2022 - Sep/Oct - SSV Medicine

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Sierra Sacramento Valley Serving the counties of El Dorado, Sacramento and Yolo

September/October 2022

“We want to make sure that California’s finest physicians are properly protected.”

A Team Approach to Medical Malpractice Coverage is a Winning Approach for Physicians More than 12,000 physicians rely on the Cooperative of American Physicians (CAP) to protect their practices every day.

Sarah E. Scher, JD Chief Executive Officer

Physician-founded and physician-governed, CAP provides superior medical malpractice coverage and solutions to help California physicians realize professional and personal success. CAP members also receive risk management services, claims support and a dedicated in-house defense firm, practice management resources, and so much more. Find out what makes CAP different.



Medical professional liability coverage is provided to CAP members by the Mutual Protection Trust (MPT), an unincorporated interindemnity arrangement organized under Section 1280.7 of the California Insurance Code.



Monkeypox? Really? Paul Reynolds, MD




David Ford, CMA Vice President, Health Information Technology


The California Data Exchange Takes Shape



Aileen Wetzel, Executive Director

Elizabeth Morrison, Ph.D, LCSW

Protecting Providers, Patients After Dobbs


Packing Boxes, Unpacking Life

Caroline Giroux, MD


Motivational Interviewing Improves Patient Dialogues and Outcomes


We welcome articles from our readers by email, facsimile or mail to the Editorial Committee at the address below. Authors will be able to review articles before publication. Letters may be published in a future issue; send emails to SSVMedicine@ssvms. org.

Board Briefs

New SSVMS Members



Fighting the Anti-Vaxxers of the Early 1900s

All articles are copyrighted for publication in this magazine and on the Society’s website. Contact the Sierra Sacramento Valley Medical Society for permission to reprint.


Med Schools Need to Awaken to Dangers of Sleep Deprivation Eric Williams, MD

Love Them or Hate Them, Faxes Run U.S. Health Care

Visit Our Medical History Museum 5380 Elvas Ave. Sacramento The SSVMS Museum of Medical History is currently open Tuesdays and Thursdays by appointment. Visit ssvms.org/museum.

Ken Smith, Managing Editor

VOLUME 73/NUMBER 5 Cover photo: The San Juan Moutains frame fall foliage in Colorado.

Photo by Enrico C. Lallana, MD

Official publication of the Sierra Sacramento Valley Medical Society

5380 Elvas Avenue Sacramento, CA 95819 916.452.2671 916.452.2690 fax info@ssvms.org

SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx

September/October 2022


Sierra Sacramento Valley The Mission of the Sierra Sacramento Valley Medical Society is to bring together physicians from all modes of practice to promote the art and science of quality medical care and to enhance the physical and mental health of our entire community.

2022 Officers & Board of Directors

Paul Reynolds, MD, President J. Bianca Roberts, MD, President-Elect Carol Burch, MD, Immediate Past President District 1 Jonathan Breslau, MD District 2 Adam Dougherty, MD Judith Mikacich, MD Susan Murin, MD Vanessa Walker, DO District 3 Ravinder Khaira, MD

District 4 Shideh Chinichian, MD District 5 Christina Bilyeu, MD John Coburn, MD Farzam Gorouhi, MD Roderick Vitangcol, MD District 6 Marcia Gollober, MD

2022 CMA Delegation District 1 Reinhardt Hilzinger, MD District 2 Lydia Wytrzes, MD District 3 Katherine Gillogley, MD District 4 Anand Mehta, MD District 5 Sean Deane, MD District 6 Marcia Gollober, MD

At-Large Delegates R. Adams Jacobs, MD Barbara Arnold, MD Megan Babb, DO Janine Bera, MD Helen Biren, MD Carol Burch, MD Amber Chatwin, MD Angelina Crans Yoon, MD Mark Drabkin, MD Rachel Ekaireb, MD Gordon Garcia, MD Ann Gerhardt, MD Farzam Gorouhi, MD Richard Jones, MD Steven Kmucha, MD At-Large Alternates Christine Braid, DO Karen Hopp, MD Arthur Jey, MD Justin Kohl, MD Syed Latif, MD Scarlet Lu, MD

CMA Trustees, District XI

Adam Dougherty, MD

AMA Delegation Barbara Arnold, MD

Editorial Committee

District 1 Alternate Tanuja Raju, MD District 2 Alternate Sharmilo Amolik, MD District 3 Alternate Toussaint Mears-Clark, MD District 4 Alternate Shideh Chinichian, MD District 5 Alternate Joanna Finn, MD District 6 Alternate Natasha Bir, MD

Sam Lam, MD Vong Lee, MD Charles McDonnell, MD Leena Mehta, MD Sandra Mendez, MD Taylor Nichols, MD Tom Ormiston, MD Sen. Richard Pan, MD Hunter Pattison, MD Paul Reynolds, MD Ernesto Rivera, MD J. Bianca Roberts, MD Ashley Rubin, DO Lee Snook, MD Tom Valdez, MD John Wiesenfarth, MD Derek Marsee, MD Carlos Medina, MD Ashley Rubin, DO Siddharth Raghavan, MD Alex Schmalz, MD Ashley Sens, MD Asmaneh Yamagata, MD

Robert Oldham, MD Margaret Parsons, MD Sandra Mendez, MD

Megan Babb, DO Sean Deane, MD Caroline Giroux, MD Robert LaPerriere, MD Karen Poirier-Brode, MD

Gerald Rogan, MD Kayla Umemoto, MS II Michelle Ann Wan, MS III Lee Welter, MD Eric Williams, MD

Executive Director Managing Editor

Aileen Wetzel Ken Smith


Sierra Sacramento Valley Medicine


Listen and subscribe to Joy of Medicine - On Call on your favorite Podcast App or visit joyofmedicine.org

Sierra Sacramento Valley Medicine, the official journal of the Sierra Sacramento Valley Medical Society, is a forum for discussion and debate of news, official policy and diverse opinions about professional practice issues and ideas, as well as information about members’ personal interests. Advertising rates and information sent upon request. Acceptance of advertising in Sierra Sacramento Valley Medicine in no way constitutes approval or endorsement by the Sierra Sacramento Valley Medical Society of products or services advertised. Sierra Sacramento Valley Medicine and the Sierra Sacramento Valley Medical Society reserve the right to reject any advertising. Opinions expressed by authors are their own, and not necessarily those of Sierra Sacramento Valley Medicine or the Sierra Sacramento Valley Medical Society. Sierra Sacramento Valley Medicine reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted. Not responsible for unsolicited manuscripts. ©2022 Sierra Sacramento Valley Medical Society SIERRA SACRAMENTO VALLEY MEDICINE (ISSN 0886 2826) is published bimonthly by the Sierra Sacramento Valley Medical Society, 5380 Elvas Ave., Sacramento, CA 95819. Subscriptions are $26.00 per year. Periodicals postage paid at Sacramento, CA and additional mailing offices. Correspondence should be addressed to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396. Telephone (916) 452-2671. Postmaster: Send address changes to Sierra Sacramento Valley Medicine, 5380 Elvas Ave., Sacramento, CA 95819-2396.


Paul Reynolds, MD

Caroline Giroux, MD

If it's not one thing, it's another. Just as we thought we were getting through COVID along comes monkeypox. Dr. Reynolds has suggestions on how to prepare patients for whatever may be next.


Ken Smith


Faxes. Why does America's health care system rely on outdated technology, with roots that predates the Gold Rush, when other countries are trying to eliminate it? Ken has the facts about the fax.

Enrico C. Lallana, MD enrico.c.lallana@kp.org

Dr. Lallana contributed this month's cover photo, a fall spectacle taken in Colorado. You can see more of his stunning photos of landscapes, Yosemite, Europe and more on Flickr.

David Ford


Moving is one of life's most stressful events, as Dr. Giroux can tell you after completing one. You're packing and unpacking more than stuff—it's your life. She looks at how to deconstruct the experience.

dford@cmadocs.org David Ford, CMA's vice president for health information technology, explains California's expansive new Data Exchange Framework and the steps providers need to take in the coming months.

Elizabeth Morrison

Eric Williams, MD

Elizabeth, who is leading a series of trainings for SSVMS, explains how motivational interviewing can lead to more honest dialogues and better outcomes for pregnant patients with substance use issues.

Anyone who has been through medical school can relate to its demand for long hours and little sleep. Dr. Williams says that's not doing anyone any good and it's time to change.



Eric Williams, MD Comments or letters, which may be published

imango@att.net in a future issue, should be sent to the author’s

Dr. Williams closes this issue with a poem email or to SSVMedicine@ssvms.org. that reminds us that even after the stormiest and most difficult of days, a magnificent sunset can await. Each is unique, reflecting one moment in time.

September/October 2022



Monkeypox? Really? How to Talk to COVID-Weary Patients About Whatever May Be Next


n August, Governor Gavin Newsom declared a state of emergency because of monkeypox. For too many Californians it was déjà vu and conjured images of the world shutting down in March 2020. Of course, monkeypox isn’t COVID-19. It’s less lethal, doesn’t spread nearly as quickly and won’t turn into the widespread pandemic COVID was. But it does deserve concern and measures to help prevent its spread. So how do medical professionals convey that message to a pandemic-weary public that would just as soon never wear or see a face mask again? And we all know that misinformation needing to be countered will be spread faster than monkeypox itself can be. First, get your story together. Listen to the concerns of your friends, family, neighbors and what is in the news. Get the facts so you can address what worries them directly and be proactive in countering messages they may hear from more dubious sources. But one size doesn’t fit all when it comes to what to say; for example, the spread of monkeypox among gay men will mean that patients who fit that demographic or another that is at a greater risk will need more extensive information and an understanding of how to reduce that risk. You can also ask patients where they are getting their information so you’ll have a better idea of the thought processes behind their concerns or resistance to a vaccine. As we learned during the COVID-19 pandemic, cable news, social media and even politicians can be the source of nonsensical conspiracy theories that seem to lead to a more hardened position the more you try to combat them with facts. I strongly urge you not to get caught up in discussing conspiracy theories with anyone because not only will you quickly fall off your intended message, you’ll simply reinforce their beliefs. Talking with your colleagues and listening to their experiences can be incredibly helpful. One thing we


Sierra Sacramento Valley Medicine

By Paul Reynolds, MD paul.d.reynolds@kp.org

learned during the COVID pandemic was that despite all the misinformation floating around, people continued to trust their doctors to give them solid information. Getting a sense from other physicians if there is an inordinate level of fear among their patients about monkeypox, if they have post-pandemic apathy, or what messages have been effective in reaching out to patients who are prime candidates for what is still a limited—albeit proven—vaccine will be helpful. You may just find that people are curious because of a lack of comprehensive information. It’s important to convey that while the number of cases is still small, it’s smart to be diligent. Their familiarity with COVID can help you put the situation in perspective. For example, you might say, “If you’re at a party, simply being near someone is enough for COVID because it’s transferred through particles in the air. But monkeypox is spread through extended physical or very close contact. So, I’d be more wary of hugs and handshakes, if nothing else to lessen your chances of getting COVID or the flu.” Unless you primarily serve demographics that are at a higher risk, it’s likely that you won’t face very many cases of monkeypox or even get questions from patients. But there is no question that the public is on heightened alert for viruses, and there is some basis for that. Authorities in New York are warning about the potential for an outbreak of polio, a disease that had been considered eradicated in this country for nearly half a century. One trip into the SSVMS Museum of Medical History is an immediate reminder that polio isn’t something to be taken lightly: the first thing inside the door is an iron lung, the dreaded machine where some polio victims had to spend their lives in order to breathe. We can’t be sure what will be next, but as physicians we can follow a regimen to make sure that patients are well informed. That helps them make decisions that are

good for their individual health as well as for public health, no matter what the epidemic du jour may be. A direct conversation is always best, but what is of utmost importance is that the information patients receive is consistent. Hearing different stories is confusing and implies that the “experts” they are listening to either

don’t really know or that there is overall uncertainty that can lead patients to seek their own—often incorrect or harmful—information. When guidance changes and today’s message might seem inconsistent with yesterday’s, it is important to fully explain that it is because new discoveries have been made in the ongoing search for better therapies and prevention measures, not because the original information wasn’t the best available at the time. Those have been some of the most important and lasting lessons of the COVID pandemic. I’m sure you try to give patients the knowledge they need to understand and better manage the more common medical conditions they have, especially when they are severe or challenging. Knowledge gives them the power to better handle what they face and limits their doubts about the care they receive. What patients need most is… patience. They haven’t gone to medical school, but they do go to Google; it is essential to understand that they do that not out of doubts about what you say to them, but because of a desire for more information. Work with them to sort out what they learn and take the time to answer their questions. Knowledge is power; the power to overcome misinformation and the power patients need to take charge of their health.

September/October 2022



Protecting Providers, Patients After Dobbs CMA, SSVMS Back Reproductive Rights Bills


ith the overturning of Roe v. Wade, SSVMS and the California Medical Association have put a renewed focus on protecting reproductive rights. First of all, SSVMS and CMA are both in support of Proposition 1, the state constitutional amendment on the November ballot that will codify reproductive freedom in California. CMA and SSVMS strongly believe that medical decisions—including those around abortion and contraception—should be made by patients in consultation with their health care providers. We are also working with CMA to protect physicians and patients in California from laws passed in other states that could put them in legal jeopardy. CMA and SSVMS are supporting AB 1242 (Bauer-Kahan, Bonta, Garcia), which would prevent arrest of those who have, perform, or aid in the performance of an abortion. Law enforcement would also be prohibited from cooperating with agencies outside of California regarding a lawful abortion. Other bills that have earned our support include AB 2223 (Wicks), legislation that would protect patients and providers from prosecution and criminalization of abortion or pregnancy loss, and AB 2626 (Calderon), which would prevent state licensing boards from suspending or revoking the license of someone who performs an abortion in accordance with California law. CMA and SSVMS are confident these bills will pass and provide necessary protections for physicians. Another bill we supported that protects clinicians who provide abortions to patients from other states from civil and criminal liability to the extent possible, AB 1666 (BauerKahan), was signed into law and is now in effect. There is also legislation we are supporting that is designed to increase access to reproductive health care. AB 657 (Cooper) would require medical boards in California to expedite license application reviews for those intending to provide abortions for an employer or 6

Sierra Sacramento Valley Medicine

By Aileen Wetzel awetzel@ssvms.org

health care entity. AB 1918 (Petrie-Norris) would create the California Reproductive Service Corps in order to improve the education pipeline. AB 2091 (Bonta) would enhance privacy protections for medical records related to abortion and pregnancy. AB 2320 (Garcia) would provide grants to implement and/or re-introduce medication abortion in clinics. SB 1142 (Caballero, Skinner) would fund abortion providers, abortion fund organizations, or other community-based organizations that secure practical support needs for patients. SB 245 (Gonzalez), which eliminates cost-sharing for abortion and related services regardless of a patient’s insurance type, has already been signed by the governor and goes into effect on January 1, 2023. CMA and SSVMS also advocated for support of reproductive health access through the state budget by calling for an investment of approximately $200 million into reproductive health, access, and justice. Within that amount is $40 million to bolster the reproductive health care workforce, including scholarships and loan repayments, to support the need for practitioners. Another $40 million in grants to reproductive health care providers will reimburse them for uncompensated care provided to patients of low to moderate income who do not have health care coverage for abortion services. “California has a long history of protecting and defending reproductive health care rights, and by reaffirming our basic and fundamental principle that women should be able to get the health care they need, our state is once again leading the way,” CMA Board of Trustees Chair Shannon Udovic-Constant, MD said in a statement supporting Proposition 1. SSVMS strongly agrees and we are proud to work on behalf of physicians and patients to protect those rights. Our ongoing goal is to ensure you and your colleagues can continue to provide quality care to our community through medically sound decisions that produce the best outcomes for patients.


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Packing Boxes, Unpacking Life

Does moving have to be a nightmare?


have rarely grasped the concept of courage as acutely and precisely as I did during a recent move. Moving ranks as the third-most severe stressor after the death of a loved one and divorce. In Canada, people move an average of five or six times over a lifetime. In the U.S., the average is twice this number: about 11 times. Recently, I counted my thirteenth move. And I hate moving. But I have had to obey life circumstances such as studies and migration, and constraints like professional relocation and finances. While I was trying to overcome my procrastination tendencies by packing a few boxes here and there—the hardest part of moving is usually to get started, or so I thought—I decided to deconstruct the experience in the hope that I would find some ways to make it more manageable this time, in the future, and also for patients I work with who find moving as completely nerve-wracking as I do. I found observing myself and paying attention to the emotions that arose for several consecutive days quite enlightening. First, I validated my sense of dread. After all, moving means putting your whole life into boxes. And if you are a bit of a hoarder like me, as life gets longer it gets bigger and filled with more stuff. Moving also creates a sudden disruption by fragmenting a life that is made of cues, mementos, and sources of comfort in a way that makes the landscape of our daily existence no longer predictable. Speaking of… things. I have a lot of things. I still (proudly) wear a barrette I had as a six year old. My grandmothers’ dishes, recipes, scarves, dressers, and my grandpa’s sweater and some cool tools migrated with me from Canada. I have a ton of my kids’ drawings, books and toys, and some of my own from my childhood. Every time things have to migrate or be shipped, I am afraid to either lose a box or two or break something of high sentimental value. There are casualties still fresh in my mind from past moves. 8

Sierra Sacramento Valley Medicine

By Caroline Giroux, MD cgiroux@ucdavis.edu

As we progress in life, the list of our losses only grows longer and our stuff or things are not spared of such attrition. That’s not to mention what we need to purge or give away because it will no longer fit in the new place. To the sense of grief experienced upon leaving a home in which we created positive memories is added the grief to having to leave stuff behind. Once I had made peace with that by reminding myself of the concept of impermanence, I realized why I am so inefficient in packing. It seems like every time, I rediscover certain objects I had forgotten I had or I realize there was a book I never got around to reading that was in full view all along (and of course, in the midst of the packing chaos, this is the book I feel a sudden urge

Speaking of… things. I have a lot of things. I still (proudly) wear a barrette I had as a six year old. to read). So, I pack words, pages, chapters, books almost apologetically, feeling sorry for neglecting them and trying to envision a new life full of promises and good resolutions, to make up for the unfulfilled dreams of adventures, as if each book was an unconquered lover (or as if I were waiting to be conquered by its story), each page not grazed enough through a kiss from the pulp of my fingers that were too rushed. I almost have a dialogue with each photo, book, treasure from a trip. The initial stage of packing is usually organized because I pause enough to mindfully regroup books and items I plan on paying attention to the next time. But who am I trying to fool? As the big day approaches, swamped in phone calls to utilities to transfer services or to find quotes from moving companies, I realize that I don’t have enough boxes for all my stuff, not enough time to strategize, and even less time to pack. Therefore, the next stage usually

involves packing things in a more disorganized fashion, putting items that have not much in common together. It adds to the growing apprehension at the thought of having my vulnerabilities exposed to strangers, soon to arrive in a moving truck, through my intractable messes from accumulating items. Shame rapidly kicks in. Then, as a trauma psychiatrist, I can’t help but wonder if trauma-informed movers exist… And during all this process (which for me, can take weeks to months), my self-care suffers and each night feels like I have to catch an early morning flight. I can no longer relate to people going about their normal life and routine; I feel like the clock goes faster just for me. There is a pre-decompensation phase just around the corner when I realize I must do it all, such as cleaning the house I am leaving (because an inspection has been scheduled) and cleaning filth from the house I am moving into (to ensure the new dirt is no longer from the former inhabitants but my own). Of course, I simply cannot do it all. I berate myself for having waited so long to clean the refrigerator or the oven or to pack the martini glasses I never use (while complaining that martinis are overrated… and even more so, martini glasses!). Life circumstances and the reasons for the move can add to the level of distress. Reasons such as migration due to war, relationship breakup or divorce, bankruptcy, house fire, or rushed relocation into a long-term care facility due to rapid deterioration of autonomy bring a traumatic flavor to the process, but there is never enough time to absorb and heal the correspond-

ing emotions. Conversely, it can also be an exciting first step on the road to a new job or new life with someone special. Even a seemingly innocuous move can become a trigger if past moves took place in traumatic contexts. In one of my out-of-state relocation moves many years ago, I had a miscarriage the day the truck arrived. This was a very tragic moment that has tainted the process since and I wonder if unconsciously I am afraid to “lose” something (a chair, a photo album, a dream, a possibility, a dear person) whenever I switch houses. This added a negative association to an event I already wholeheartedly disliked. In other words, the web of emotional experiences in a move can be complex, and I realized these experiences must be ideally attended to, otherwise they will keep coming back at each subsequent move. Finding supportive people is essential to process the feelings about the transition. In my most recent move, I had decided for practical and financial reasons to leave a home I had been renting for a year. Even though I knew this rental was temporary (it was on the pricier end and not in the most convenient location), as I was emptying one room after another I felt swept by a wave of conflicting feelings: irritation towards certain annoying features about the house and gratitude for the positive moments I cherished in that house with dear people in my life. The ambivalence was challenging. I even sensed an emotion close to guilt: guilt of abandoning the house, that beautiful yellow house with a view on a lake. September/October 2022


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Sierra Sacramento Valley Medicine

Even harder than this for me was grieving the dreams I had for this house to contain and see unfolding: welcoming certain people more often, hearing their laughter, doing more art. This all had to be put in a box, too. By that time, many tears had been shed and I was so overwhelmed that I put everything that was left into bags and boxes without triaging despite my always renewed, but rarely honored, intentions to purge. I didn’t have time to go through all the pieces of paper containing ideas and notes, the kids’ outgrown clothes, and the miscellany of items that had value, but mostly only to me. Like in any difficult experience, I learned to try to identify what it taught me and what were the positive elements. I realized I was fortunate to be able to count on the frequent and precious help of a few friends. The movers were very meticulous and experienced and would have passed the traumainformed care test if such a thing existed. I admitted I couldn’t have done it all and that it is important to seek help and pace ourselves. Finding any area of control and trying to expand it can also give a sense of agency so we don't feel totally disempowered as we do with other stressors (death of a loved one, divorce, illness, job loss). Voicing one’s evolving needs and processing emotions as they come up are ways to find self-empowerment and access resilience with enough serenity to finally enjoy the comfort of a new place and to remember that home, after all, is always carried within.


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Love Them or Hate Them, Faxes Run U.S. Health Care Why are health providers still relying on technology from the Disco Era?


axes were a marvel of their time. Suddenly, documents could be sent in a matter of hours (or minutes!) across town or across the country, an experience that must have been similar to the arrival of the first dits and dashes of Morse Code when telegrams connected the vast reaches of our growing nation. Federal Express tried to get ahead of the curve in 1984 by offering “Zapmail,” which would get your documents from here to there faster than you could get to the mailbox. It wasn’t long after that before the office fax machine became a thing that everyone had to have. They still sit there, in most offices gathering dust or embedded within a printer as a quaint reminder of an earlier, pre-digital age. Except at physician offices, of course. Why is it that in health care, one of the most technologically advanced industries on the planet, so much of the information that is transferred still relies on paper slowly being transmitted with 1980s technology and the hope that the receiving line isn’t busy? Oddly enough, the history of the facsimile—fax for short—machine dates back well before the invention of the telephone to a clock-making Scotsman. Alexander Bain’s British patent for a machine that would reproduce an image transmitted electrically through wires was granted in 1843, a year before Samuel Morse filed for a patent on the telegraph. Using a clock for synchronization, one pendulum was used to scan an image line-by-line and another wrote it onto a cylinder by applying metal pins. An electric probe read the pins and transmitted the signals to a remote station where the message appeared on paper that was electrochemically sensitive. Bain came out with an improved version a few years later but was beaten to the patent by Fredrick Bakewell,


Sierra Sacramento Valley Medicine

By Ken Smith ken@kdscommunications.com

whose “image telegraph” was closer to what we think of as today’s fax machine. The bigger step came with Giovanni Caselli’s “Pantograph,” so named because it copied both images and words, in 1860—a full 16 years before Alexander Graham Bell received a patent for the telephone. (That would seem to create a conundrum: How can you call to see if the fax is received if the telephone hasn’t been invented yet?) Over the next 100 or so years, the advances in sending what we think as faxed images included transatlantic and wireless transmission. It wasn’t until the mid 1960s

“Fax machines conjure within me a similar clunky and nostalgic memory that Walkmans, TI-89 calculators, and rotary phones do.” — Magi Aurora, MD that Xerox introduced the Magnafax Telecopier, the first version that could be connected to any telephone line. It took six minutes to send one letter-size page. Faxes still aren’t known for their speed. Most faxes still work at a transmission rate of just over 14,000 bytes per second. That’s compared to a fairly standard Comcast home internet speed of 200 megabytes per second—or well over 100 times faster what what a fax machine can handle. Still, faxes are pervasive at all levels of health care. Lab reports that could be delivered electronically instead have to wait for a busy signal to go away before a low-resolution image is printed out and distributed to

the recipient. Doctors’ offices and hospitals fax patient records back and forth using a high-tech world’s equivalent of a carrier pigeon. Astonishingly, a study at the end of the last decade discovered that 75% of all patient data exchanged in the U.S. was done by fax. “As a millennial, I’m not unfamiliar with the idea and function of a fax machine,” said Magi Aurora, MD. “While fax machines remain surprisingly widespread, they conjure within me a similar clunky and nostalgic memory that Walkmans, TI-89 calculators, and rotary phones do.” Dr. Aurora says the process of printing a document to provide a “wet” signature followed by scanning it for a fax or email “seems cumbersome, inefficient and costly.” Smartphone technology should render fax machines obsolete, he said, leaving them as a secondary or tertiary method of communication in a world that can leverage digital technology to streamline and simplify health care. It is possible for health care to function without fax machines. In the U.K., as of April 1, 2020, National Health Service trusts were banned from buying what the chair of the Royal College of Surgeons called “absurd” fax machines. RCS and others in the U.K. have recommended secure email instead, and the “axe the fax” effort has been relatively successful with about half of the machines removed after a year. The Obama Administration successfully passed the HITECH act in 2009, which included over $30 billion to encourage hospitals and physician offices to convert to electronic medical records. There was a lot of success: adoption of at least a basic electronic health record system rose from 9% in 2009 to almost 84% by 2015.

The application drawing for Alexander Bain's 1850 patent for the forerunner of the facsimile machine. An improvement of his 1843 version, Bain was denied the patent because Fredrick Bakewell had been granted a patent for a superior device called an image telegraph. What that number doesn’t say, however, is that hospitals and health systems aren’t all using the same EHR system and that their incompatibility isn’t by chance. Health systems can benefit from keeping patient information walled within their ecosystem so it’s harder to change providers but easier to schedule appointments, view lab results and find specialists. “The vendors compete with each other. They don’t want to make it compatible,” said Alex Chan, a health care software engineer. “The health care system is very cutthroat.” An investigation by Kaiser Health News found that many physicians found EHR systems clunky and unintuitive. The systems also could invite upcoding, or inflating bills, the antithesis of how efficient, cost-saving electronic systems were supposed to save people money. Software glitches could put patients at risk of severe injury or death, which increases a physician’s liability. On top of that, as of the inves-

September/October 2022


tigation in 2019 there were over 700 vendors making systems that don’t all talk to each other. But fax machines do talk to each other. Their simplicity in a complex world allows one to contact another and pass on vital information in clear form, even if it’s coming in a relatively rudimentary way. It’s not surprising, then, that one of the primary reasons fax machines continue to be one of the most common ways of sharing records is that doctors are used to them. Put paper in the machine or open an e-fax program on a computer, punch in a 10-digit telephone number, listen to a few boops and beeps, and it’s done. Faxing also continues to be HIPPA compliant. It’s true that it’s much more attractive for hackers to break into a cloud server containing millions of data bits than it is a piece of hardware that is slowly loading one page of information at a time. While it’s possible that the recipient could leave information sitting in the machine or on a desk that might be viewed by the wrong eyes, most physicians are careful about protecting patient data and the impact would be nowhere as great as it would with a server breach. On the other hand, digital data is stored off-site where it’s protected from fire, the office ceiling sprinklers going off, or burglary. One semi-retired doctor who dispensed with his fax machine years ago said he continues to be amazed how when he needs to order imaging or other services, the radiology labs normally require a fax request. He said that means a trip to the nearest location where one is available, often a UPS Store or FedEx office. That does not seem any more private than an email or online request, nor does it improve efficiency. Sending one item of personal health information may not seem to be a big deal, but that’s not always true at the other end. During the summer 2020 spike in COVID19 cases, reporting and tracking of cases in Austin, Texas were completely bogged down for one reason: fax machines. Thousands of cases were coming in each day by fax that had to be responded to. At one point, the stack of printed faxes that health officials had to comb through was seven inches high. "We were probably getting thousands of cases a day that we were responding to. It was madness," Janet Pichette, the chief epidemiologist for Austin Public Health, told the BBC. "You cannot fight a pandemic using 19th century technology.”


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Just the Fax, Ma’am

• 75% of patient information is still exchanged via fax

• 30% of tests are reordered due to lost faxes

• 9 billion fax pages are exchanged each year

• 25% of faxes don’t arrive before a patient’s first visit

Source: Direct Trust

There are alternatives to faxing, even some that use familiar names. Emails are HIPPA-compliant if they have end-to-end encryption, are retained permanently and you get permission from patients to communicate that way. Outlook, Google and Dropbox all have the capability (although certain software suites or service levels may be required) to meet HIPPA standards and providers can sign a HIPPA business associate agreement easily online. There’s undoubtedly an “If it ain’t broke, don’t fix it” attitude toward using technology that has roots predating the Gold Rush but, despite widespread amazement, is still an essential cog in the American health care system. But as COVID showed Austin and other places around the world, it’s more broke than most people realized. It’s the American health system’s often self-inflicted

inefficiency that continues to give fax machines the

“You cannot fight a pandemic using 19th century technology.” — Janet Pichette Chief epidemiologist, Austin (Texas) Public Health

lifeline they need to survive well beyond when they should have been peacefully retired and been reincarnated through an electronic waste recycling program. A Vox Media article aptly called the fax machine “the cockroach of American medicine: hated by doctors and medical professionals but able to survive—even thrive—in a hostile environment.” For the fax machine to be totally relegated to history and earn its final resting place in the SSVMS Museum of Medical History’s collection of quaint reminders of medical days gone by, several significant events will have to occur. Electronic health systems will have to speak the same language and meet consistent standards so they are universally accessible, even if it means health systems could lose patients who have more freedom to take their records to other providers. Physician and staff attitudes will have to change; there seems to very little

effort at the grassroots level to do away with faxes and not just accept that as long as someone else uses one, it’s OK (and even necessary) for you to use one, too. Those are both big mountains to climb. Until the day comes, fax machines will likely sit in a corner of provider offices at all levels of our health care system. But could they one day become obsolete in the U.S., as they are becoming in other countries, as EHR systems learn to talk to each other like a loving family rather than trying to get through to a drunk uncle on Thanksgiving? “They could find a way in the future to make it compatible,” Chan says. “It’s not impossible. It’s just whether anyone is willing to do it.” Ken Smith is managing editor of SSV Medicine.








Joy of Medicine Annual Wellness Summit Discovering Your Relational Self-Portrait After ACEs Workshop Part I SIP/HILL Physicians Evening with Residents Discovering Your Relational Self-Portrait After ACEs Workshop Part II

September/October 2022



The California Data Exchange Takes Shape Most Providers Will Need to Implement New Information Sharing Framework by January 2024


ith a combination of mandates, a new governing board and publicly funded assistance, the California Data Exchange Framework is set to pull health information exchange into the 21st century. Probably every physician practice has had the frustrating experience of trying to deliver the best possible care to a patient, only to be hampered by the inability to access relevant health information. Important pieces of a patient’s history, such as prescriptions, chronic conditions, or previous diagnoses may be trapped in data silos held in a million different places, inaccessible to the patient or the physician at the point of care. Myriad studies of the health care system have shown that lack of health information at the point of care often leads to duplication, waste, and delay. Despite the widespread adoption of electronic health records across the state, this problem persists. A combination of technology challenges, competitive forces, and some legal uncertainty has kept data locked away from both patients and physicians. The federal government began working in 2020 to address this problem through the 21st Century Cures Act Final Rule, often known as the “Information Blocking Rule.” This rule clarified in federal regulation that patients have the right to access their own medical information through the technology of their choosing. For the first time, physicians, hospitals, and health plans must make that information available. This rule started the country down the path of widespread and seamless data exchange. Now, the California Medical Association is working with the State of California to build on the federal regulations to accelerate and expand data exchange efforts here in the state. After a year of legislative negotiations, state budget appropriations and stakeholder meetings, the California Health and Human Services Agency published the


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By David Ford dford@cmadocs.org

Data Exchange Framework on July 5, 2022. Usually abbreviated “DxF,” the Data Exchange Framework will require all actors in the health care system—physicians, hospitals, health plans, skilled nursing facilities, etc.— to make patient data available to all other actors within the bounds of federal and state privacy laws. It will do this by requiring all those participants to sign the Single Data Sharing Agreement (DSA), which contractually obligates practices and others to share data across the health care system. Importantly, the Data Exchange Framework does not require provider practices to utilize any particular data sharing technology. The state is not building a statewide health information exchange. When the law that created the framework was being written, CMA’s position was that physicians should have the flexibility to choose the technology that works best for their practice. Based on CMA’s advocacy, the law prohibits the state from forcing physicians into one system. Instead, the DxF is intended to be “technology agnostic,” meaning that practices are free to choose the method of data exchange that works best for them. This could include a local health information organization, a national data sharing network, or other data sharing technology. Now that the Framework has been published, the timeline for implementation is going to move quickly. It will be important for practices to familiarize themselves with the requirements of the Framework and begin their preparations as soon as possible.

The Data Exchange Framework The Data Exchange Framework consists of four major components. Data sharing requirement: The DxF includes a legal requirement that physician practices and other health

care entities make data available to other signatories of the Data Sharing Agreement. The date by which practices must comply with this requirement depends on the size of the practice. In general, practices of more than 25 physicians will need to be engaged in data exchange by January 31, 2024. Practices smaller than 25 physicians will have two additional years, until January 31, 2026, to join the data exchange. Single Data Sharing Agreement: To govern the DxF, the state has created the Single Data Sharing Agreement. This document is a contract that all practices are required by law to execute by January 31, 2023. The intent of the DSA is to act as a contract between physician practices, hospitals, health plans, and other providers that they agree to make data available to each other upon request. The DSA lays out the parameters of how that data exchange should happen, predominantly via accompanying policies and procedures that describe what data elements need to be exchanged, privacy and

security standards, and permitted uses of health data. The DSA also lays out practices’ responsibility to comply with the HHS Data Exchange Board. HHS Data Exchange Board: The State has proposed creating a governing body of five to seven members that will oversee data exchange in California. This board will be charged with overseeing and updating the Data Sharing Agreement, ensuring compliance with the DxF, and qualifying health information organizations for participation. The details about this board will be included in a legislative proposal that will be introduced next year. Technical Assistance for Small and Safety Net Practices: The 2022-23 State Budget included $50 million for providing technical assistance to small practices and other safety net providers. CMA is in actively engaged in ensuring that the funding will reach physician practices quickly and efficiently to help them prepare for the DxF.

The California Data Exchange will enable pharmacies, physicians and hospitals to share data more effectively and have better access to a patient's health information in order to lessen errors and improve outcomes. September/October 2022


“As a pediatrician, if I treat a child, but the child has food and housing insecurities, then the benefits of that health care have been erased. California needs much more robust connections between health care and social services—and we can’t build them without data exchange that allows patients and providers to access this information, wherever they are and whenever they need it. It’s the only way we will be able to treat the whole person, in every community, from the beginning.” — Dr. Mark Ghaly, Secretary, California Health and Human Services Agency For more details on these components, CMA members can access the CMA DxF Fact Sheet on the CMA website.

Timeline CHHS published the final Data Exchange Framework in July. By January 31, 2023, all health and human services organizations (including physician practices) must complete and sign the DSA. The Data Exchange Board is also expected to begin its work in the first quarter of 2023. By January 31, 2024, most health care providers must implement the DxF. Small and safety net practices have an additional two years from that date to implement the DxF. Even though practices are required to sign the Data Sharing Agreement in just a few months, the state has not yet announced how that process will take place so keep an eye out for further announcements from CMA or the state. In addition, it is important for physicians to know that they must sign the agreement by January 31, 2023 even if your practice is small enough to be in the cohort that does not have to comply until 2026.

What Practices Can Do Now With these new requirements coming down over the next four years, practices will want to get started on building their game plan for compliance as soon as possible. If you participate in a medical group or an IPA, a good place to start is by contacting that entity to inquire about their plans for compliance with the Data Exchange Framework. If you get access to an EHR system or population health platform through the group or IPA, and they already engage in data exchange, an individual practice may not need to sign its own DSA. The organization will sign the Data Sharing Agreement on your behalf and data exchange will be handled at that level. 18

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But for independent practices, now is a good time to familiarize yourself with the health information organizations (HIOs) that serve your community. Members of the California Association of Health Information Exchanges (www.ca-hie.org) represent the largest and most well-established HIOs in the state. They have already signed an agreement to work together. As more entities become aware of the requirements of the DxF, lead times to sign up with an HIO may become longer, so it will help to approach them soon. Finally, be sure to work with your EHR vendor, especially if you work with a smaller, specialty system. These systems can require custom interfaces to onboard to an HIO, which can be both time-consuming and costly. On the plus side, some EHRs connect through a national data sharing network, allowing you to comply without adding a new vendor. Either way, it helps to include your EHR vendor early and often.

CMA is Here to Help To help practices get ready for the DxF, CMA is developing resources as quickly as information becomes available. CMA held an online briefing this summer on the Data Exchange Framework, and recording of the briefing is available on the CMA YouTube Channel (www.youtube.com/c/CMAdocs). In addition, CMA has published a fact sheet that is available to all physician members on the CMA website. The fact sheet summarizes the requirements and components of the DxF and includes a frequently asked questions document that will be updated regularly as more information becomes available. And remember, CMA members can always call the CMA Member Helpline at 800-786-4262 for assistance. David Ford is Vice President, Health Information Technology at CMA.


raised for safety net care in the greater Sacramento region May 25th, 2022 at Cafeteria 15L outdoor patio with musical performer Dr. Dave Cosca Wine donated by Heringer Estates, Mark Ellis of the Astoria Wine Group, Yorba Wines, and Andy Walter (Deus Allées)

Supporting the following organizations who provide 1 million underinsured patient visits annually UC Davis affiliated student run free clinics CommuniCare Health Centers Loaves & Fishes SSVMS SPIRIT Program

WellSpace Health HALO Health & Life Organization Peach Tree Health Center Elica Health Center

Highlighting health leaders who shepherded our region through the pandemic Brad Crutchfield, 10X Genomics Dr. Suzanne Eidson-Ton, CommuniCare Health Centers Dave Roughton, SAFE Credit Union Dr. Bradley Pollock, Healthy Davis Together

Thank you to our generous corporate and individual sponsors -

Transformational: Brad & Cynthia Crutchfield Awe: Dr. & Mrs. Rick & Liza Vitangcol, Vanguard Charitable (as recommended by Drs. Alan Anzai & Shing Chung) Kindness: Mr. & Mrs. Bill & JoAnn McGowan Hope: Dr. Yvonne Otani & Mr. Gasem Sahit, Mr. Giacomo Marini, Mr & Mrs. Ron & Mary Brown, Dr. & Mrs. Thomas & Elizabeth Atkins Love: Drs. Oliver Stanton & Virginia Joyce, Dr. Yvonne Otani In Memory of Dr. Elliot Wong, Mr. & Mrs. Tim and Kim Lien, Dr. & Mrs. Andy & Sharon Opfell, Dr. & Mrs. Hilary & Maureen Brodie, Mr. & Mrs. Steve & Becky Lessler, Dr. Rose Arellanes. Joy: Drs. Joanne Low & Marty Hikido, Dr. Kristen Robinson & Mr. Mike Cleary, Mr. Mike Wiethorn, Dr. & Mrs. Doug and Dana Gross, Dr. & Mrs. Jack & Nancy Rozance, Drs. Jason & Stephanie Yee-Guardino, Mr. & Mrs. Tom & Stacy Welsh, Dr. & Mrs. Mike & Lisa Chun, Mr. & Mrs. Tanner & Kendall Mohr, Mr. & Mrs. Rex & Janet Berry, Mr. Paul Chuck & Ms. Liane Wong, Mrs. Julie Kuo & Dr. Mark Eaton, Dr. & Mrs. Chris & Carol Jensen, Mrs. Suzanne Boyden.




Motivational Interviewing Improves Patient Dialogues and Outcomes

By Elizabeth Morrison, Ph.D, LCSW elizabeth@emorrisonconsulting.com

SSVMS Videos Show How to Reach Pregnant Women With Substance Issues


hen we talk about substance use disorders in pregnant or parenting women, our first focus is understandably on access to treatment. Many of us have become accustomed to scarcity of treatment resources, and even with expanding medication assisted treatment (MAT) programs finding the right treatment at the right time, continues to be daunting. A pregnant patient using substances can also bring up strong feelings for us. We often feel a sense of urgency to get the patient to stop, we might feel a tinge of hopelessness about whether they will or not, and many of us dread the interactions we will have with them about it. I’ve been a clinician for many years, working judiciously on skilled communication and anti-bias work, and still have an internal voice shouting, “Please, just stop!” when a pregnant woman discloses her use to me. It is these very interactions—the first few sentences we exchange, the first conversations, that often have the most powerful impact on the health of the mother and the baby. It is our dialogue in the exam (or virtual) room that can have a tremendous influence on the patient’s readiness to make significant changes in their use or willingness to get treatment.

Motivational Interviewing: Communication as Treatment Motivational interviewing (MI) refers to the therapeutic approach developed by psychologists William Miller and Stephen Rollnick in 1983. They defined motivational interviewing as “a collaborative, person-centered form of guiding to elicit and strengthen motivation for change.” It is based on the conceptual model of the Stages of Change, which posits that changes we make in our lives are not linear, or quick, but instead a (sometimes


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slow) progression. In the most basic sense, motivational interviewing is eliciting from others what is important to them, what they most deeply want to do, instead of us telling them what to do. Motivational interviewing was originally developed and used in the treatment of substance use disorders; at the time, most treatment was based on confrontation of clients, essentially shouting at them to “break them down.” In addition to the ethical and bias problems with treating someone with a chronic disease this way, it was patently ineffective. In chronic disease management, much of the treatment is based on telling a patient what to do to manage their illness. Unfortunately, adherence hovers around 50%, underscoring the limits of advising. Without confronting people and without advising people, what are we left with? This is the gap which motivational interviewing has filled. MI is now the core of all substance use treatment as well as almost every health, public health, and social care setting. It has proven to be successful for weight management, medication adherence, exercise, smoking cessation, vaccine hesitancy, mental health conditions, parenting support, intimate partner violence programs, HIV and sexual health programs, public health efforts, and almost every chronic disease. Motivational interviewing is one of the most well-researched interventions in medical and behavioral health sciences, resulting in it being categorized as an evidenced-based practice for many years.

Empathy: The Foundation of Motivational Interviewing What is at the heart of MI’s incredible effectiveness? The answer is empathy. Research on empathy and its effects on patient experience and treatment outcomes originated in the field of psychology during the 1950s with the work of

SSVMS, in conjunction with Elizabeth Morrison and the Sacramento Opioid Coalition, has produced a series of training videos on how motivational interviewing and other techniques can help you have a more constructive dialogue with pregnant patients who have substance use issues. Carl Rogers, who is credited for establishing the foundational importance of empathy in the field of behavioral health. His research demonstrated the deep power of “unconditional positive regard” or what we sometimes call “radical acceptance.” Or, more simply, empathy. This research is the basis for what is considered the most important factor in therapy: the Therapeutic Alliance, a cooperative working relationship between client and therapist. In the last 25 years, there has been an explosion of research in the medical sciences on the impact of empathy on health outcomes. The literature is varied and fascinating: research has shown that when medical providers effectively convey empathy, it lowers blood sugar levels in diabetics, lessens the duration and severity of the common cold, increases weight loss in those with obesity, lowers self-reported pain levels, and makes wounds heal faster. Research also demonstrates that communicating with empathy decreases symptoms of depression, anxiety, problematic alcohol use and other substance use disorders.

Conversely, conveying a lack of empathy—often characterized by judgment—has been shown to lower adherence to treatment recommendations, increase weight gain in patients with diabetes, increase selfreported pain levels, and worsen alcohol use and other substance use disorders. Communicating negative judgment also decreases meaningful health disclosures, lowers adherence to recommendations, and increases patient complaints, grievances, and litigation. In short, if patients don’t feel we care about them, we simply aren’t able to influence them effectively. They are less apt to follow our recommendations, tell us the truth, or even come back. Many of us have had personal experiences of not feeling listened to by a health provider when we were a patient. Typically, it makes us more ambivalent about following the recommendations. How do we reliably communicate empathy to our patients? There are a host of evidenced-based empathy conveyance strategies, many of which we may engage in normally and some that might be newer to us. Core empathic communication strategies include: September/October 2022


Make a connection: The initial connection, when we come on the video or walk in the room, is the most important time to establish an empathic relationship. Eye contact (virtual or in-person), smiling (or narrating smiles: “I’m smiling right now under my mask”), introducing ourselves and using the patient’s name along with purposeful compliments or other connecting and humanizing statements are potent ways to convey empathy. We’ve probably all had the experience ourselves of walking into an office and having the front office person continue to type on their computer, not looking up, saying, “Sign in” as if it is a greeting. A negative start to the relationship is hard to repair. Ask open-ended questions. Open-ended questions, which the Institute of Medicine calls the gold standard of communication, serve three main purposes. First, they demonstrate empathy and a desire to truly understand a patient’s thinking, struggles, strengths, and experiences. Secondly, open-ended questions increase accurate and meaningful information patients’ share with us. Lastly, they increase patient engagement and activation in their health and wellbeing. The phrase “Tell me more about that...,” or questions that start with “what” or "how," as in, “What are your thoughts about treatment?” or “How do you feel about your use?” are high-quality approaches to generating thoughtful and accurate answers from patients. Show empathy and acknowledge feelings. Instead of relying solely on asking questions, in motivational interviewing we typically respond to clients with empathetic reflective statements that encourage or guide the client to continue talking and that capture the patient’s feelings. For example, “I hear that your pain is really terrible and that you don’t know what you’d do without the pills,” demonstrates empathy and encourages the patient to continue talking with us. Most of us have had the experience of ordering a complicated drink at Starbucks and having the staff repeat back our order; we feel relieved! If they don’t, we often repeat some of the order to them for fear they didn’t get “It’s a decaf.” Patients are the same; they will repeat themselves if they don’t feel we’ve heard or understood them. Affirm strengths, values, aspirations, and positive qualities. We actively look and listen for the patient’s strengths, values, aspirations, and positive qualities and reflect them back in an affirming manner. For example,


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SSVMS, with the Sacramento Opioid Coalition, is holding two in-person trainings with Elizabeth Morrison. “Making a Difference in 10 Minutes” will be held November 1 and “Continual Growth: Self-Reflection as a Tool for Improving Patient Outcomes,” will be on November 8. In addition, SSVMS has produced a series of short videos on how to create a more productive dialogue with patients, especially those with substance abuse problems. To learn more, scan the QR code or visit sacopioidcoaliton.org/mat-program.

if a patient states, “I know it isn’t great for the baby, but neither is being stressed out all the time,” we can say, “I can hear how much you are worried about your baby.” This brings the focus onto an underlying positive value and encourages patients to share more with us. As a result of schooling and professional training, most of us in the helping professions are deeply problem focused; as a result, it can take quite a bit of discipline to focus first on strengths.

Empathic Communication as a Practice We are in the helping professions because we care about our patients and we want them to make changes that will make their lives better. Knowing that establishing an empathic relationship is the most critical component of successful behavior change doesn’t make it easy. Feeling empathy doesn’t always translate to communicating empathy, and being in a state of hurry, stress, or burnout, as well as implicit bias and other negative judgments, all impact our ability to feel and communicate empathy. Empathic communication may be simple in concept, yet it isn’t always easy at work or at home! For most of us it is a lifelong practice, one that has big rewards for patients, ourselves, and our loved ones. Elizabeth Morrison Ph.D, LCSW is the CEO and principal at EM Consulting. She is presenting at the 2022 Joy of Medicine Summit in September and leading two in-person seminars in November.

Making a Difference in 10 minutes:

Motivational Interviewing for Substance Use Disorders Presented by Elizabeth Morrison PhD, LCSW CEO and Principal at EM Consulting

Elizabeth has a PhD in Social Psychology, is a licensed clinical social worker and a Master Addiction Counselor, who has been in clinical practice for over 25 years. She was one of the early Integrated Behavioral Health vanguard leaders in California and now has over 15 years of success in helping medical organizations evolve into integrated care systems to include behavioral health and addictive conditions services, complex care management and social care programs. She has developed and conducted hundreds of workshop series and train the facilitator courses in empathy and equity-based communication and practices.

Motivational Interviewing (MI) has more research to support its effectiveness than most medicationsand using it increases the chances our interactions will be more rewarding, more connected and less argumentative. MI is applicable to any behavior change, has been studied cross-culturally, and

Tuesday, November 1st, 6:30 PM In-person, Sacramento, CA

employs some strategies that can actually shorten some visit types. In this practical workshop, you’ll get a brief overview of the most current and compelling research on MI and substance use disorders; learn the 5 most powerful strategies for helping patients struggling with SUD or other behavior changes; and 2 anti-growth statements to avoid saying to patients (and our friends and family!) to increase the likelihood of positive care outcomes.



Med Schools Need to Awaken to Dangers of Sleep Deprivation “Rite of Passage” of Not Getting Quality Sleep Is Putting Patients and the Next Generation of Physicians at Risk


t was a brisk, fall day during my internship year. I was fortunate enough to leave the hospital early—it was 6 p.m., and I had been on call the previous night. It was a rare joy. As I lifelessly drifted out the hospital doors, one of my OB-GYN attendings stopped me to ask how I was doing. Honestly, I was exhausted but still had to study for an exam the next day, which I told him. “Then where are you going?” he asked. “All of your textbooks are upstairs in beds.” I had to agree with what he seemed to be saying: No textbook can provide you as much knowledge as caring for patients. But what I really heard was, “You don’t need rest; you need to be working.” All these years later, this stuck with me. Not because of how cruel his nonchalant comment sounded to me, but also because of how common the belief was then— and remains today. A 2017 study found that over 70% of the medical students who responded to a survey said they need at least seven hours of sleep to function optimally. Yet, 69% percent of those students said they slept for less than seven hours on the average school night. During exams, the numbers were even worse: 44% of the students said they slept for six hours or less. Adults need seven to nine hours of good sleep a night, said Alan Shatzel, DO, CEO of Mercy Medical Group and a specialist on sleep disorders. “The all-night study cram session is likely causing more harm than good relative to performance and outcome on testing,” Shatzel said. “Concentration and retrieval of information are more difficult with sleep deprivation. In addition to stress and irritability, a sleep-deprived student may experience an increase in appetite, which could further exacerbate downstream long-term effects including obesity and blood glucose dysregulation.” 24

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By Eric Williams,MD imango@att.net

The state of New York implemented regulations limiting residents’ work to roughly 80 hours per week following the death of Libby Zion, a Bennington College freshman, in 1984. Libby’s father claimed her death was the result of overworked and sleep-deprived physicians, and it took until 2003 for the Accreditation Council on Graduate Medical Education to issue similar recommendations. ACGME’s numbers have bounced around since: in 2003, it recommended residents spend no more 30 consecutive hours (24 hours in a clinical training setting, six in their classes and studies), and in 2011 it set a standard of 16 consecutive hours for first-year students. But that increased to 24 hours in 2017, and the upper limit is still an arduous maximum 80-hour week (twice what is considered a normal work week) for residents. Quality of sleep is as important as the number of hours. Good sleep comes from keeping a regular sleep schedule with minimal interruptions. Both rapid eye movement and non-REM sleep are important to capture memories of the day’s activities and move them from temporary and limited storage to permanent storage for long-term retrieval in our brains. This could include information pertinent to the care of a patient. Lack of sleep has been shown to lead to medical errors, burnout, depression and anxiety. Twenty-four hours of sleep deprivation, Shatzel said, is equivalent to having a blood alcohol level of .01%. And because most medical students sleep at least an hour less than they should each night, they are essentially losing the equivalent of an entire night’s sleep each week. Poor sleep during your early medical education can carry over to your clinical practice and teaching: it has been associated with the loss of essential empathy and emotional intelligence. Numerous studies also demonstrate a close correlation between poor sleep and poor academic performance, which leads to increased anxiety and even less sleep. Anxiety and depression are just

two of the mood and psychiatric disorders associated with insomnia, and the field of medicine experiences high rates of both. “When we are chronically sleep deprived, we begin to tell ourselves that we must need less because we are surviving on less,” Dr. Shatzel said. “The reality is that our tolerance for sleep deprivation is increasing while we build sleep debt and our ability to recognize we are sleep deprived becomes lowered, resulting in a vicious cycle and a resetting of our own expectations of what qualifies as a good quantity of quality sleep.” In 2015, the Journal of Clinical Dr. Williams has been involved with the Future of Medicine program for Sleep Medicine published a study nearly a decade. He's finding it harder to tell high school students like recommending increased education these, who were in this summer's class, that they won't face the long in medical curriculum on the imporhours he did during his training. tance of sleep. It was suggested, though not directly stated, that the of Medicine program. I want to hide under a rock when intense and compressed education of medical profesthey ask about what kind of hours we worked. I want sionals makes adequate sleep nearly impossible to to tell them it isn’t going to be like that anymore. I want maintain. As the shortage of medical professionals to tell them they’ll be put in a position to succeed and worsens, prolonging medical education to allow for to provide quality care for their patients. I want to, but better-rested, more alert students and residents may I can’t. produce more capable and resilient physicians even if We need to recognize how we’re failing today’s it leads to a short-term insuffiiency in the number of medical students and start to acknowledge that these providers. In the end, those doctors would likely better expectations will inevitably lead to tragedy. When you internalize their education, retain and access what they see it in a residency program, call it out. When you see learn as their career progresses, have an improved it in a medical school, call it out. When you see it in a “bedside manner,” and make fewer mistakes. colleague, or even yourself, call it out. I can do better We don’t have to force medical students to go too; I see the irony in writing this piece at two o’clock in through the same sleep deprivation that those of us at the morning. or near retirement went through. I get that there is a We’re medical practitioners who live by evidencesense that sleep deprivation in medical school is some driven data, but the clear evidence that lack of sleep sort of rite of passage or that it shows we’re all in the is detrimental to resident health and the development trenches together, but it doesn’t benefit the students and of future physicians has yet to be fully addressed. We certainly isn’t good for patients. owe it to the next generation of practitioners to learn By expecting such ridiculous hours, residency from our mistakes and leave the field of medicine a programs are setting up students to fail—if not in better place than it was than when we entered the passing their exams, at least in promoting a quality field, whether it was just a decade ago or four. We can of life that will encourage a long career in medicine. do better, and must, for the future of the profession we I have spent nearly a decade dedicating myself to have dedicated our lives to. encouraging high school students to pursue the field of Brandon Craig contributed to this article. medicine through Kaiser and through SSVMS’s Future

September/October 2022



Board Briefs July 11, 2022 THE BOARD: Approved the 2021 Audit Report. Approved the 1st Quarter 2022 Financial Statements and Investment Reports & Recommendations Ending March 31, 2022. Approved Changes in SSVMS Delegation as follows: 1) Janine Bera, MD to Delegate Office 15; 2) Ashley Rubin, DO to Delegate Office 28; 3) Resignation of Jonathan Breslau, MD, Delegate Office 12; 4) Vong Lee, MD to Delegate Office 12.

For Active Membership — Lindsay Cassey, MD; Grace Tidwell, MD; Monica Willsey, MD; Sun Yi, MD. For Retired Membership — Carol Grench, MD. For Resignation — July Mcmamus, MD For Transfer of Membership to Placer-Nevada — Jennifer H. Yang, MD Deceased — James M. Moorefield, MD 5/17/22

Approved the June and July 2022 Membership Reports as follows:

New SSVMS Members The following applications have been approved by the Sierra Sacramento Valley Medical Society. Information pertinent to consideration of any applicant for membership should be communicated to the Society. — Adam Dougherty, MD, Secretary.

New Active Members *Physician specialty abbreviated following name.

Erik Campbell, MD, AN, Mercy Medical Group Lindsay Cassey, MD, FP, UC Davis Health Walter Chien, MD, CD, Mercy Medical Group Lucy Funk, MD, P, Woodland Clinic Medical Group Mary Gauthier, MD, FP, Solo Med 7 Urgent Care Sanaz Ghafouri, MD, HO, Woodland Clinic Medical Group Camille Huwyler, MD, OTO, Woodland Clinic Medical Group Azad Karim, MD, CTS, Mercy Medical Group Jaskiran Ranu, MD, NP, Mercy Medical Group


Sierra Sacramento Valley Medicine

Uday Sandhu, MD, CD, Mercy Medical Group Aaron Thornburg, DO, PUD, Mercy Medical Group Grace Tidwell, MD, FP, Elica Harkanwal Singh, MD, H, Mercy Medical Group Monica Willsey, MD, OBG, Mercy Medical Group Sun Yi, MD, RO, Mercy Medical Group

Continual Growth: Self-Reflection as a Tool for Improving Patient Health Outcomes

Presented by Elizabeth Morrison PhD, LCSW CEO and Principal at EM Consulting

Elizabeth has a PhD in Social Psychology, is a licensed clinical social worker and a Master Addiction Counselor, who has been in clinical practice for over 25 years. She was one of the early Integrated Behavioral Health vanguard leaders in California and now has over 15 years of success in helping medical organizations evolve into integrated care systems to include behavioral health and addictive conditions services, complex care management and social care programs. She has developed and conducted hundreds of workshop series and train the facilitator courses in empathy and equity-based communication and practices.

We are in the helping professions to help yet being human means we, like everyone else, have negative judgments, biases and stigma about particular conditions,




Excavating our own biases around addiction, drug use during pregnancy, problem patients and more

Tuesday, November 8th, 6:30 PM In-person, Sacramento, CA

can help us be of optimal service to those in our care- and can help us in our personal lives, as well. In this workshop you ll get a brief overview of the most current and most intriguing research on stigma and its impact on health outcomes; practical strategies for identifying our own biases, and evidenced-based techniques to mitigate bias, judgment and stigma, in order to provide the best care possible. https://tinyurl.com/ContinualGrowth












Wo. 7

2210 Jackson St,



Jan, 12, 1907.


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Respectfully yours


From Our Museum: Fighting the Anti-Vaxxers of the Early 1900s


nti-vaxxers aren’t a new thing. Opposition to the smallpox vaccine, which was first used as far back as the early 1800s, gathered steam in the latter part of that century. An epidemic lead to more vaccination requirements in the early 20th century which prompted additional opposition. Philip Mills Jones, MD, who was also an attorney, an archeologist for the University of California at Berkeley and founder of the California State Journal of Medicine, wrote this letter in opposition of attempts to overturn school vaccination mandates. In 1920, anti-vaxxers gathered the 55,000 signatures needed to put an initiative on the California ballot that would have prevented any vaccination Eric Williams, MD (468,911 votes) to 43.43% (359,987). requirements for attending public schools. — It was defeated handily, 56.57% Fun fact: Inoculation against smallpox first involved introducing virus from cowpox lesions, which caused mild fever but then led to immunity from smallpox. The Latin word for cow is vacca, which derived into the name of the cowpox virus, vaccina—and later into the word for a product that prevents disease: vaccine. — Ken Smith 28

Sierra Sacramento Valley Medicine

Closer to home + enhanced referrals = easier access to world-class care Shirin Jimenez, M.D. Associate Professor, Division of Cardiovascular Medicine Specialties: Cardiology, Advanced Heart Failure

UC Davis Health offers nationally ranked expertise — now with added convenience for our referring providers From the most delicate robotic and catheter procedures to the latest precision therapeutics, we’re proud to offer up-to-the-minute diagnostic and treatment options for both adult and pediatric referring providers across Northern California and the Central Valley. Your referred patients benefit from shorter drives, less traffic gridlock, affordable lodging, and more support from local family and friends. We also offer robust telehealth and telemedicine options, for both initial consultations and follow up care. Referring your patients to UC Davis Health specialty and subspecialty care is now easier than ever. Our physician referral liaison team is here to serve as direct lines of communication — helping to navigate and expedite referrals.

Our liaisons can also help to: ■

Facilitate access to our secure EMR system, PhysicianConnect Arrange meetings and/or webinars with our clinicians Assist with UC Davis Health clinical trials and telemedicine Keep you abreast of new services, providers and research programs Share information about CME and events such as tumor boards, grand rounds, symposiums, etc.

Reach out to your local Physician Referral Liaison today: Tracy Bayne | 916-281-8734 | thbayne@ucdavis.edu


You’ve worked hard to achieve success. You deserve financial advisors who work as hard for you. As an Ameriprise private wealth advisory practice, we have the qualifications and experience to help navigate your complex financial needs. Whether it’s investment management, tax strategies or legacy planning, we can work with you to grow and preserve what you’ve worked so hard to achieve. Call us today and discover the personal service you deserve.

Douglas A. Crumley Jr. CFP®, CRPC®, APMA®, CKA® CERTIFIED FINANCIAL PLANNER™ practitioner Private Wealth Advisor Business Financial Advisor Crumley & Associates A private wealth advisory practice of Ameriprise Financial Services, LLC 7956 California Ave, Fair Oaks, CA 95628 916.638.4600 | dougcrumleyjr.com douglas.2.crumley@ampf.com Crumley & Associates will donate $100 to the Joy of Medicine program for each SSVMS physician member who engages in financial planning.

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