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SPRING 2022

A P U B L I C AT I O N O F T H E M A R I C O PA C O U N T Y M E D I C A L S O C I E T Y

Disease Detectives

25

Physicians share why their patients are hesitant to get vaccines and what could improve vaccination rates

Epidemiologists Rebecca Sunenshine, MD, and Nick Staab, MD, lead Maricopa County's efforts to overcome vaccine hesitancy

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CONTENTS VOLUME 4 • ISSUE 1 Editor-In-Chief John McElligott, MPH, CPH

IN EVERY ISSUE 6 | From the MCMS Board President 8

| From the Editor-in-Chief

Edward Araujo

9

| MCMS Partner Program

Associate Editor

10 | Briefs

Managing Editor

Mariana Nicolaides

Creative Design Randi Karabin, KarabinCreative.com

Cover & Featured Articles Photography Ben Scolaro, scolarodesign.com

26 | What Arizona Docs are Saying 30 | Legal Corner 32 | How To 34 | Physician Spotlight

Advertising ads@arizonaphysician.com

President Ricardo Correa, MD, EdD, FACP, FACE John Prater, DO

President-Elect Treasurer Anne Maiden-Hope, DO, FAAP

Karyne Vinales, MD Anchit Mehrotra, MD Rahul S. Rishi, DO, FAAAAI, FACAAI Ann Cheri Foxx Leach, MD, D.ABA Christopher DeNapoles, MD Ruchir Patel, MD, FACP

16 How the Arizona Department of Health Services Supports Vaccinations

Pleasant Pediatrics

Zaid Fadul, MD, FS, FAAFP

Directors

What’s old is new again.

Mariana Nicolaides takes us from the cowpox vaccine to COVID-19.

22 In Depth:

Immediate Past President

Jane Lyons, MD

The Evolution

Karen Lewis, MD, Medical Director of the state health department, explains ASIIS and VAERS.

Maricopa County Medical Society Board Members

Secretary

14 Vaccine Hesitancy:

18 C O V E R S T O R Y

Drs. Nick Staab and Rebecca Sunenshine lead Maricopa County’s efforts to overcome vaccine hesitancy

Dr. Sanhya Ravi and her husband, Prasad Ravi, CEO, of Pleasant Pediatrics, a multi-location practice, explain their growth and approach to educating patients about vaccines.

Resident & Fellow Director Emma Schnuckle, MD

Medical Student Director Anirudh Singh, OMS-III

Digital & Social Media arizonaphysician.com ArizonaPhysician @AZPhysician

Check out our most recent episodes: •M arilyn Heine, MD, on Scope of Practice •K ishlay Anand, MD, on Cardiology and Value-Based Care arizonaphysician.com/podcast

@AZ_Physician

A R I ZO N A P H Y S I C I A N . C O M

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FROM THE MCMS BOARD PRESIDENT

Vaccines and Marginalized Groups

T

he COVID-19 pandemic has intensified health and social disparities that affected minority groups in the United States.

This situation has been reflected in many aspects of health, including increased morbidity and mortality, reduced adherence to medical and scientific recommendations, and less access to healthcare.

Understanding the population’s specific sociodemographic and cultural characteristics may serve as a catalyst to address the gaps and concerns, reduce health care inequities, increase compliance, and improve health and social-related short and long-term outcomes.

The FDA officially approved the first COVID-19 vaccine from Pfizer in late December 2020 for people above 16 years old, and after those two more vaccines (Moderna and J and J) were approved. Later in the Spring of 2021, the Pfizer vaccine was authorized to expand to an age range from 12 years and older, and in the Fall of 2021, the Pfizer vaccine was expanded to use on five years and above. Now the vaccines are broadly available in the US, but there is an evident skepticism from the marginalized communities to get vaccinated.

Given the importance of vaccination to alleviate the devastating effects of this pandemic, multiple studies evaluating vaccine acceptance rates were conducted from the beginning. In addition, several studies targeted marginalized groups known for their high hesitancy regarding vaccination. Numerous data from these studies showed that they don’t trust the healthcare system due to the systemic racism and discrimination from prior episodes on medical history.

A recent review revealed an overall prevalence of COVID-19 vaccination hesitancy of 26.3%, with a little higher percentage in the Black/African American and Latinx communities. The significant predictors of vaccine hesitancy were sociodemographic characteristics, medical mistrust, and history of racial discrimination. Other reasons included:  Misinformation.  Perceived risk of getting infected.  Beliefs about vaccines.  Concerns about the safety and efficacy of the COVID-19 vaccines.

We know that marginalized communities have a higher prevalence of many conditions that lead to poor health and chronic diseases, which could 6

n A R I ZO N A P H Y S I C I A N M A G A Z I N E

worsen their outcome if they became infected with COVID-19. Additionally, the misinformation provided through social platforms contributed to hesitancy towards vaccination.

Several strategies have been implemented to decrease misinformation and disinformation and, with this, reduce vaccine hesitancy. Some projects focus on using social media as a platform to spread the word. Hashtags of #thisisourshot, #vacunateya, #vaccinate4all are some of the efforts that have had a significant impact on younger people. Other methods like using the community centers, knocking door by door, and putting a trusted physician on the TV and radio have helped to educate patients.

The marginalized communities need more, not just from the physician community but from the local, state, and federal government, to change their perspective.

The pandemic has highlighted healthcare disparities amongst marginalized groups. Promoting health equity for minority groups will alleviate these groups’ differences and help mitigate vaccine hesitancy and improve compliance with preventive measures. All these will allow more underrepresented minorities to receive vaccines and reduce the burden vaccinepreventable diseases have on such groups in society.

Respectfully,

Ricardo Correa, MD, EdD, FACP, FACE MCMS Board President Dr. Ricardo Correa is an endocrinologist at the Phoenix VA Medical Center. He is also the Endocrinology, Diabetes and Metabolism Fellowship Director, Director of Diversity GME, and Chair of the GME Diversity Subcommittee for the University of Arizona College of Medicine Phoenix. Dr. Correa is the Health Equity Fellowship Director for the Creighton School of Medicine and Medical Director of the Phoenix Allies for Community Health (PACH) Clinic. He is a Major in the U.S. Army Reserve.

A Four-Year Medical School for the Greater Good Medical Doctor | Physician Assistant | Nursing | Occupational Therapy Pharmacy | Physical Therapy Creighton’s Phoenix campus is open now. Creighton University is the largest Catholic Health Professions educator in the U.S., and and we’ve been educating changemakers for more than 140 years.

The Creighton University Health Education Alliance is a partnership to provide diverse teaching environments and includes:

Learn more at creighton.edu/phoenix

FROM THE EDITOR-IN-CHIEF

“WHEREVER THE ART OF MEDICINE IS LOVED, T H E R E I S A L S O A L O V E O F H U M A N I T Y.” —Hippocrates

Y

ou practice medicine because you love humanity. Hippocrates of Kos knew that back in 400 BC. You want humans young and old to live happy and healthy lives. You want the next generation to have a brighter future.

A powerful tool in your doctor’s bag is the vaccine. Licensed vaccines are available for over two dozen preventable infections. When used, vaccines can greatly reduce morbidity and mortality.

They also save the healthcare system a great deal of money.

VAC C I N E H E S I TA NC Y For our cover story, Managing Editor Edward Araujo interviews Drs. Rebecca Sunenshine and Nick Staab of the Maricopa County Department of Public Health to discuss how the county tracks vaccine-preventable diseases, educates patients, and involves doctors to protect the public’s health.

Karen Lewis, MD, medical director of the Arizona Department of Health Services, provides helpful information about how the state supports vaccinations through data systems, school immunization requirements, education campaigns, and more.

In What Arizona Docs are Saying, we learn that eighty-four percent (84%) of survey respondents says their patients use social media to learn about vaccines and almost half (48%) of respondents use telehealth and telephone to communicate with patients about vaccines.

We go In Depth with Pleasant Pediatrics, which has expanded since 2008 to six locations. Check out the Q&A with CEO Mr. Prasad Ravi and his wife Sandhya Ravi, MD, FAAP, Medical Director.

Associate Editor Mariana Nicolaides writes about the evolution of vaccine hesitancy, connecting the dots from opposition to Edward Jenner’s work on the smallpox vaccine to modern uses of messenger RNA. We thank pediatrician Janes Lyons, MD, for sharing her approach to speaking with parents who are hesitant to have their children vaccinated. Dr. Lyons says, “I always start with open ended questions to find out their concerns, so I can target my counseling.”

VA LUA BL E A R T IC L E S In the How To section, Matthew Lowery, Sr., a certified financial planner with DFG Advisors, shares an update about the 4% Safe Withdrawal Rule. Matt delves into the benchmark of retirees spending about 4% each year in retirement to prevent from running out of money and why recent events have called that rule into question.

In our section Legal Corner, lawyer Ike Devji shares ways physicians can mitigate risks on their own. Simple steps may include checking credit reports, using a paper shredder at home, and securing personal electronics.

Contact us at info@arizonaphysician.com with any comments or suggestions.

Enjoy the magazine.

MCMS PARTNER PROGRAM Our latest section of the magazine features a company or organization that is partnering with Maricopa County Medical Society (MCMS). This first highlight focuses on Mutual Insurance Company of Arizona (MICA), a physician-owned and physiciandirected mutual insurance company and exclusive provider of medical professional liability coverage for members of MCMS.

We are looking for article contributors, podcast guests, and virtual event presenters.

Contact us at info@arizonaphysician.com for these and many more opportunities.

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By John E. McElligott, MPH, CPH

PARTNER PROGRAM

E XCLUSI V E PA RTNER

MUTUAL INSURANCE PROTECTING AND DEFENDIN SINCE 1976

What Is It?

Maricopa County Medical Society's Partner Program is designed to introduce select companies to our members. MCMS strives to facilitate physician growth in all areas of their life and practice. As we work to support our members, we think there are excellent opportunities work closely with business partners that can facilitate that growth.

How Are Partners Selected?

The main criteria we look for are simple: companies that demonstrate value in their products/services and have staying power. The companies that have an honest approach and treat our members with an exclusive feel have historically had the best success.

What Are the Tiers?

ADVERTISING PARTNER | Organizations that partner with MCMS to advertise their products/services to members through our media platforms.

DISCOUNT PARTNER | Companies that offer blanket discounts to MCMS members.

PREFERRED PARTNER | Vetted companies that com-

mit to providing superior service, special discounts, and incredible value to physicians. These companies stand out from their peers. They demonstrate staying power and consistently deliver high-quality products and services to clients.

EXCLUSIVE PARTNER | Top partner company that MCMS will promote and endorse as the only company in its business category.

“MICA is physician founded and physician governed. I feel secure knowing that I am insured by a company that understands what it’s like to practice medicine. In addition to the friendly and responsive customer service, MICA will share dividends with policyholders when financial performance allows. This can be a big help, especially for those in smaller, privately owned practices.”

Miriam Anand, MD Allergy Associates & Asthma LTD President, Arizona Medical Association Former President, Maricopa County Medical Society

Here are the top reasons why MICA is the exclusive provider for malpractice insurance for Maricopa County Medical Society members: HIGH TOUCH SERVICE | Each time you reach out to MICA, their team will return every email, phone call, and inquiry promptly with a thorough explanation.

ASSERTIVE CLAIMS DEFENSE | Their

experienced claim professionals support and defend MICA members every step of the way.

FINANCIAL STRENGTH & STABILITY | MICA’s

financial position continues to be among the strongest in the medical professional liability industry with an A (Excellent) rating with AM Best.

TRUSTED GUIDANCE | MICA

provides members access to medical and legal experts through a variety of risk management programs at no additional cost.

“Almost 15 years ago I was introduced to MICA and cannot adequately describe the positive impact they made on the physicians I work with. The associates at MICA are always there as a resource and guide no matter what occurs in the practice. Every time I am faced with a complex situation, MICA helps me to navigate it and manage it with ease. I truly am thankful for everyone at MICA for being a true ally in practice management.”

MICA STARTE

WITH PHYSICIA LIKE YOU IN MIN

Kyle Matthews, CEO Phoenix Heart PLLC

MICA was formed by a group of physicia that their peers could depend on. By kee top of mind, MICA has been the leading liability provider in Arizona for over 45 y

To learn more about MICA or to request callto 800-681-1840 or visit info.mica-ins Submit your request be part of the MCMS Partner Program @surveymonkey.com/r/MCMS_Partner_Program

BRIEFS

NEWS AND NOTES FROM THE FIELD

Health Care Trends in 2022 VIRTUAL BEHAVIORAL

DRUG COSTS | No surprise but

DATA FROM WEARABLES |

HEALTH | Cases of anxiety and

they continue to increase.

Specialty medications accounted for over half of pharmacy spend in 2020, although about 2% of people use these drugs. The price of generics has fallen by 42%.

These trends should weigh on physicians prescribing habits and guidance for generics, home delivery of medications, and alternatives for specialty drugs.

More people are wearing smart watches and fitness trackers that have data helpful for patient care.

Companies will develop ways to empower patients to harness the data for disease prevention and monitoring.

depression have risen, and insurers are covering more outpatient behavioral health visits per patient. Telehealth has allowed for more convenient and private visits with psychiatrists and other behavioral health professionals.

EMPLOYERS AND HEALTH EQUITY | Since about 55% of

the workforce receives health benefits from employers, there is an onus on employers to foster greater equity. We hope that doing so would lead to a healthier and more productive workforce. The same applies to jobs in healthcare.

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VIRTUAL CARE | Telehealth visits

spiked over the past few years.

Experts are planning for steady consumer demand and lower provider payments for virtual visits, as compared to in-person.

Expect to see an evolving list of specialties that leverage virtual visits to manage patients remotely.

MEDICAL RESIGNATIONS |

Mayo Clinic survey of 20,000 physicians revealed about 20% would likely leave their current practice within two years and about 33% would reduce hours.

This comes from burnout, workload, fear of COVID infection, and increased anxiety or depression.

Spring has Sprung!

4. MULCH | Adding mulch to your veg-

CARING FOR ARIZONA GARDENS 1. LOCATION | Vegetables require 8-10

hours of direct sunlight per day, so finding the perfect location is key. Take the time to find when and where shadows are cast in your yard. Remember, you can always shade your garden if there is too much sun, but you cannot change where shadows cast!

2. FERTILIZE | Soil contains the neces-

sary nutrients plants need to grow.

When these nutrients are missing, plants suffer from nutrient deficiency and can stop growing. Native trees such as palo

verdes, mesquites, and acacias usually do not need fertilizing, as they’ve adapted to low nitrogen available in Arizona soils, but you can prepare soil for your garden by adding compost.

3. WATERING | Vegetables need to be

watered a foot deep, and as Arizona temperatures rise plants will require more water to thrive. The best time to water is in the morning, as it helps to retain water and prepare the plant for the day. Watering at night can lead water to rest in the soil, encouraging rot, fungal growth and insects.

etable plants is an individual choice and not necessary, but may be key to larger fruits, vegetables, and make it easier to care for garden beds. Mulch can reduce soil temperature, help retain moisture, and add organic matter to the soil.

5. PESTS | There are numerous ways

to control pests, whether it be through pesticides or more organic alternatives. If you don’t feel up to the challenge, there are companies that will take care of the problem for you. To naturally control pests, find pestrepelling plants that emit natural scents to keep the pests away and invite good bugs into your garden.

For information on native plants and their importance, check out these websites: aznps.com/native-gardening/ azstateparks.com/desert-plants

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A R I ZO N A P H Y S I C I A N . C O M

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EXPLORE THE GRAND CANYON | The Grand Canyon

is a geological marvel, averaging 10 miles across and 277 miles in length. This natural formation of layered red rocks is a sight that people around the world come to visit, and its beauty is something everyone should experience at least once in their lifetime. Spring brings ideal weather to the location, making the trip more magical.

CHIHULY IN THE DESERT | Dale Chihuly brings art,

architecture, and nature to the Sonoran Desert with exhibitions at both the Desert Botanical Garden and Frank Lloyd Wright’s Taliesin West.

These stunning pieces will be on display from December 3, 2021 till June 19, 2022.

PHOTO BY NATHANIEL WILLSON / DESERT BOTANICAL GARDEN

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CAMPING OR GLAMPING | Whether

ARIZONA RENAISSANCE

SEE THE WILDFLOWERS | Starting in

you prefer backcountry or airconditioned rentals, Arizona has it all. You can find guided tours, trail rides on horseback, and countless locations to unwind and recharge.

FESTIVAL | The Renaissance

February and lasting until May, the flowering season is in full bloom. Take a hike and admire the beauty Arizona has to offer. Popular parks and trails include the Spur Cross Ranch Conservation Area, Estrella Mountain Regional Park, South Mountain Park and Preserve, and the Phoenix Sonoran Preserve.

Do you have

Festival is back, and with it comes live music and entertainment, jousting, and feasting! The fair is open during the weekends of February 5th to April 3rd from 10 AM-6 PM. Huzzah!

an idea to

improve health

or the delivery of healthcare?

The Health Entrepreneurship and Innovation Lab (HEALab) at Arizona State University, along with our partners at Flinn Foundation and Maricopa County Medical Society, can help.

This two-day, interactive workshop will teach you how to identify health-related problems, ideate potential solutions, develop a business model, navigate legal issues, find paths to revenue, and pitch your idea to investors.

Healthcare Innovation and Entrepreneurship Workshop Presented by HEALab @ ASU

A Two-day Workshop at ASU, Downtown Phoenix Campus Friday, April 29, 2022 2pm - 6pm

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RSVP at: https://na.eventscloud.com/healthcareworkshop This event may be eligible for continuing medical education (CME and CPE) credits.

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A R I ZO N A P H Y S I C I A N . C O M

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Figure 1. Hand colored etching, The Cow Pock—or—the Wonderful Effects of the New Inoculation (Gillray, 1802)

Vaccine Hesitancy The Evolution

A

dvances to combat vaccine-preventable diseases have been hailed as one of the greatest public health achievements.

While some believe recent arguments over influenza, MMR, or COVID-19 vaccines are new, it should be known that this is not the case. Vaccines have long stirred public passions, going back 300 years ago to the 1721 smallpox inoculation in Boston. One cold November day in 1721, a bomb was thrown into the residence of Cotton Mather, a local Boston Reverend. While the bomb did not detonate, there was an explosive letter signed to Mather with the message: “Cotton Mather, you dog, dam you! I’ll inoculate you with this; with a pox to you.’’

This was a violent response to Reverend Mather’s promotion of smallpox inoculation in response to the deadly ongoing epidemic (Niederhuber, 2021).

During the late 1700s, Edward Jenner discovered milkmaids who had been ill with cowpox were

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immune from smallpox, and the use of cowpox in vaccinations became widespread while the fear of the unknown (see Figure 1) continued to spread throughout the masses (Ault, 2021).

Immunization has contributed hugely to preventing deaths and has been found to dramatically increase life expectancy and economic development (Bustreo, 2017). That said, there are numerous reasons why this movement has been hotly debated, with parents passionately fighting for what they think is safest for their children, and pushing individuals to refuse vaccines. Reasons such as personal freedoms, lack of government trust, poorly conducted studies, and a mistrust of science have plagued vaccine acceptance. The decision one makes to not vaccinate oneself or one’s children affects everyone, and individuals shying away from vaccination due to uncertainty risk the possibility of infectious diseases reemerging in their communities.

P E R S ON A L F R E E D OM S The state of Arizona legally allows vaccine exemptions for religious and moral reasons, but what many miss is the responsibility the government must take to safeguard life. While no vaccine is 100% effective at preventing disease, it is crucial that the childhood vaccine coverage of 95%-100% is still met to fully protect communities and reduce the spread of diseases such as polio, measles, mumps, and

For article sources and to learn more about the evolution of vaccine hesitancy, please visit arizonaphysician.com/evolution-vaccine-hesitancy

State-level Data

State-level Data

2017

2017

Children receiving the doses of HepB, DTaP, polio, MMR, varicella and PCV mo va Children receiving the recommended doses ofrecommended DTaP, polio, MMR, Hib, varicella andHib, PCVHepB, vaccines by age 19–35 (percent) Children receiving the (percent) recommended doses of DTaP, polio, MMR, Hib, HepB, varicella and PCV vaccines by age 19–35 months

State-level Data (percent)

2018

2018

2017

2018 WA

WA WA

rubella (AZDHS, n.d.). According to the Office of OR Disease Prevention and Health Promotion, national immunization coverage of children receiving the NV recommended doses of DTaP, polio, MMR, Hib, HepB, varicella, and PCV vaccines by age 19–35 CA months in the United States is at 72.8%, with Arizona falling behind at a 69.6% vaccination rate (see Figure 2). Rates so far below the target percentage leave communities at risk for contracting preventable AK diseases, giving them opportunities to spread.

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L AC K OF T RU S T

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States with available dataInsu!cient are shown indata white States with no available data are shown innowhite 76.9-79.9 80-88.7 National Target Met

Vaccine hesitancy may come from feeling asData though States with no available data are shown in white Data Source: National Immunization Survey (NIS); Centers for Disease Control andfor Prevention, National Center for Immunization Source: National Immunization Survey (NIS); Centers for Disease Control and Prevention, National Center Immunization and Respiratory Diseases andand NatiR Center for Health Statistics (CDC/NCIRD and CDC/NCHS) Center for Health and CDC/NCHS) personal choice and freedoms are at risk, but a lack ofStatistics (CDC/NCIRD Data Source: National Immunization Survey (NIS); Centers for Disease Control and Prevention, National Center for Immunization and2.

Respiratory Diseases and National Figure Children receiving the Center for Health Statistics (CDC/NCIRD and CDC/NCHS) trust in one’s government also plays a role in hesitancy. recommended doses of DTaP, polio, MMR, IID-8 Complete children IID-848.1% Complete vaccination amongvaccination children among HepB, varicella and PCV vaccines by age According to the United States Census Bureau, months (ODPHP, 2018) Children receiving the recommended doses ofHepB, DTaP,varicella polio,19-35 MMR, Hib, HepB, varicella PCVmonths vaccines by age 19– Children receiving the recommended doses of DTaP, polio, MMR, Hib, and PCV vaccines by ageand 19–35 (percent) IID-8 Complete vaccination among children of those who are hesitant to take the COVID-19 vaccine Children receiving the recommended doses of DTaP, polio, MMR, Hib, HepB, varicella and PCV vaccines by age 19–35 months (percent) do not trust the US government (Anderson et al., STATES 2014 2016 2015 2017 2016 2018 2017 2018 2014 2015STATES barred from practicing medicine. Since then, there 2021). To further that statement, a study published STATES 2014 2015 2016 2017 2018 have different showing that 71.6been DATA 72.225 70.4 74.1 studies 70.4 72.8 NATIONAL 71.6 DATA 72.2 NATIONAL 74.1 over 72.8

by Jennings et al. (2021), found that those who said NATIONAL 71.6 DATA were 72.2 more 74.1 70.4 is no connection 72.8 there between the two. Yet, people they would take the COVID-19 vaccine STATE DATA the connection holds truth (LeGare, STATE LEVEL DATA still LEVEL believe likely to have stated they trusted the government’s STATE LEVEL DATA 2017).

As of 2019, 45.3% of adults 18 years of age and handling of the pandemic because they “followed the 76.9 70.6 74.5 71.2 79.3 Alabama 76.9 70.6 Alabama 74.5 71.2 79.3 older were, on average, unsure if vaccines caused science,” while those refusing vaccines were Alabama 76.9 70.6 more 74.5 71.2 79.3 autism, 67.6 and 9.3% believed there was a connection likely to believe conspiracies, that data was “made 66.3 67.6 69.5 68.2 Alaska67.3 up,” 66.3 Alaska67.3 69.5 68.2 (Elflein, 2020). and that the government put too on 67.6 Alaska 67.3much emphasis 66.3 69.5 68.2While the spread of misinformation travels myths created by 66.1 like 72.3 66.7 69.6 lockdown measures at the expense of the economy.

Arizona 66.1 72.3 Arizona 66.7 wildfire, 66.5 dispelling 69.6 the 66.5 misinformation can take years to resolve.

Arizona 66.1 72.3 66.7 66.5 69.6 Many Americans are skeptical, especially people of The number of individuals choosing to not vaccolor. “The African American community, for good https://www.healthypeople.gov/2020/data/map/4722?year=2018 https://www.healthypeople.gov/2020/data/map/4722?year=2018 cinate their children in Arizona has risen in the last reason, unfortunately, has seen a legacy of disparate https://www.healthypeople.gov/2020/data/map/4722?year=2018 few decades. Non-medical immunization exemption care, of lack of care, including several high-profile rates among Arizona children had more than tripled incidents like Tuskegee and others where they feel between the years 2000 to 2017, which is leaving room the medical system abandoned them,” says Arther for these infectious diseases to spread (Lewis, 2021).

Daemmrich, director of the Lemelson Center for the Vaccine hesitancy puts Arizonan lives at risk for Study of Invention and Innovation at the Smithsonian these vaccine-preventable illnesses, and as trusted Institution. “There’s a lot of distrust,” Daemmrich voices, physicians play a significant role when it adds, “it’s not entirely clear how you overcome that comes to making health decisions. Be prepared to distrust, [...] but just showing up now in the midst of speak to those that are hesitant, or against vaccines the pandemic and saying okay trust us now isn’t the in general. Healthcare workers are heroes, the power way to do it.” (Ault, 2021). of their voice can change communities, and help shape them into a stronger, healthier future. ■ B A D S C I E NC E

It’s hard to trust something one doesn’t understand, and “bad science” has a way of sneaking into the spotlight. One well-known example was Andrew Wakefield’s study in 1998. Wakefield suggested that there was a link between vaccinations and autism spectrum disorder and was later found guilty of ethical violations, scientific misrepresentation, and

Page 1 of 4

By Mariana Nicolaides Associate Editor Arizona Physician mariananicolaides@gmail.com

A R I ZO N A P H Y S I C I A N . C O M

15

How the Arizona Department of Health Services

Supports Vaccinations

V

accination is one of 10 great public health developments of the 20th Century. The Arizona Immunization Program Office (AIPO) of the Arizona Department of Health Services (ADHS) oversees many state and national programs that support proper use of vaccines approved or authorized by the Food and Drug Administration (FDA).

The Arizona State Immunization Information System (ASIIS) is managed by AIPO. ASIIS is an electronic registry started in 1998 to record immunizations administered in Arizona. Healthcare providers are required under Arizona Revised Statute (ARS) §36-135 to report to ADHS all immunizations administered to children 18 years old and younger; this is done through ASIIS. ARS § 32-1974 requires pharmacists to report to ASIIS all vaccines that they administer regardless of the recipient’s age. In addition, healthcare providers of adult vaccines are also encouraged to enter data on adult vaccinations into ASIIS to provide a life-long vaccine record. The ASIIS Help Desk assists providers with questions about ASIIS enrollment and use.

AIPO administers the Vaccines for Children (VFC) program in Arizona. VFC is a federally funded program established in 1994 when studies showed that a reason for vaccine-preventable disease outbreaks in the U.S. was that some parents could not afford vaccines for their children. Children are VFC-eligible if they are AHCCCS-eligible, uninsured, underinsured, or if they are American Indian or Alaska Native. Parents of VFCeligible children are not charged for VFC vaccines.

AIPO staff visits healthcare providers who participate in VFC to educate staff and to ensure that VFC vaccines are being properly handled and administered.

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The laws and rules governing school immunization requirements are Arizona Revised Statutes §15-871-874 and Arizona Administrative Code, R9-6701-708. Children need to receive specified vaccines to attend childcare or schools. In turn, schools and childcare institutions are required to report yearly to ADHS as to how many children have received these state-required vaccines and how many have exemptions (religious exemptions for childcare; medical or personal belief exemptions for schools). AIPO collects these aggregate reports with no identifiable information, analyzes them, and displays them by state, county, and school.

AIPO educates county health departments, health care providers, and the general public as to the benefits of vaccines, how to properly use vaccines, and how to understand vaccine safety issues.

Vaccines have been carefully studied in clinical trials and in post-marketing surveillance. AIPO emphasizes that vaccines are very safe and are essential to protect against vaccine-preventable diseases. One way that vaccine safety is monitored through the Vaccine Adverse Events Reporting System (VAERS). VAERS data cannot show a causeand-effect relationship between a vaccine and an adverse event. However, VAERS data can be used to look for rare adverse events that may not have been found during clinical trials. VAERS data is further analyzed using Vaccine Safety Datalink, a collaboration between CDC and nine health care organizations to use anonymous electronic health information in determining if there could be a relationship between a vaccine and specific serious adverse events.

If you would like to learn more about how ADHS supports vaccinations, please visit arizonaphysician.com/adhs-vaccine-support

AIPO promotes reporting to VAERS of adverse events after vaccination and of vaccine administration errors. Healthcare providers are required by law to report any adverse event listed in the VAERS Table of Reportable Events Following Vaccination that occurs within the specified time after vaccination.

They are also required to report any adverse event listed by the vaccine manufacturer as a contraindication to further doses of the vaccine. In addition, healthcare providers are encouraged to report to VAERS any significant adverse event that happens after vaccination, whether it is or is not clear that a vaccine caused the adverse event.

In response to the COVID-19 pandemic, ADHS and AIPO have been actively involved in organizing the distribution of COVID-19 vaccines in Arizona.

Healthcare providers who want to administer COVID-19 vaccines need to enroll in the ADHS Pandemic Provider Onboarding process. Providers

who give COVID-19 vaccines use ASIIS for ordering COVID-19 vaccines, recording administration of COVID-19 vaccines, and maintaining accurate vaccine inventory. COVID-19 vaccine safety is carefully monitored through VAERS, v-safe (a real-time cell phone tool to report adverse events after vaccination to CDC), and Vaccine Safety Datalink. AIPO reminds healthcare providers to use VAERS and to ask patients to participate in v-safe after COVID-19 vaccination.

Despite how well vaccines protect against vaccine-preventable diseases, some people are hesitant to receive vaccines, including COVID19 vaccines. Providers should emphasize to patients that COVID-19 vaccines are much safer than COVID-19 infections. Other vaccines are also very safe and their use has resulted in vaccine-preventable diseases to reach historic low levels. ■

By Karen Lewis, MD Medical Director Arizona Department of Health Services (ADHS) karen.lewis@azdhs.gov

LEARN MORE The Maricopa County Department of Public Health (MCDPH) is the primary point of contact for immunizations. Please contact MCDPH at (602) 506-6767 or visit maricopa.gov/1805/ Child-Immunizations.

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Disease

MARICOPA COUNT Y'S

Detectives

Rebecca Sunenshine, MD and Nick Staab, MD

A

mericans are hesitant to receive vaccines for numerous reasons. From not having access, not being able to pay for it, to just not wanting a shot, vaccine hesitancy has proven to be a major obstacle to reducing many infectious diseases.

Yet at a local level, public health leaders work tirelessly to bring awareness, education, and solutions to stop the spread of disease and to prevent future pandemics.

YOU CANNOT FIGHT DISEASE UNTIL THE EXPERTS FIND IT Sometimes referred to as disease detectives, key players in the effort to improve population health are epidemiologists. A big tool in their toolbox is vaccines. Charged with leading the efforts to combat disease and educate the public are Rebecca Sunenshine, MD, FIDSA, medical director for disease control at Maricopa County Department of Public Health (MCDPH) and R. Nicholas Staab, MD, MSPH, medical epidemiologist at MCDPH. They and their teams identify the source of disease, define populations at risk, and recommend strategies to control or stop the spread of diseases. As physicians, they are qualified to combine clinical aspects of disease with the science of population health.

Dr. Rebecca Sunenshine has been at MCDPH since 2009 when she came over from the state health department to support the H1N1 pandemic response and has led the Disease Control Division since 2011. She now also serves as Medical Director for disease control providing medical and epidemiology technical guidance to the Executive Director.

These roles are in addition to her role as a CDC Career Epidemiology Field Officer assigned to Maricopa County and Captain in the US Public Health Service. Her specialties are internal medicine and infectious disease. Dr. Sunenshine graduated from Indiana University’s School of Medicine and then completed both her residency and fellowship at Oregon Health & Science University, followed by the CDC Epidemic

Intelligence Service fellowship in applied public health from 2004-2006 at CDC in Atlanta.

Dr. R. Nicholas (Nick) Staab has been a medical epidemiologist at MCDPH since 2020. Dr. Staab’s prior experiences include being medical director of the Bureau of Epidemiology and Disease Control at Arizona Department of Health (ADHS) and a pediatric hospitalist at Phoenix Children’s Hospital. He attended the University of Southern California’s Keck School of Medicine and completed his residency in pediatrics at Advocate Christ Medical Center in Oak Lawn, Illinois. Dr. Staab earned his Master of Science in Public Health degree from George Washington University.

PUBLIC HEALTH’S DISEASE PREVENTION By collecting and analyzing data, medical epidemiologists like Drs. Sunenshine and Staab can make informed recommendations to Marcy Flanagan, executive director of MCDPH. One of the important data sources at their disposal is a state system called Medical Electronic Disease Surveillance Intelligence System (MEDSIS). It allows for real-time reporting of case investigations, which inform about disease trends and allow for rapid identification of potential outbreaks. Another tool is the Arizona State Immunization Information System (ASIIS). Vaccinators are required to input COVID-19 data within 24 hours to the immunization registry (and all pediatric vaccine data), making this tool highly effective for understanding vaccination rates and and communities to target for vaccination drives in Maricopa County.

Educating the public, including parents of children, has been of the utmost importance for both physicians.

Dr. Staab states, “Sometimes these are longer than expected conversations, and that’s okay.” Dr. Sunenshine does not believe in pressuring but offering facts, empathy, and exploring people’s specific reasons about vaccine

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On the Personal Side with Dr. Sunenshine 1. If you could describe yourself in one word, what would that be?

A: Collaborative 2. Do you have family? Pets?

A: My partner, Jarrod and a daughter, Ella (age 14) plus Lily (Golden retriever), Desmond Tutu (white fluffy cat), and Nebula (gray cat)

3. Do you have a hidden talent most people wouldn’t know about you?

A: I played the clarinet all through high school and really can start a conversation with “This one time at band camp…”

4. What career would you be doing if you weren’t a physician?

A: I think I would have ended up in local public health either way.

It’s really my passion.

5. What book are you reading right now, or recently?

A: I’m reading The Sacred Pipe: Black Elks Account of the Seven Rites of the Oglala Sioux by Joseph Epes Brown

6. What’s your favorite movie?

A: The 6th Sense and Usual Suspects. I love movies with a plot twist at the end.

7. What’s your favorite local restaurant?

A: Otro Cafe 8. Do you have a favorite sports team?

A: The Phoenix Suns 9. What’s your favorite activity outside of medicine?

A: Kayaking in Oregon

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“The most important predictor of a parent vaccinating their child is that their primary care physician or nurse recommends it.”

– Dr. Sunenshine hesitancy. As new facts emerge about diseases, the county has more opportunities to communicate with hesitant populations.

Educating physicians and healthcare providers is pivotal to achieve a higher vaccination rate. Dr. Sunenshine states, “The most important predictor of a parent vaccinating their child is that their primary care physician or nurse recommends it.” Talking to parents about the vaccinations that are required or recommended by the Advisory Committee on Immunization Practices goes a long way toward getting children vaccinated for a variety of diseases, including COVID-19.

FRAMING THE HESITANCY PROBLEM MCDPH knows of vaccine-hesitant communities that predated COVID-19.

Dr. Staab says some reasons include lack of access and cost of healthcare,

preference for infection-derived immunity, a distrust of government, misinformation, and other social determinants of health.

Access and cost of healthcare are issues that continue being a problem in getting the public vaccinated. From lack of individual transportation to facilities that administer vaccinations to lack of insurance which increases out of pocket costs, not having access to vaccines has proven to decrease vaccination rates, per Dr. Staab. “People who don’t work for a large enough employer that provides health insurance are less likely to have access to vaccines,” says Dr. Sunenshine. The lack of vaccine availability through primary care providers makes access more difficult.

Another problem that public health faces in getting people vaccinated is some of the population’s preference for infection-derived immunity, which comes from infection with the disease organism. Unfortunately, reaching herd immunity through previous infection can take much longer, increase costs of healthcare resources, and risk more lives.

Distrust of government has always been an issue for vaccines. It is fed by misinformation, a history of unethical

“I just use a lot of tools we’ve learned over the last year in terms of what’s effective to different people. Trying to meet people where they are, understanding that for some families it is a quite easy decision and for others it’s not.” – Dr. Staab

On the Personal Side with Dr. Staab 1. If you could describe yourself in one word, what would that be?

A: Social 2. Do you have family? Pets?

A: Married with 3 kids 4-11 years old with 2 dogs and 2 cats

3. Do you have a hidden talent most people wouldn’t know about you?

A: I crossfit 4. What career would you be doing if you weren’t a physician?

A: Architecture 5. What book are you reading right now, or recently?

A: Never by Ken Follett 6. What’s your favorite movie?

A: Not much of a movie person 7. What’s your favorite local restaurant?

A: El Bravo Mexican Food 8. Do you have a favorite sports team?

A: Georgetown Basketball 9. What’s your favorite activity outside of medicine?

A: CrossFit Training

government and non-government studies, misunderstandings about vaccine side-effects and how the body develops immunity from vaccines, and questions about the efficacy and safety of vaccines.

Misinformation and disinformation about vaccines, by news sources and social media platforms, have slowed vaccination rates. That effect has accelerated during the COVID-19 pandemic.

Finally, social determinants of health impact one’s likelihood of accepting vaccines. Some examples are household living conditions, philosophical and cultural beliefs, and religious affiliations.

MCDPH COMBATS VACCINE HESITANCY Finding solutions to increase vaccination rates has not been easy for Drs. Sunenshine and Staab. They forge ahead by building strong partnerships and collaborations, using effective messaging to destabilize frequent misinformation and disinformation, and collaborating directly with specific communities to create significant inroads and build trust.

Relationships with a variety of partners has been indispensable, says Dr. Sunenshine. Partnerships with Maricopa County’s healthcare systems are what allowed large numbers of residents to get vaccinated quickly when the COVID-19 vaccine first rolled out.

ADHS plays a significant role in collecting data. Dr. Staab raves about The Arizona Partnership on Immunizations (TAPI), which has helped the county to identify healthcare providers who are more easily accessible to the public in specific vaccine-hesitant communities.

Local leaders help in connecting healthcare providers who are willing to go into communities in need of vaccines.

Typically, the county health department counters misinformation by placing factual and easy-to-understand information about vaccines through a variety of channels including its website, social media, local television, and radio.

More importantly during COVID-19, Dr. Sunenshine states, “We work directly with local leaders in vaccine-hesitant communities as well as primary care physicians and nurses.”

Local leaders from nonprofit and faith-based organizations are relied upon as trusted messengers to the communities they represent.

Primary care physicians and nurses speak to their patients consistently, making them better messengers to combat misinformation.

“The community plays a pivotal role in public health’s battle against vaccine hesitation,” states Dr. Sunenshine. When the public has a positive experience getting vaccinated, they share that message with friends and neighbors.

Dr. Sunenshine finds key allies in non-profit and faith-based groups.

“They have done an excellent job of sharing the county’s message on vaccines to their respective communities,” says Dr. Sunenshine. ■

By Edward Araujo Managing Editor Arizona Physician earaujo@mcmsonline.com

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IN DEPTH

MANAGEMENT INSIGHT ARIZONA PHYSICIAN: You accept many

insurance plans. How do you determine which plans not to accept?

A CONVERSATION WITH

Pleasant Pediatrics

T

he philosophy at Pleasant Pediatrics is to “create a pleasant and congenial environment for patients and their parents.” They find

no question is a silly question. With an eye on ensuring children can grow and thrive physically, mentally, and developmentally, staff at Pleasant Pediatrics try to guide parents throughout the child’s medical milestones. A priority along that journey is preventative medicine.

Arizona Physician sat down with Mr. Prasad Ravi, CEO, and his wife Sandhya Ravi, MD, FAAP, Medical Director, to discuss the practice and vaccines.

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MR. RAVI: The biggest issue is the administrative burden. Some small plans require high levels of credentialing and paperwork but bring only 50 patients.

The administrative overhead done per claim doesn’t make it feasible. The headaches might be there for a big payer in the market, but administrative costs are spread across thousands of patients.

A second issue is reimbursement. There are so many plans with silly rules that limit covering services and it becomes a nightmare to manage. Another consideration is narrow networks. It became a challenge to maintain patients on narrow networks when we need to coordinate care and avoid getting the short end of the stick if we’re stuck with any physicians out of network. We refuse to take any narrow network unless they add all our providers to the network.

AP: Do you speak with other practices

to share notes?

MR. RAVI: We learn on the job. I didn’t have any healthcare management experience before launching the practice. Maybe that’s a blessing in disguise because we haven’t followed the normal rules. We’ve been able to grow without matching what other practices are doing. At the same time, there are growing pains.

PATIENT RECRUITMENT

“70-80% of new patients are from word of mouth.”

AP: How do you recruit new patients?

MR. RAVI: 70-80% of new patients are from word of mouth. The rest tend to come from good reviews online. That seems to be taking over. It’s switching from word of mouth with neighbors to online. It’s very challenging.

Happy patients tend not to go online to leave positive reviews. Upset patients will leave bad reviews. For example, sometimes we get blamed for insurance issues like rejecting a prior authorization request. We did everything right, but the patient left a one-star review.

VACCINES AND HESITANCY AP: We heard that Pleasant Pediatrics is the

only pediatric practice doing COVID vaccines on a mass scale. Which vaccines are you offering and at which of your six locations?

DR. RAVI: Yes, initially the COVID-19 vaccines were only for adults, especially older adults.

Despite being a pediatric practice, we chose to serve this population and have administered 100,000 COVID vaccines so far. My husband is our CEO. We worked about seven weeks without taking a day off to ramp up and meet the demand for the initial wave of cases when the demand was more among the elderly and immunocompromised.

AP: Are parents receptive to getting their

children vaccinated?

DR. RAVI: About 25-30% of our parents say yes to having their children vaccinated for COVID19. When we ask them, some parents say they did their research but, as a pediatric or medical community, we know most people are influenced from social media, their family and are following some misleading sources.

AP: Is there carryover from the concerns

parents expressed about previous vaccines and autism to COVID-19 vaccines?

DR. RAVI: I believe about 5-10% are hesitant towards vaccines because of misinformation that vaccines could cause autism. When it comes to our practice, we provide care for the families who are willing to follow CDC vaccine schedule. That doesn’t apply to influenza or COVID-19. If they say, “I haven’t vaccinated my child but I’m coming and open to discussion,” then we talk to them. But if they say that they’re not convinced, then we advise them to seek medical care with the providers with whom their ideas align as the unvaccinated children pose a threat to other patients, especially if they are immunocompromised or infants. And I would say more than 90% of pediatricians have stopped accepting children whose parents reject vaccines.

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IN DEPTH

“Almost all of our patients get the vaccines recommended by CDC.” AP: Are there vaccines some parents are more reluctant

to request than others?

DR. RAVI: Almost all of our patients get the vaccines recommended by CDC. About 20-30% refuse HPV vaccine. About 40% refuse influenza vaccine. It’s much higher for COVID-19 vaccine.

AP: What does your medical staff say to parents who are

hesitant to get their kids vaccinated?

DR. RAVI: Our providers ask about the reasons for their vaccine hesitancy and address those reasons giving statistics from studies supported by American Academy of Pediatrics. To be honest, most of the parents have already made up their minds as they are constantly brainwashed by the misinformation on their social media feed and/ or forwarded messages from their friends or family with similar views. We are able to change the minds of only very few.

AP: What is the impact of vaccine hesitancy

on Pleasant Pediatrics?

MR. RAVI: Vaccine hesitancy has been going up. When we started, only 1-2% of the pediatric population was hesitant. That has grown to about 4-5% since the COVID vaccines were released. I thought there was going to be more adoption of vaccines, but it was the opposite.

People coming to get COVID vaccines fear the disease.

They are happy we’re able to provide the service. I was expecting to see more angry patients. Some people who weren’t patients parked next to our tents shouting, “Hey, you’re injecting poison!” or shouting at the parents, but it hasn’t happened often.

Some parents are not compliant with the physician’s recommendations for any vaccine. We decided to not accept them into the practice. We tried repeatedly to convince them, but there is no way to fight the 24/7 misinformation fed through social media, compared to 15-30 minutes conversation with a physician.

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GROWING PAINS AP: Where has Pleasant Pediatrics

grown over the years?

DR. RAVI: We opened our practice here because it was close to our home.

Prasad looked at all the demographics, including pediatricians per population.

We started the first location just half a mile from home. Then, we expanded wherever there was a need. Prasad monitors new homes built with younger families and the zip codes where patients are coming from. One location came from someone who was looking to sell their practice.

AP: What have you faced when

managing growth?

MR. RAVI: When we were small, our main issue was recruiting physicians.

Now, we have good name recognition but hiring nonclinical front office staff is difficult. We also run into an imbalance in the reimbursement levels.

Big hospital systems get two or three or four times more for the same earache.

So, how do we compete? It’s not a level playing field. If we got the same reimbursement, then we could compete for the talent.

PLEASANT PEDIATRICS By the Numbers

FOUNDED IN 2008

SUCCESS STORIES AP: What would you consider to be the top one

or two success stories for Pleasant Pediatrics?

MR. RAVI: Recently, the COVID vaccines. When we started, we heard only about roadblocks.

We pushed those concerns aside and said we’d work through them. We were one of the first clinics to get COVID vaccines. Despite being in only one part of the valley, we provided about 1% of the state’s doses of COVID vaccines. As a pediatric practice, we used tents outside for adult patients to be vaccinated. Because we were an early adopter, it gave us traction in the community. So many people say, “I’m only coming to Pleasant Pediatrics for shots. I’m not going to a pharmacy or other clinic.”

Another success story was early, around 2010. We were aggressive in opening locations. That allowed us to hire physicians and fill their schedules quickly. We took the risk and it put us on a growth path. ■

6 LOCATIONS Lake Pleasant/North Peoria Park West (Peoria) Glendale Peoria and 67th Ave (Glendale) Happy Valley Ahwatukee

120 EMPLOYEES 15 Physicians 15 Physician Assistants 65 Medical Assistants 10 Front Office Staff 8 In Billing 8 Business Managers including a site manager overseeing staff at each location, HR/payroll manager, billing manager, triage manager, quality control manager, and operations manager.

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(NP) and Physician Assistants (PA).

CELEBRATING 10 YEARS A R I ZO N A P H Y S I C I A N . C O M

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What

Arizona

DOCS are Saying Why do you think some patients are hesitant to get vaccines?

They think there is still not enough information about the vaccine and think it is unsafe. —Ashwin Patel, MD Fear. Reading small bits of incorrect information repeated many times that lend credibility. —Vinay Kwatra, DO Being told wrong information, not understanding the benefits, not understanding that they have a responsibility to prevent the spread of disease. —David Baratz, MD Lack of basic knowledge. —Paul Baranko, MD Spurious information. —David Sanderson, MD Misinformation. —Mellissa Holden Leborgne, DO Minorities tend to have greater mistrust of the healthcare system. But I think political beliefs underlie the strongest refusal to get vaccines and that is the major reason people are hesitant.

—Arthur Chou, MD Political ideology, death of expertise, platforms to spread misinformation. —Molly Solorzano, MD

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Previous loss of trust in government, the medical profession and health care industry.

Continual changing of messaging from official agencies. —Leo Martin, MD Patients have mentioned not knowing short- and long-term side effects.

—Mary Garcia Kumirov, MD Not having all the information.

—Marcela Cristea, MD They believe adverse effects are under reported.

—Jeffrey Taffet, MD The diseases they prevent are rarer now, so they aren’t as scary. —Jane Lyons, MD They are inundated with stories of side effects, even though serious ones are extremely rare, it creates a fear that we must combat on a daily basis. —Cheri Nason, MD Religious reasons, concerns about the side effects, the belief that you should have a right to decide what treatments and therapeutics you receive, political coercion. —Brenda A. Gentz, MD, FASA

What media resources of information do your patients use to learn about vaccines?

Television | 81% Social media | 85% Print media | 27% Radio | 23% Podcasts | 35% Website for your medical practice | 8% Other websites | 27%

How do you communicate with your patients about vaccines?

In person | 100% Telehealth 48% Telephone 48% Text messages 12% Social media 32% Emails 20% Online chats 0%

Which vaccines are patients most reluctant to take?

COVID-19 | 100% Influenza | 52% Human papillomavirus (HPV) | 48% Shingles | 12% Pneumococcal polysaccharide vaccine (PPSV23) | 4% Hepatitis B | 8% MMR (Measles, Mumps, and Rubella) | 12%

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What is needed to convince more patients about the safety and efficacy of vaccines?

Evidence of safety and efficacy that is not contaminated by manufacturer funding of Congress, the FDA, medical societies, medical journals, and other means of publication. —Leo Martin, MD

Allowing for personal decision making without coercion. —Joseph Brooks, MD Objective information from public health resources. —Ronald Serbin, MD Stop the misinformation that so many people give out. —David Baratz, MD Continue frequent factual statements.

—David Sanderson, MD Objective nonpolitical scientific information.

—Tim Bonatus, DO One on one communication is the best form of information for the resistant individuals.

—Mellissa Holden Leborgne, DO More time than the standard, “by the way, would you like to get this vaccine you’re due for,” as you’re concluding a visit would go a long way. —Matthew Nelson, DO, MPH, MA Actively engage patients who are hesitant about vaccines in a supportive, nonjudgmental, and empathic way. Motivational interviewing techniques can be effective. —Arthur Chou, MD

It is no longer a rational/informational decision. It has become emotional and that is a difficult barrier to break. —Steve Hoshiwara, MD More educational material and short informational video clips. —Marcela Cristea, MD Transparency. —Jeffrey Taffet, MD The anti vax crowd has an army of people who work together to discredit vaccine advocates and spread misinformation and yet we don’t have the same army of people spreading the truth.

—Cheri Nason, MD Convincing evidence that they are safe and effective.

—Mark Baldree, MD Patients are seeking a strong, unified voice from the medical community in a time where doubt and uncertainty are running as rampant. Some patients respond to data and safety measures, others need to hear personal testimonies/endorsements.

—Anne Maiden-Hope, DO, FAAP Normalcy of getting vaccines in their social settings and the Governor should get behind the CDC recommendations (that is, stop making it harder for common sense public health initiatives).

—Ann Cheri Foxx, MD

Please rate how well you believe the government (local, state, and federal) has done with educating the public about the importance of vaccines?

(10 being the best and 0 being the worst)

Average of

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4.3

What could the government (local, state, and federal) do better to educate the public about the importance of vaccines?

Media blitzes with trusted experts/celebrities educating on the importance of vaccines and regulating and stopping false information on all social media platforms. —Ashwin Patel, MD Not sure they have the credibility at this point.

—Vinay Kwatra, DO Let physicians do the education. —Paul Baranko, MD Tell folks the truth. Don’t try to force or legislate people taking vaccines. —James E. Gerace, MD Make online data more accessible to the public. It’s difficult to digest a voluminous CDC site or clunky state health department webpage. —Matthew Nelson, DO, MPH, MA To educate their constituents that extraordinary times and public health crises are one of the reasons we do have a centralized government that is given power to act for the greater good. —Molly Solorzano, MD Increase the ease and user-friendly experience.

—Richard Dobrusin, DO, FACOFP Only allow physicians and scientists that are knowledgeable about vaccines to educate the public about them.

—Mary Garcia Kumirov, MD I would like to see a debate with a panel of medical experts and the pundits who are so vocal in dispersing misinformation in a nonpartisan setting.

—Steve Hoshiwara, MD Public health campaigns (television, radio). —Jane Lyons, MD People want to know the risks are in taking ANY medicine.

Where is the informed consent? —Mark Baldree, MD Have a strong, consistent message regarding the safety and efficacy of the vaccine. —Anne Maiden-Hope, DO, FAAP Government vaccine messaging needs to be in lockstep regardless of political party affiliation. —Ann Cheri Foxx, MD Stop focusing just on vaccines- consider therapeutics and treatment options. What about focusing on public healthdecreasing known risk factors such as diabetes mellitus, hypertension, and obesity? —Brenda A. Gentz, MD, FASA

Read more about what these docs are saying about vaccine hesitancy at arizonaphysician.com.

Learn more about the participating physicians Ann Cheri Foxx, MD Nocio Interventional Pain Management WEB | NocioPain.com Anne Maiden-Hope, DO Adelante Healthcare WEB | Adelante Healthcare.com

Marcela Cristea, MD Banner Children’s Banner Health Clinic WEB | BannerHealth.com/ services/pediatrics Mark Baldree, MD Arcadia Ear, Nose & Throat WEB | baldreemd.com

Arthur Chou, MD Horizon Health and Wellness WEB | hhwaz.org

Mary Garcia-Kumirov, MD Mariposa Community Health Center WEB | mariposachc.net

Ashwin Patel, MD Ashwin R Patel, MD, PLLC WEB | urgentcareofaz.com

Matthew Nelson, DO Canyonlands Healthcare WEB | canyonlandschc.org

Brenda A Gentz, MD District Medical Group WEB | dmgaz.org

Mellissa Holden Leborgne, DO Banner Health WEB | BannerHealth.com

Cheri Nason, MD Desert Shores Pediatrics WEB | DesertShores Pediatrics.com David M. Baratz, MD Pulmonary Associates WEB | Pulmonary Associates.com David R Sanderson, MD Retired James E Gerace, MD Retired Jane Lyons, MD Dignity Health – St Joseph’s Hospital WEB | Dignityhealth.org/ arizona/locations/ stjosephs Jeffrey Taffet, MD Biltmore ENT Surgeons WEB | Biltmoreent.com Joseph Brooks, MD Arizona Specialized Gynecology WEB | ArizonaSpecialized Gynecology.com

Molly Solorzano, MD Grand Canyon Anesthesia WEB | GrandCanyon Anesthesiology.com Paul V Baranko, MD Dr Paul V Baranko MD Richard Dobrusin, DO Cigna Medical Group WEB | cigna.com/cmgaz/ Ronald Serbin, MD Pediatrix WEB | pediatrixmd.com Steve Hoshiwara, MD Covenant Care Family Medicine Tim Bonatus, DO Northern Arizona Orthopaedics WEB | northazortho.com Vinay Kwatra, DO Phoenix Children’s Pediatrics – Paradise Valley WEB | PhoenixChildrens.org

Leo Martin, MD Leo A Martin MD PC

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LEGAL CORNER

D.I.Y. Asset Protection Steps to Take Today

I

consistently advise physicians that as significant a risk as professional liability is, doctors must think beyond litigation risk broadly about all the risks they face. While some of your risk management will involve the use of specialized advisors and complex legal tools, there are also some important issues you should address yourself, today.

1. CHECK YOUR CREDIT. Most people overlook that we should all be doing this (at least) annually to identify any fraud or errors and to be sure that no unauthorized credit or accounts have been obtained using your identity. This fraud is most common at the end of every year, during the holidays, when new accounts are commonly opened and consumers make more purchases than usual.

This transaction volume provides good camouflage for scammers who can slip charges in among your legitimate purchases and take advantage of delayed billing and other new account promotions.

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2. CHANGE YOUR PASSWORDS, store them securely, and set up two-factor authentication on all your online accounts.  Don’t use the same password at more than one website  Don’t store passwords on your desktop in a document marked “passwords”  Use a secure password storage service  Don’t use passwords with your own name or that end in “21” or “22” 3. INSURE YOURSELF HEAVILY, including an umbrella policy and risk specific coverage, with the best carriers, at the right (high) dollar amounts. This is the most predictable and cost-effective asset protection available.

In addition to own occupation disability insurance and life insurance adequate to replace your income, I advise that personal liability umbrella coverage of two million dollars minimum should be carried by every successful person, as well as loss coverage adequate to cover the true value of Learn more about asset protection at arizonaphysician.com/DIY-asset-protection

your property given increased materials and labor costs.

I routinely get panicked calls from people I have to turn away because they are looking for help after something bad has happened and they find out that they are either ununinsured or under-insured for a particular risk, when it is legally too late to implement asset protection measures, including insurance.

4. BUY AND REGULARLY USE A HOME SHREDDER. A lot of ID theft still happens the old-fashioned way, when mail or trash is stolen and information including account numbers and other personal identifying information on yourself or of 3rd parties you have a legal duty to protect, falls into the wrong hands. The FTC has a simple guide to help identify what you need to keep and what you should securely shred. For other tips on preventing identity theft, visit: ftc.gov/idtheft.

5. UPDATE BENEFICIARY DESIGNATIONS. If there have been significant changes in your life including marriage, divorce, or changes in your assets or family structure, it’s important that you review and update both your estate plan itself and the current beneficiary designations on bank accounts, retirement plans, insurance policies and other financial accounts to avoid unnecessary expense, delay and mistakes in to whom your assets (or assets you yourself should be receiving) from a spouse or other family member, are directed.

6. SECURE PERSONAL ELECTRONICS like laptops, smartphones, and iPads. Millions of Americans got new devices over the holidays due to significant upgrades in technology and financial incentives. Both personal and business usage of these devices has greatly increased due to remote working scenarios and the fact that trade-in

programs are more common than ever, especially for Apple users. Given the crossover in use of these devices and the amount of sensitive personal and financial data they contain, it’s important you and all your family members (are you sharing any accounts?) think and act carefully about security and properly deleting your information before trading them in, gifting them or otherwise disposing of them.

7. REASSESS YOUR HOME EQUITY EXPOSURE. Property values have soared over the last three years, and even doubled, in some high-end Phoenix area zip codes. You have more exposed home equity than ever before, and Arizona’s recently increased homestead exemption is only $250K. It may be time to act and use tools like trusts for personal residences and LLCs for your income producing investment properties to provide protection that traditional estate planning alone does not provide. ■

By Ike Z. Devji, JD Asset Protection Attorney and Founder of Arizona Wealth Law & Of-Counsel Davis Miles McGuire Gardner ike@azwealthlaw.com

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HOW TO

The Demise of the 4% “Safe Withdrawal” Rule

W

hen you think about your future, how do you envision your retirement years?

For most, retirement is a chance to enjoy doing more of what you want to do. You’ll have more time to travel, or maybe you just want to finally slow down, spending more time with loved ones. Unfortunately, for many busy professionals that fail to plan well, that peaceful vision of retirement will now be tougher to attain. Between the global pandemic, rising inflation, and market volatility that’s (always) just around the corner, it is difficult to determine what your nest egg will look like in 5 years, let alone 30 years from now. One of the biggest concerns we hear from clients is their uncertainty regarding how much money they can expect to safely spend each year once they retire without running out of money. Traditionally, the 4% “safe withdrawal” rule has been used as a rule of thumb, but recent events have called into question how sustainable the 4% rule really is.

WHAT IS THE 4% RULE? The 4% rule is a retirement income theory about how much money you can safely withdraw from assets each year without running out of money. It became widely publicized after Bill Bengen’s research in 1994, which showed that withdrawing up to 4% of one’s invested assets each year (adjusting annually for inflation) could sustain the typical 30-year retirement. This published research used data going all the way back to 1926.

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For more information, please visit arizonaphysician.com/4-percent-rule

IS THE 4% RULE OUTDATED? Recent research suggests that the 4% rule is outdated.

Three analysts conducting research at Morningstar concluded that some pertinent historical variables that made Bill Bengen’s conclusion possible no longer apply in our current economic environment.

These factors include: LOW BOND YIELDS | Yields on bonds are historically low, at just 1.73% for a 10-year bond as I write this, compared to the 15.68% rate in September 1981.Coupled with rising inflation and the expectation that interest rates will also rise, many experts question how today’s bonds can help sustain the traditional 4% withdrawal rate.

HIGH STOCK VALUATIONS | Stock valuations are historically high, and many experts don’t understand the phenomenon. You’re probably thinking about “meme stocks” you’ve seen on the news that just seem to unexplainably trade higher, like it’s a popularity contest to own them. Yet, some of these companies’ financials look like they are the “walking dead” because they have so much debt. We call these companies “zombies”, and they are ones to avoid owning.

WAYS TO PROTECT YOUR RETIREMENT INCOME SUSTAINABILIT Y AND GET MORE There are things you can do to better protect yourself from market uncertainty, and in the process create even higher sustainable retirement income.

CONSIDER ADDING A “VOLATILITY BUFFER” ASSET One smart option to consider is to fund a cash value life insurance policy as a safe complement to your market holdings at-risk. Adding this instrument as a “2nd Economic Power” (the power of actuarial science) will rev up the horsepower behind your retirement income plan. During the “accumulation years” of life, most people solely use capital markets investing, and that is generally inefficient by comparison to a “combination approach” in terms of both income sustainability and the actual amount of retirement income you’ll have. Let’s examine. Cash value life insurance can be guaranteed to grow. The cash inside your policy is not exposed to downside risks that affect your other assets (i.e., stocks and bonds). Therefore, this cash can act as a type of supplemental emergency fund that can be used for entire years’ worth of your expenses during (or just after) market downturns while you let your (at-risk) investments recover. This approach can both substantially help your level of retirement income and keep it more sustainable.

CONSIDER GUARANTEED INCOME SOURCES Another way to protect your retirement assets from market fluctuation is by considering other guaranteed income sources available to you.

These sources include: SOCIAL SECURITY | For maximum longevity protection and amount of income, consider delaying your Social Security income until age 70 to obtain the latest delay credit.

PENSION INCOME | While not available to most people, pension income is another source of guaranteed retirement funding that can be in the form of a lump sum at retirement, or a stream of lifetime payments — with or without rights of

survivorship if you have a spouse.

CREATING LIFETIME ANNUITY INCOME | An annuity is a type of insurance prod-

uct for which you trade accumulated assets for a guaranteed stream of income to begin now or in the future. Many annuities offer income payments guaranteed for life, which ensures you will not outlive your retirement funds no matter how the future markets perform.

TAKE ACTION TO POSITIVELY IMPACT YOUR FUTURE The more you can rely on alternative and/or other sources of retirement income as a complement to your traditional investment portfolio, the less you will have to rely on the ups and downs of the market in the future. Regardless of whether the 4% rule is dead, it’s important to make sure you plan your future income well so your retirement funds will sustain your lifestyle needs. ■

By Matthew B. Lowery, Sr, CFP Managing Director DFG Private Client matt@dfgadvisors.com

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PHYSICIAN SPOTLIGHT Jane Lyons, MD, of Dignity Health - St. Joseph’s in Phoenix, AZ shares her thoughts on vaccine hesitancy.

Q: What do parents often say to you about why

they are hesitant to have their children vaccinated?

A: Most often parents will say they have heard about the controversy over vaccines. Sometimes the parents will tell you it’s against their religion, or simply a “we do not vaccinate.”

Q: How do you explain vaccines to hesitant parents?

A: I always start with open-ended questions to find out their concerns, so I can target my counseling.

Starting with general questions such as “What are your concerns?” or “What are your vaccine plans?” can help you to also find out if they are open to discussion or unlikely to change their minds. If they are open to discussion, I have a few CDC vaccine FAQ pages and handouts I will print out for them and explain to them these vaccines are very safe and very effective. And explain that these vaccines have been given to millions of children for years and years and protect against scary diseases.

I will tell the family they can always ask me more questions and we can continue the discussion, and I am willing to work with them on a modified schedule and prioritize vaccines that protect against scarier diseases. If they are very adamant that their family does not vaccinate, I may just provide them the CDC handouts and tell them I am always here for questions.

consider some or all vaccines. I do not believe in dismissing vaccine refusal families from your practice, as there are some families that do eventually agree to at least some vaccines and providing primary care to families is not only about vaccinations. By maintaining the therapeutic relationship, I can continue to monitor the child’s growth and development, provide care in all other aspects of their health, and prevent the family from either not obtaining any healthcare for their child or seeking out an alternative provider who may reinforce or provide additional misinformation.

Q: Are there policy changes you

recommend for vaccines?

A: I would love to see more public health campaigns over basic health issues such as vaccines, and viral illnesses/the cold (to help combat overuse of antibiotic resistance and overuse of emergency medical care for non-emergent issues). Vaccine skepticism is widespread and without a scientific basis, and most often families have their information from family and friends, so it is very hard to combat that. ■

Q: Which vaccines are parents most hesitant

about getting for their children?

A: COVID19, influenza, HPV. Q: What sources of information do parents

often use to learn about vaccines?

A: Word of mouth.

Q: What advice do you have for primary care

physicians whose patients question a vaccine?

A: I recommend always starting with open ended questions to help you target your counseling, and to find out if the family is even willing to discuss or 34 n

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JANE LYONS, MD Pediatrician Dignity Health – St. Joseph’s Hospital Jane.lyons@commonspirit.org

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