Freeman, MD; Joseph Schwartz, MD; Julie Fallon, MD; Priti Gagneja, MD; Rachel May, MD; Rahim Raoufi, MD; Thomas Hale, MD CHIEF EXECUTIVE OFFICER Dana Goba, MBA CMA HOUSE OF DELEGATES REPRESENTATIVES Sharon Basham, MD; Edward Bentley, MD; Kevin Casey, MD; David Dodson, MD; Priti Gagneja, MD;
Multiple physicians in our community will receive student loan repayments through CalHealthCares, and their names will be announced soon. Physicians receive debt relief in exchange for maintaining a caseload of at least 30% Medi-Cal patients among other criteria.
Jennifer Hone, MD; Samira Kayumi-Rashti, MD; Christopher Lumsdaine, MD; Joseph Schwartz, MD CMA DISTRICT V TRUSTEE Rene’ Bravo, MD CENTRAL COAST PHYSICIANS MAGAZINE EDITOR Jennifer Hone, MD
CalHealthForce and CalHealthCares are funded by Proposition 56 (tobacco tax), which was passed in part to the significant support of a coalition led by the California Medical Association. Prop 56 funds are providing more than $1 billion annually to improve provider payments, graduate medical education (GME) funding increases, and medical school loan repayments. For more information about CalHealthCares and CalMedForce, visit www.phcdocs.org.
MANAGING EDITOR Dana Goba, MBA CREATIVE DIRECTOR Sherry Lavone Design CONTRIBUTING WRITERS American Medical Association; Henning Ansorg, MD; California Medical Association; CenCal Health; David Dodson, MD; Elizabeth Schwyzer; Susan Shepard, MSN, RN; Jose Yongco, MD CONTRIBUTING PHOTOGRAPHERS CenCal Health, Elizabeth Schwyzer, Sierra Vista Regional Medical Center SUGGESTIONS, story ideas, or completed stories written by current Central Coast Medical Association members are
For physicians who aren’t yet members, join your colleagues who are working to improve the future of healthcare. You can become a member at www.cmadocs.org/join or by calling 800.786.4262.
welcome. Opinions expressed by authors are their own and not necessarily those of the CCMA. CCMA reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. PLEASE DIRECT EDITORIAL INQUIRIES AND SUBMISSIONS TO: Central Coast Physicians
Together we are stronger.
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ADVERTISING rates and information sent upon request. Acceptance of advertising in Central Coast Physicians in no way constitutes approval or endorsement by CCMA of products or services advertised. CCMA reserves the right to reject any advertising. All advertising inquiries can be sent to magazine@sbmed.org.
Dana Goba Chief Executive Officer Central Coast Medical Association
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CENTRAL COAST PHYSICIANS
Summer 2019
HIGHEST HOSPITAL SAFETY RATING. 7 YEARS IN A ROW. Thank you to our nurses, doctors, staff and volunteers for helping Sierra Vista and Twin Cities Hospitals achieve recognition as two of the safest hospitals in America, every year since 2012. Just five hospitals in the state of California have the honor of this distinction.
Summer 2019
SierraVistaRegional.com
TwinCitiesHospital.com
CENTRAL COAST PHYSICIANS
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First CalMedForce award cycle funds 156 residency positions Physician Shortages by Region
In the inaugural cycle of CalMedForce in January 2019, PHC awarded $38 million to GME programs across the state to fund approximately 150 physician residents. In total, PHC received funding requests for nearly 600 residency positions from 131 residency programs, totaling more than $147 million! “These CalMedForce grants will help California grow and strengthen the physician pipeline to meet the demands of our state’s growing and changing patient population,” said Lupe Alonzo-Diaz, MPAff, PHC president and CEO.
NORTHERN & SIERRA
SACRAMENTO AREA
GREATER BAY AREA
The 73 programs that received awards in the first cycle represent residency positions in both urban and rural areas. Programs that focus on medically underserved areas and populations were given priority. Of the 156 residency positions funded, 74 are existing residency slots that could have been eliminated if not for this funding. Eighty-two of the positions funded are brand new – 60 of them in new residency programs and 22 at existing programs.
SAN JOAQUIN VALLEY
NORTHERN & SIERRA
CENTRAL COAST
INLAND EMPIRE
LOS ANGELES COUNTY ORANGE COUNTY
SAN DIEGO AREA
Number of Physicians per 100,000 population by Health Care Region 60–69
50–59
40–49
30–39
CalMedForce Awardees (73 Total)
Recommended supply of primary care physicians is 60-80 per 100,000 population. California state average is 50 primary care physicians per 100,000 population. Source: Meeting the Demand for Health: Final Report of the California Future Health Workforce Commission, 2019.
The California Medical Association (CMA) foundation— Physicians for a Healthy California (PHC)—is committed to growing a diverse physician workforce by supporting, incentivizing, and expanding graduate medical education (GME) in California. PHC this year launched a new grant program, CalMedForce, which will support primary care and emergency medicine residency programs in California. The program was made possible by the Proposition 56 tobacco tax, which was sponsored in 2016 by CMA, the California Hospital Association and Service International Employees Union-United Healthcare Workers West. The University of California is the designated recipient of the funding and has contracted with PHC to administer the annual grants.
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CENTRAL COAST PHYSICIANS
PHC announces second application cycle for CalMedForce GME grants The application will be released September 23, 2019 and is due by October 28, 2019. Priority will be given to programs in medically underserved areas and programs who serve medically underserved populations. For more information, visit phcdocs.org. Summer 2019
Funding Residents by Discipline 2018–19 Existing Positions
New Positions
Total
Family Medicine
14
29
43
Internal Medicine
14
19
33
OB/GYN
11
8
19
Pediatrics
22
11
33
Emergency Medicine
13
15
28
Totals
74
82
156
Discipline
“ Inadequate funding for medical residency programs forces talented young doctors who want to stay and practice in California to train in other states.” - CMA President David H Aizuss, MD
Applicants for CalMedForce Grant Cycle 2018–19 Number of Residency Programs Requested: 131
Total Funding Amount ($) Requested: $147,255,500
Awarded: 73
Awarded: $38,195,000
“ The demand for these funds is a clear indicator of the statewide need for this funding and an example of how the new tobacco tax will help improve access to care in California.” - Cathryn Nation, MD
“The demand for these funds is a clear indicator of the statewide need for this funding and an example of how the new tobacco tax will help improve access to care in California,” said Cathryn Nation, MD, associate vice president for health sciences in the UC Office of the President. Sadly, California is a mass exporter of medical students. Every year, hundreds of graduating medical students do not find a residency slot in California to continue their training. Every dollar invested into expanding residency slots in California is significant, considering one primary care resident can conduct approximately 600 patient visits per year. “Inadequate funding for medical residency programs forces talented young doctors who want to stay and practice in California to train in other states,” said CMA President David H Aizuss, MD.
Summer 2019
The data shows that most physicians set down roots in the areas where they train and remain there after their training to care for their communities. When California-educated medical students leave to another state for a residency program, they often do not return. Overall, 54.2% of individuals who completed residency training from 2008-2017 are practicing in the state of where they trained. California ranks the highest of all states, with a 77.7% rate for in-state retention. We can grow our physician workforce by expanding the number of California residency positions.
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CENTRAL COAST PHYSICIANS
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O
Employed Physicians
Outnumber
Self-Employed
Changes of this magnitude
are not unprecedented.
Older AMA surveys show
the share of self-employed
physicians fell 14% points
during a six-year span
between 1988 and 1994.
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CENTRAL COAST PHYSICIANS
For the first time in the United States, employed physicians outnumber self-employed physicians, according to a newly updated study on physician practice arrangements by the American Medical Association (AMA). This milestone marks the continuation of a long-term trend that has slowly shifted the distribution of physicians away from ownership of private practices. Employed physicians were 47.4% of all patient care physicians in 2018, up 6% points since 2012. In contrast, self-employed physicians were 45.9% of all patient care physicians in 2018, down 7% points since 2012. Changes of this magnitude are not unprecedented. Older AMA surveys show the share of self-employed physicians fell 14% points during a six-year span between 1988 and 1994. >>
Summer 2019
Given the rate of change in the early 1990s, it appeared a point hospital or in a practice at least partly owned by a hospital in was imminent when employed physicians would outnumber 2018, up from 29.0% in 2012. self-employed physicians, but the shift took much longer than Younger physicians and women physicians are more likely anticipated. The AMA’s research notes this example and suggests to be employed. Nearly 70% of physicians under age 40 were “caution should be taken in assuming current trends will employees in 2018, compared to 38.2% of physicians age 55 continue indefinitely.” and over. Among female physicians, more were employees than The majority of patient care physicians (54.0%) worked in physician-owned practices in 2018 “ T ransformational change continues in the either as an owner, employee, or delivery of health care and physicians are contractor. Although this share fell from 60.1% in 2012, the trend away responding by reevaluating their practice from physician-owned practice appears arrangements.” to be slowing since more than half of the shift occurred between 2012 and - AMA President Barbara L. McAneny, M.D. 2014. Concurrently, there was an increase in the share of physicians working directly for a hospital or in a practice at least partly owned practice owners (57.6% vs. 34.3%). The reverse is true for male by a hospital. Physicians working directly for a hospital were physicians, more were practice owners than employees (52.1% 8.0% of all patient care physicians, an increase from 5.6% in vs. 41.9%). 2012. Physicians in hospital-owned practices were 26.7% of “Transformational change continues in the delivery of health all patient care physicians, an increase from 23.4% in 2012. In care and physicians are responding by reevaluating their practice the aggregate, 34.7% of physicians worked either directly for a arrangements,” said AMA President Barbara L. McAneny, M.D.
Summer 2019
CENTRAL COAST PHYSICIANS
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“Physicians must assess many factors and carefully determine for themselves what settings they find professionally rewarding when considering independence or employment. The AMA stands ready to assist with valuable resources that can help physicians navigate their choice of practice options and offers innovative strategies and resources to ensure physicians in all
contractors (27.3%). Family practice was the specialty with the highest share of employed physicians (57.4%). Despite challenges posed by dynamic change in the health care landscape, most physicians still work in small practices. This share has fallen slowly but steadily since 2012. In 2018, 56.5% of physicians worked in practices with 10 or fewer physicians compared to 61.4% in 2012. This change has been predominantly driven by the Despite challenges posed by dynamic shift away from very small practices, especially solo practices, in favor of very change in the health care landscape, most large practices of 50 or more physicians. physicians still work in small practices. The new study is the latest addition to the AMA’s Policy Research Perspective series that examines long term changes in practice sizes and settings can thrive in the changing health practice arrangements and payment methodologies. The new environment.” AMA study, as well as previous studies in the Policy Research As in past AMA studies, physicians’ employment status Perspective series, is available to download from AMA website varied widely across medical specialties in 2018. The surgical at www.ama-assn.org/about-us/physician-practice-benchmarksubspecialties had the highest share of owners (64.5%) followed survey. by obstetrics/gynecology (53.8%) and internal medicine subspecialties (51.7%). Emergency medicine had the lowest share of owners (26.2%) and the highest share of independent
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CENTRAL COAST PHYSICIANS
Summer 2019
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Summer 2019
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CENTRAL COAST PHYSICIANS
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SIERRA VISTA LAUNCHES
24-Hour
HOSPITALIST PROGRAM Program improves patient experience and provides more efficient care BY JOSE YONGCO, MD, MEDICAL DIRECTOR OF HOSPITALIST PROGRAM AT SIERRA VISTA
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CENTRAL COAST PHYSICIANS
Sierra
Vista Regional Medical Center has launched a new program that provides 24-hour, in-house physician coverage for patients. Our sister hospital, Twin Cities Community Hospital in Templeton, also has a 24-hour hospitalist program.
Sierra Vista – the largest hospital in San Luis Obispo County – had the goal of providing comprehensive care for our patients around the clock. Together, Sierra Vista and Twin provide 24/7 coverage so that no matter where patients are within the health system, patients can trust that they will always receive the highest quality of care, at all times of the day. Our Hospitalist Program at Sierra Vista is comprised of seven physicians and three nurse practitioners, all of which are board certified in their respective fields. Physicians whose practices are dedicated to providing care specifically to patients within the hospital are called Hospital Medicine Specialists or Hospitalists. Hospital Medicine is the latest medical specialization to be recognized by Medicare as a specialty. By providing inpatient coverage 24/7, 365 days a year, our patients receive care immediately, day or night. There is continuously a hospitalist on campus, readily available, who can evaluate patients as needed and adjust treatment plans throughout the day. The hospitalist coverage at Sierra Vista is in addition to what was already provided by the Emergency Department physicians around the clock. Patients and families can expect more face-to-face time with their physician hospitalists. This allows them to be better informed and educated about their condition and what to expect moving forward. Overall, patients typically recover faster and head
Summer 2019
home sooner when they feel connected to their physician and are in tune with their health. With this program in place, patients will notice their care being more team-based. Hospitalists collaborate with each patient’s primary care physician, other physician specialists, therapists, and members of a multi-disciplinary group of providers to ensure patient care is timely, coordinated, and seamless. Without delay, hospitalists are able to admit patients from referring community physicians, trauma surgeons and the emergency department. They are also available immediately to respond to urgent or emergency inpatients concerns. Our team of hospitalists are here with our patients on campus, at all times. It’s like having your own dedicated physician when you are hospitalized. We ensure the care we provide is comprehensive and patient-centered. By providing this around the clock coverage at both Sierra Vista and Twin, patients and their families know earlier in the day when they will be discharged, allowing them ample time to prepare. In addition, patients who need to be hospitalized can expect to be moved out of the emergency department sooner, and emergency patients can expect a shorter wait time before being seen by a physician.
PATIENTS AND FAMILIES CAN EXPECT MORE FACE-TO-FACE TIME WITH THEIR PHYSICIAN HOSPITALISTS. THIS ALLOWS THEM TO BE BETTER INFORMED AND EDUCATED ABOUT THEIR CONDITION AND WHAT TO EXPECT MOVING FORWARD.
CENTRAL COAST PHYSICIANS
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CenCal Health NEWS HUB:
Fighting the Good Fight: Increasing Vaccination Rates with Vaccine-Awareness Campaigns Vaccination has become a hot topic in the national news, on social media platforms, and at dinner tables across America. More recently it has become a divisive political issue. A vocal movement of “anti-vaxxers� continues to influence some individuals and groups resistant to evidence-based facts on public health. Most people today did not experience or have little knowledge of the polio epidemics of the early 20th century; few diseases frightened parents more than polio - a crippling, potentially deadly infectious disease. Widespread vaccination eliminated polio in the Western Hemisphere in 1994. Measles was declared eliminated (absence of continuous disease transmission for greater than 12 months) from the United States in 2000 but there has been a resurgence of it and other conditions/diseases that can be prevented by vaccines. CenCal Health is committed to increasing vaccine-awareness and improving vaccination rates on the Central Coast by offering educational tools and resources for both providers and patients. Through a grant awarded by the American Cancer Society (ACS), CenCal Health recently implemented an educational
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CENTRAL COAST PHYSICIANS
Summer 2019
For more information on CenCal Health’s vaccination tools and resources, physicians can contact Gaby Labraña in Education and Promotion at 805.562.1662, healthed@cencalhealth.org.
program to address a disparity in Human Papillomavirus (HPV) Vaccination rates in south Santa Barbara County. Launched in January with Santa Barbara Neighborhood Clinics (SBNC), parents - with children in a targeted age range and without full HPV vaccination - are handed a computer tablet. Health information is presented on the tablet, promoting the importance of HPV vaccination. Available in both English and Spanish, the digital lesson includes a short video designed to persuade parents to choose to vaccinate against HPV. The goal of the project is to increase the rate of HPV vaccination of all children by age 13, as recommended by the Center for Disease Control (CDC). Data collected from the visit includes immediate vaccination and scheduled vaccination. Data collection will continue through December of this year. If successful, CenCal Health plans to make the program available throughout its network. CenCal Health executed other improvement strategies as part of the ACS grant. For example, guardians of any adolescents who are due for HPV vaccination (not just SBNC patients) receive a mail reminder to schedule an appointment to have their child vaccinated. “We have previously partnered with the American Cancer Society on HPV vaccination rate improvement,” said Bob Freeman, CenCal Health CEO. “Their funding of our program in cooperation with the Santa Barbara Neighborhood Clinics will undoubtedly increase the vaccination numbers in south Santa Barbara County, preventing HPV infection and related cancer, and improving lives.”
Summer 2019
A new intervention tool stressing the importance of all vaccines is a fotonovela (a story told through a series of captioned photographs). CenCal Health is making the fotonovelas available to high-volume Primary Care Providers in its network. CenCal partnered with USC School of Pharmacy, a recognized pioneer in the development of these healthfocused fotonovelas. USC’s fotonovelas are evidence-based, have shown to improve knowledge, and have been recognized and awarded by organizations including the American Pharmacists Association. This bilingual story-telling method is attention-grabbing and uses a non-traditional communications medium – a printed paper version of a telenovela (a TV soap opera) – to deliver facts about the safety and efficacy of vaccines. The entertaining fotonovela includes recommended vaccine schedules for both children and adults, as well as information on how to apply for Medi-Cal. There is also a digital version of the fotonovela that CenCal Health is making available in both English and Spanish on their website. Another immunization education resource that CenCal Health continues to promote is the annual Preventive Health Guidelines. These publications summarize the CDC recommended immunization schedules for all adults and children. Each year, they are updated and are made available on the CenCal Health website, mailed to all member households, distributed at health fairs, and offered to providers for use as patient education materials.
CENTRAL COAST PHYSICIANS
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MINDING
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CENTRAL COAST PHYSICIANS
Summer 2019
T H E H E A LT H C A R E
HOW ONE CENTRAL COAST MEDICAL RESIDENCY PROGRAM IS ADDRESSING THE
PHYSICIAN SHORTAGE By Elizabeth Schwyzer
A boxy, two-story stucco building with red-tiled roofs and a breezy central courtyard, the Santa Maria Women’s Health Center sits just across Palisade Drive from Santa Maria’s hospital, Marian Regional Medical Center. The Women’s Health Center is the community’s largest provider of obstetrics and gynecological services. It’s also the site of a brand new OB/GYN residency. Like the rest of the region, Santa Maria is facing a significant physician shortage in the coming years as the population ages and a critical mass of doctors reach retirement age. Training new physicians is a key part of the region’s response to this growing problem. >>
Summer 2019
CENTRAL COAST PHYSICIANS
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The program’s first-year residents -- Dr. River Saul, Dr. Chris Carls, and Dr. Rebecca Ruebsamen -- are all doctors of osteopathy or DOs: fully licensed physicians whose training and philosophy emphasizes a “whole person” approach to medicine. As the program’s inaugural residents, these young physicians have a critical role in developing and shaping this residency at a hospital whose mission centers around a commitment to serving the poor and disenfranchised. The hope is that they, and those who follow them, will choose to remain in the region and to serve this population for years to come.
FACI N G A PH YS I CIAN S H O R TA G E
Santa Maria isn’t alone in facing a growing gap between health care supply and demand. The entire Central Coast is experiencing a physician shortage. The region currently has 50 primary care physicians per 100,000 residents -- well below the recommended range of 60 to 80 -- while the region clocks in at 93 specialists per 100,000: within the recommended range of 85 to 105, but below the statewide average of 104. Numerous regions in California faces similar figures. According to a 2017 UCSF study, California’s Primary
DR. CHRIS CARLS
Care Workforce: Forecasted Supply, Demand, and Pipeline of Trainees, 2016-2030, California will need to employ multiple strategies in order to fill the growing gap. The study recommends a number of approaches: recruiting more primary care physicians, improving physician retention, expanding primary care residency programs, expanding nurse practitioners and physician assistant education programs, and allowing NPs and PAs to work at the highest level possible. If the shortage were to go unaddressed, the UCSF study suggests, a growing number of Californians would be left without a primary care provider and would be forced to rely on emergency room visits for minor conditions like ear infections or chronic illnesses like asthma. Those who do have a primary care provider would have to wait longer to receive care. And the problem goes well beyond the state level. According to a study published in April by the Association of American Medical Colleges (AAMC), the United States at large will see a shortage of 122,000 physicians by 2032. As the nation’s population grows and ages, the study suggests, the demand for health care provision will increasingly outstrip the supply of new medical professionals. This dearth will be felt across the country, but particularly in more rural and historically underserved communities. According to the American College of Obstetricians and Gynecologists (ACOG), there will be a nationwide shortage of
D CENTRAL R . R I COAST V E RPHYSICIANS S A U L
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Summer 2019
MINDING
T H E H E A LT H C A R E
“IF THE SHORTAGE WERE TO GO UNADDRESSED, A GROWING NUMBER OF CALIFORNIANS WOULD BE LEFT WITHOUT A approximately 8,800 OB/GYNs by 2020 and up to 22,000 by 2050. Californian cities look to be among some of the hardest hit. U.S. Congressman Salud Carbajal represents California’s 24th district, including all of Santa Barbara and San Luis Obispo Counties. When asked about the physician shortage facing the region and the nation, Carbajal responded, “Americans have a right to accessible health care, but without enough physicians to care for patients, this will mean longer waiting times for medical appointments and preventative care.” In response to the issue, Carbajal is cosponsoring the Resident Physician Shortage Reduction Act of 2019: a bill aimed at increasing the number of Medicare-supported residency positions statewide by 3,000 each year over the next 5 years. Of these positions, at least 1,500 each year will be reserved for residents in a specialty where the need for physicians is projected to exceed the supply. Obstetrics and gynecology are among those specialities. Meanwhile, back at the state level, the California Medical Association (CMA) has been working hard in recent years to address the growing shortage. In 2016, the CMA played a critical role in advancing Proposition 56: an increase on tobacco excise tax rates that would be earmarked for health care expenditures, including graduate medical education programs and loan repayment assistance for recently graduated physicians. In November of that year, Californians overwhelmingly voted to pass Prop 56.
Summer 2019
PRIMARY CARE PROVIDER AND WOULD BE FORCED TO RELY ON EMERGENCY ROOM VISITS”
D R . R E B CENTRAL E C C ACOAST R U PHYSICIANS E B S A M19E N
“HOW DO YOU COMMUNICATE WITH PEOPLE ON A BASIC HUMAN LEVEL ABOUT BASIC HUMAN NEEDS WITHOUT LANGUAGE?”
CMA’s charitable group, Physicians for a Healthy California (PHC), in 2018 launched CalMedForce, a medical residency grant program that in its first year awarded more than $40 million to graduate medical education programs. A few months later, in early 2019, PHC introduced CalHealthCares, a loan repayment program for physicians. Individual awardees are eligible to receive as much as $300,000 to repay debt incurred in pursuit of a medical or dental degree; the awards will be announced at the end of June. The deadline for 2019 CalHealthCares applicants was May 3. The 2019/2020 CalMedForce grant application cycle opens September 23, 2019 and closes October 28, 2019. Among the programs to receive CalMedForce funding in the first year was Marian’s new OB/GYN residency program, which was awarded $300,000 and began training its first residents in summer 2018. The hospital had previously launched its first residency program in family medicine in 2014; its first graduates completed their training in 2017. It’s no coincidence that Marian chose family medicine and OB/GYN -- both primary care fields -- as its residencies. According David Oates, MD, the director of medical education at Marian Regional Medical Center, expanding the reach of primary care has been a strong focus for the hospital. “Access to primary and preventive care services is the primary factor that affects the region,” he explained. “Patients without access to care often seek out care in the Emergency Department, where care is designed to be delivered for acute care issues, often leaving chronic care issues less optimally managed.”
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CENTRAL COAST PHYSICIANS
A central aim of both the family medicine and OB/GYN residencies is to address this issue by training new physicians and recruiting them to stay and practice in the Santa Maria community, Oates said. As for why Marian chose obstetrics and gynecology specifically as its second residency program, he explained, “Marian has a very high volume of obstetrical patients and a very strong teaching faculty of OB/GYN physicians.” On interview day, Chaudhry noted, one of the questions he’s asking potential residents is how they see themselves serving this particular community and these patients. The three incoming residents joining the program this summer have demonstrated an active interest in serving the Santa Maria population.
S E R V I N G S A N TA M A R I A
In his book, Fresh Fruit, Broken Bodies, anthropologist and medical doctor Seth M. Holmes examines the breakdown of health care provision for Mexican migrant farm workers in the US. The topic hits close to home for OB/GYN resident Dr. River Saul. Drawn to Santa Maria by the promise of providing health care to women in an underserved community where many are undocumented immigrants, Saul spoke of a constellation of issues affecting her patient population. “A lot of these patients first come in for care late in their pregnancies -- 20 weeks, 28 weeks, or even when they go into labor,” she said. “Oftentimes, you figure out that a woman’s primary concern about a cesarean or breastfeeding is actually the inability to return to the fields. Once they do return to work,
Summer 2019
MINDING
there are sometimes pop-up shelters for nursing, but many women can’t quite confront the work of pumping milk.” “One area that’s of critical concern to us is disparities in women’s health care,” summarized Dr. Taimur Chaudhry, the director of the residency. “We are driven to ensure we provide the best care to all of our patients.” Like Marian Regional Medical Center, the Women’s Health Center is overseen by CommonSpirit Health, the result of a recent merger between Catholic Health Initiatives and Dignity Health. A self-described “ministry,” the giant nonprofit health system includes more than 700 care locations and 142 hospitals in 21 states. Its mission includes advocating for the poor and vulnerable and working for positive social change. It is with this mission in mind that the first class of OB/ GYN residents approach their work. Santa Maria is a largely agricultural community where more than 70 percent of the population identifies as Hispanic, more than half speak Spanish at home, and many residents are undocumented. In keeping with Marian’s mission, the majority of Women’s Health Center patients qualify as “poor or disenfranchised.” Among the challenges of providing quality health care to this population are language barriers between patients and providers. Of the three new OB/GYN residents, only Ruebsamen speaks Spanish fluently. At Marian, an interpreter telephone system is in place, and hospital translators are sometimes available, but funding limits their availability. Furthermore, many women seeking care in the clinic and the hospital speak only Mixtec languages: a broad term for a cluster of more than 50 closely related languages spoken primarily in the Mexican states of Oaxaca, Puebla, and Guerrero. “Language is definitely a barrier we encounter daily,” Chaudhry noted. “The Mixtec people don’t have a written language. We only have one nurse who speaks Mixtec.” As for how Marian is working to address this challenge, Chaudhry said the hospital administration “fully recognizes” the need for more translators. “Eventually, Marian Regional Medical Center intends to provide more accessible in-person translators,” Oates said, adding, “We are currently working on the development of a video series to improve communication.” Meanwhile, family members of patients often serve as unofficial translators. When all else fails, physicians sometimes find non-verbal ways to communicate. Carls spoke about the communication challenges he faces in his daily work in terms
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T H E H E A LT H C A R E
of an ethnographic study: “How do you communicate with people on a basic human level about basic human needs without language?” “That’s definitely one of the unique things about being here,” Carls continued. “It forces us to address the question of power differentials, and to ask how we can improve communication to best meet our patients’ needs.” Carls’ colleague Ruebsamen is a Ventura native with a passion for women’s health advocacy. Like Carls, she did a rotation at Marian as a medical student before matching with the program as a resident. She and Carls recently attended an ACOG conference in Washington, D.C. where OBs were taught how to lobby and serve as activists in their communities. Both described the experience as an exciting opportunity, and one that in a larger medical residency would likely be reserved for more senior residents. What does it mean for an OB/GYN to serve as a women’s health activist? “Activism can look like anything from our work in the clinic every day, to helping patients be informed, to getting our local representatives on our side, to advocating for legislation at the state and national level,” Ruebsamen explained. Against concerns over the growing gap between health care supply and demand, young residents like Ruebsamen and her colleagues are setting their aims high. Discussions continue at the local, state, and national level over whether the gap in women’s health care should in part be filled by other health care professionals like midwives, certified nurse practitioners, and physician assistants. Meanwhile, Marian continues to invest significant time and resources in training new OB/GYNs. As medical educators like Oates are fully aware, that commitment relies heavily on a broad network of supporters: from lobbying organizations like CMA and PHC to citizens who vote on how to allocate tax dollars; from the established physicians committed to educating the next generation to the young physicians willing to dedicate their professional lives to this work. In short, it takes an entire community that values the kind of care physicians provide. “Physician training is a long, complex, and expensive process, Oates acknowledged. “I am so grateful for Dignity Health and Marian Regional Medical Center’s support of our graduate medical education programs.”
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MEN’S HEALTH
FATHERHOOD BY DAVID DODSON, MD
Certainly, a good father can make a huge and important contribution to their children’s success
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Fathers. All of us have or (had) one. Some of us are lucky enough to be able to truly celebrate ours, some feel they have thrived despite theirs, others are unlucky enough to curse theirs. Some barely know or barely knew theirs, some never knew them at all. And in this age of DNA testing, a significant percentage of people have learned the man they believed was their biological father was in fact, not. Certainly, a good father can make a huge and important contribution to their children’s success. Rates of truancy, drop-out, drug and alcohol abuse, teen pregnancy, depression, and suicide are all higher among children raised without a father. Sadly, Dads are viewed by many in society as almost superfluous, apart from their roles a sperm donors or
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wallets to be emptied, as men who’ve been to family court can attest. The truth is, there is no more important role for a man than to be a good father, because to the extent that he succeeds, by being a good father, a man leaves a lasting legacy in the form of children who can make the world a better place. Or, if he fails, his offspring are significantly more likely to do the opposite, or at least to continue spreading misery.
likely to wind up in relationships with similar guys. Thus, the father’s role is pivotal.
Of course, men also play a key role in their son’s development, because children learn by imitation. If Dad values hard work, justice, and respect for others - particularly for women - son is likely to do so too. If not, not so much. In this way, the role of father is key to the kind of society we have. This is not to diminish the While there is little doubt the genetic link between a role of women and mothers. But motherhood is widely man and his children is a strong bond, the parenting agreed to be critically important in a way fatherhood is not. The situation is analogous to “Half the Sky”: the thesis that not educating The role of “Father” is not in many circles, girls in much of the Third especially the family courts. Ironically, at the World leaves them much poorer as a result. In a same time men are criticized for not being similar way, denigrating the role of men and fathers involved enough in their children’s lives, divorced in society cannot help but and never-married Dads often are denied access lower the quality of the society we live in. to their children. role can to some extent be filled to a child’s benefit from a surrogate in the father’s absence, such as a teacher, coach, mentor, or a step-parent. While the fabled evil step-parents of fairy tale infamy have their real-life avatars, many men and women perform this role beautifully, to the child’s great benefit. But it is well established that children are best served when raised by two healthy parents, usually a mother and father who have each contributed equally to the child’s genetic makeup. One critical aspect of fatherhood is the quality of the father-daughter relationship. As the first male role model for a baby girl, a father’s influence can be the key to her becoming a happy and fulfilled individual, or not. If growing up, a girl has a loving, supportive, devoted father, she is much less likely to settle for less in a mate. If the father is unsupportive or absent, she’s a lot more
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I write these words two weeks after Father’s Day, and I ask apart from setting aside one day per year, what does society do to promote fatherhood? The unfortunate answer is, very little. While measures like more paid paternity leave could help, I think the intangible factor of more respect of the importance of fatherhood would also be important. The role of “Mother” is assumed by most to be of key importance. The role of “Father” is not in many circles, especially the family courts. Ironically, at the same time men are criticized for not being involved enough in their children’s lives, divorced and never-married Dads often are denied access to their children. This short-sighted approach breaks father’s hearts, children’s hearts, and is very much to the detriment of society. These opinions are mine and are not in any ways those of the Central Coast Medical Society. As always, your feedback is appreciated.
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CL
Office Space Available NEWLY REMODELED MEDICAL OFFICE SPACE for rent across from Santa Barbara Cottage Hospital. Suite is home to one OBGYN. Available for rent is one office and one or two exam rooms. Staff can be shared and all equipment, supplies, and utilities included. Please call for more information 805.563.9100.
Positions Available The COUNTY OF SAN LUIS OBISPO is seeking physicians to fill the role of Staff Psychiatrist. For more information, go to www.slocounty.ca.gov.
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DS
F I S IE S A
The COUNTY OF SANTA BARBARA is seeking physicians to fill the role of Supervising Physician in Lompoc, and the Behavioral Wellness Department is seeking physicians to fill the roles of Medical Director for Inpatient & Crisis Psychiatric Services, Psychiatrist and Psychiatrist (Child-Adolescent Specialty). For more information, go to www.sbcountyjobs.com. SANSUM CLINIC is the largest and oldest multi-specialty group between San Francisco and Los Angeles with over 180 physicians and surgeons and a staff of healthcare professionals in over 30 specialized areas of medicine. Physician openings can be found at www.sansumclinic.org/physicianprovider-job-opportunities.
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Summer 2019
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Public Health
Update
Should I Test For Measles? A Guide for California Healthcare Providers
STEP 1– HISTORY
While suspecting measles in your patient, immediately mask and isolate the patient per airborne precautions.* In the 21 days prior to onset of illness, has patient had any of the following? • Known exposure to a person with measles? • International travel, contact with an international traveler, or been to an international airport in the US? • Visited a venue popular with international visitors? • Resided in or visited a US community with measles cases? Current listings at bit.ly/2JqBbMW
Calendar
If NO to all, measles very unlikely, testing not required.
STEP 2 – EXAM
If YES to any, continue • FEVER • And one or more of: COUGH, CONJUNCTIVITIS, or RUNNY NOSE • And RASH† – Red-brown macules or papules - may become confluent patches – Begins on face and progresses downwards to the rest of the body – Typically appears within a few days after other symptoms begin If no rash within 4 days after onset of illness, you may consult your local health department.
STEP 3
CALL your local health department to report illness and discuss testing. COLLECT specimens for PCR testing. • Urine (10-50 ml in sterile container) AND • Dacron swab of throat (preferred) or nasopharynx in viral transport medium
If NO Measles unlikely, testing not required. As needed, call your local health department for consultation.
Local health department contact information: bit.ly/LHD-Reporting *Place patient in a negative pressure room when available; if not, examine the patient outside the facility or in a private room with the door closed; minimize the time patient spends in the facility. Other precautions apply. Immunization in last month with MMR or MMRV can be a cause of measles-like rash - check immunization history. Testing is not indicated if immunized against measles in last month and answer is no to all questions in Step 1.
†
California Department of Public Health | Immunization Branch Adapted with permission from Tennessee Department of Health
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by Henning Ansorg, MD, Public Health Officer, Santa Barbara County Public Health Department
Has the patient had a combination of...?
If YES
Not every rash with a fever is measles…
IMM-1269 (5/19)
At a time when hardly any physician remembers having seen a patient with measles in their career, it is challenging to determine if a febrile illness with a rash has a high or low likelihood of being measles. As the Public Health Officer in Santa Barbara County during the most prolific measles outbreak in the US since 1992, my team and I have been involved in deciding about the need for PCR test measles confirmation - on multiple occasions. By now we are getting more and more comfortable in triaging cases due to their clinical presentation. But let’s go back to some basics of this fascinating disease: • Measles has traditionally been
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one of the six typical childhood exanthemas. • Prior to introduction of the measles vaccine about 95-97% of children did get measles sometime in their childhood resulting in lifelong immunity. • The virus is the most contagious agent known to us. It is truly airborne and has the capacity to stay viable in the air of a room up to two hours after the infected person has already left the area. This explains, how the two confirmed cases this May in Santa Barbara contracted the virus: namely during international travel on their way through the airport. One additional case who came down with measles in another California county, happened to have travelled through the same airport on the same day at the same time - interesting, indeed. The fact that the shedding of the virus starts about four days before onset of the rash makes it likely that infected individuals will spread it widely before feeling ill themselves. The incubation time from exposure to prodrome averages 10 to 12 days. From exposure to rash onset averages 14 days (range 7 to 21 days). The prodrome lasts 2 to 4 days (range 1 to 7 days). The typical rash starts on the face at the hairline and descends down over shoulders, torso, and to the legs. It will recede again in the same sequence. Rash onset coincides usually with another significant spike in fever (102-104), which distinguishes it from the vastly more common roseola infantum where the fever breaks with the onset of the rash. The rash of Parvovirus B19 infection, also known as “slapped cheek” rash, can be mistaken for possibly measles.
Measles
Risks of Measles Infection
Common complications from measles include otitis media, bronchopneumonia, laryngotracheobronchitis, and diarrhea. Even in previously healthy children, measles can cause serious illness requiring hospitalization. • One out of every 1,000 measles cases will develop acute encephalitis, which often results in permanent brain damage. • One to three out of every 1,000 children who become infected with measles will die from respiratory and neurologic complications. • Subacute sclerosing panencephalitis (SSPE) is a rare, but fatal degenerative disease of the central nervous system characterized by behavioral and intellectual deterioration and seizures that generally develop 7 to 10 years after measles infection. (Source: National Center for Immunization and Respiratory Diseases, Division of Viral Diseases, 3/2019)
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Parvovirus B19
Roseola Infantum Testing
IgM are notoriously unreliable due to poor sensitivity and specificity. The only confirmatory test is a PCR on buccal swab and/or urine for wild type measles RNA. This test is not available in commercial labs and has to be arranged for through the Public Health Lab. Given that all cases this year in California were introduced through travel, we recommend to clinicians who are confronted with a patient with high fever and rash to follow the algorithm provided by the California Department of Public Health Immunization Branch to determine whether to test for measles (http://eziz.org/assets/docs/IMM-1269.pdf). If in doubt, please do not hesitate to call the Disease Control reporting line: 805.681.5280 for Santa Barbara County and 805.781.5500 for San Luis Obispo County.
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Challenges of
Cultural Diversity
in Healthcare
Protect Your Patients and Yourself BY SUSAN SHEPARD, MSN, RN, SENIOR DIRECTOR, PATIENT SAFETY AND RISK MANAGEMENT EDUCATION, THE DOCTORS COMPANY
Suggest a referral to a physician who speaks the patient’s primary language. Be sure to document in the medical record the patient’s refusal and your explanation of the risks and benefits of an interpreter.
Ensuring safe and quality healthcare for all patients requires physicians to understand how each patient’s sociocultural background affects his or her health beliefs and behavior. The Doctors Company’s closed claims studies have shown that inadequate provider-patient communication is a frequent contributing factor to patient noncompliance, poor patient outcomes, and litigation. In multicultural and minority populations, the issue of communication may play an even larger role because of behavioral, cognitive, linguistic, contextual, and cultural barriers that preclude effective patient-provider communication. Research has shown that services for minorities can be improved by removing language and cultural barriers. How can physicians easily acquire and maintain the skills to provide culturally responsive and appropriate care to the increasingly diverse population of patients in the United States?
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Consider taking the following steps: • Evaluate any personal attitudes, beliefs, biases, and behaviors that may influence your care of patients.
• Conduct a self-assessment: Cultural and Linguistic Competence Health Practitioner Assessment available from the Georgetown University National Center for Cultural Competence (www.clchpa.org/#welcome).
• Use language services for your limited English proficiency (LEP) patients. - Partner with your health plans and hospitals to identify written and oral language services. - Find out your state requirements. In some states, Medicaid plans may call for providing language access.
• Use a communication model such as ESFT or LEARN: - Listen to the patient’s perception of the problem. - Explain your perception of the problem. - Acknowledge and discuss differences and similarities. - Recommend treatment. - Negotiate treatment.
• Ask the patient or interpreter to repeat back what you said during the informed consent process, during the discussion of the treatment plan, or after any patient educational session with you or your staff.
• Use “Ask Me 3,” a tool that identifies three simple questions all physicians should be ready to answer— regardless of whether the patient asks. More information is available in our article, “Rx for Patient Safety: Ask Me 3,” (www.thedoctors.com/articles/rx-for-patient-safetyask-me-3/) and “Ask Me 3: Good Questions for Your Good Health” (www.ihi.org/resources/Pages/Tools/ Ask-Me-3-Good-Questions-for-Your-Good-Health. aspx) on the Institute for Healthcare Improvement’s website.
• Explain to patients who refuse interpreter services that it is very important to the patient’s care and safety that you and the patient/family member understand each other. Suggest a referral to a physician who speaks the patient’s primary language. Be sure to document in the medical record the patient’s refusal and your explanation of the risks and benefits of an interpreter.
• Improve cultural competence: - Recognize that culture extends beyond skin color. - Find out each patient’s cultural background. - Determine your cultural effectiveness. - Conduct culturally sensitive evaluations. - Elicit patient expectations and preferences. - Understand how your cultural identity affects your practice. The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
Obtain more information from these useful websites U.S. Department of Health and Human Services, Office of Minority Health, National Standards for Culturally and Linguistically Appropriate Services (CLAS) https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53 U.S. Department of Health and Human Services, Think Cultural Health, A Physician’s Practical Guide to Culturally Competent Care https://cccm.thinkculturalhealth.hhs.gov Agency for Healthcare Research and Quality, What Is Cultural and Linguistic Competence? www.ahrq.gov/professionals/systems/primary-care/cultural-competence-mco/cultcompdef.html Health Resources and Services Administration, Culture, Language, and Health Literacy Resources www.hrsa.gov/about/organization/bureaus/ohe/health-literacy/resources/index.html
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5 New & Rejoining The Central Coast Medical Association welcomes the following physicians as members
...and even more on the way. Keith Alan Ayrons, MD Medical Oncology Central Coast Medical Oncology Arroyo Grande 805.474.5300
Michael Joseph DiBiase, MD Nephrology Central Coast Renal Care Inc San Luis Obispo 805.548.8585
Scott Baringer Tobis, MD Urology Sansum Clinic Santa Barbara 805.681.6550
Retired James J Murray, Jr, MD Internal Medicine Santa Barbara
Sylvia Cristina Rivera, MD Endocrinology Sansum Clinic Santa Barbara 805.681.7500
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In Memoriam
In Memoriam
James Harvey Wells, MD James (Jim) Harvey Wells, MD died on May 1, 2019 – three days before his 96th birthday and three months after the death of his wife of 73 years, Elizabeth (Betty) Graham Wells. Jim will be remembered for his good nature, wit, intelligence, and service in medicine. Born May 4, 1923, in Wichita, Kansas to William Harvey Wells and Mary Roanna Stokes, Jim spent his youth in Missouri, Kansas and Iowa. He enjoyed sports and excelled at running, earning a track scholarship to Drake University in Des Moines, Iowa. While at Drake, Jim met and fell in love with Betty Graham. They were married in April 1945. Jim joined the U.S. Navy Reserve in 1942, entering a program to attend medical school while in service. In 1945, he earned his Bachelor of Arts degree in absentia from Drake University. After training
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at Miami University, Ohio; Great Lakes Naval Training Center, Illinois; and Indiana University, Bloomington and Indianapolis, Jim obtained his Doctor of Medicine from Indiana University in 1947. He continued his training in Indianapolis as a rotating intern and a resident in psychiatry and neurology. At a time when medical education was much less specialized than today, he spent time directing an emergency room, driving an ambulance, and even delivering babies. In 1949, Jim transferred to the regular U.S. Navy. His assignments included the Marine Corps Recruit Depot in Parris Island, South Carolina; the National Naval Medical Center in Bethesda, Maryland; and the U.S. Naval Hospital in Yokosuka, Japan. After returning to civilian life in 1955, Jim directed psychiatric programs at hospitals in Indianapolis, Indiana and Stockton, California. He also held faculty appointments at Georgetown University and Indiana University Medical School. Jim and his family settled in Santa Barbara, California in 1958, where he established a private practice in psychiatry. He helped develop the mental health resources of the city and county, including the Santa Barbara County Mental Health Facility and the psychiatric unit at Cottage Hospital. He contributed significant pro bono work, such as volunteering for the Santa Barbara Unified School District and the Mental Health Center at the University of California, Santa Barbara. Active in legal and industrial psychiatry, he was a consultant to the Santa Barbara Superior Court, a Medical Examiner for the State of California, and a Qualified Medical Examiner for the California Worker’s Compensation Appeals Board. He was designated a Distinguished Life Fellow of the American Psychiatric Association in 1987. Retiring at age 82 because of advancing blindness, Jim became involved with the Braille Institute of Santa Barbara, first as a student then as a volunteer. A lifelong learner and teacher, he led a popular Science and News class there for 10 years, well into his 90s. Jim is survived by his son James Graham Wells, daughter Amy Wells Graham (John; daughters Leslie FitzGerald and Tracy Graham), and brother Robert Francis Wells (Sally; daughters Pamela Phelps and Melissa Dale).
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Central Coast Medical Association 100 N Hope Ave, Ste 14 Santa Barbara, CA 93110
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Mark Your Calendar JOIN US AT OUR UPCOMING EVENTS
September
San Luis Obispo, The Station Wine Bar
August
5: Happy Hour Physician Social
4: OSHA Workshop, Santa Barbara 6: OSHA Workshop, San Luis Obispo 21: Santa Barbara Heart & Stroke Walk
4: Annual Membership Meeting , San Luis Obispo
ccmahealth.org/events
October
1: Annual Membership Meeting, Santa Barbara