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Sierra Sacramento Valley
Looking Forward to a Brighter Year in 2021 Carol Kimball, MD
EXECUTIVE DIRECTOR’S MESSAGE
Aileen Wetzel, Executive Director
A Psychiatrist’s Weekend On Call Amid COVID-19 Caroline Giroux, MD
CMA Successfully Holds First Virtual House of Delegates Meeting James Schlund, MD Sean Deane, MD
COVID-19 Puts the Spotlight On Public Health Officers Ken Smith, Managing Editor
The Mid-Life Crisis That Wasn’t Faith Fitzgerald, MD
New SSVMS Members
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. 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.
Caring to the End Bob LaPerriere, MD
Visit Our Medical History Museum 5380 Elvas Ave. Sacramento Temporarily closed due to the pandemic. Visit our website at ssvms.org/museum for updates and virtual events.
California’s Completely Unpredictable, Totally Chaotic Legislative Year
Janus Norman, CMA Senior Vice President, Centers for Government Relations and Political Operations
VOLUME 72/NUMBER 1 Cover photo: Fireworks frame the Tower Bridge on New Year’s Eve 2019. Although this year’s show is likely to be cancelled, we can all join in the spirit of ringing in—we all hope— a better 2021.
Photo: David Evans, MD
Official publication of the Sierra Sacramento Valley Medical Society
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SSV Medicine is online at www.ssvms.org/Publications/SSVMedicine.aspx
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.
2021 Officers & Board of Directors
Carol Kimball, MD, President Paul Reynolds, MD, President-Elect John Wiesenfarth, MD, Immediate Past President District 1 Jonathan Breslau, MD District 2 Adam Dougherty, MD J. Bianca Roberts, MD Vanessa Walker, DO District 3 Ravinder Khaira, MD District 4 Ranjit Bajwa, MD
District 5 Christina Bilyeu, MD Sean Deane, MD Kristin Gates, MD Farzam Gorouhi, MD Roderick Vitangcol, MD District 6 Marcia Gollober, MD
2021 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
District 1 Alternate Brian Jones, MD District 2 Alternate Vacant District 3 Alternate Toussaint Mears-Clark, MD District 4 Alternate Vacant District 5 Alternate Joanna Finn, MD District 6 Alternate Natasha Bir, MD
At-Large Delegates R. Adams Jacobs, MD Barbara Arnold, MD Megan Babb, DO Helen Biren, MD Jonathan Breslau, MD Amber Chatwin, MD Mark Drabkin, MD Gordon Garcia, MD Ann Gerhardt, MD Farzam Gorouhi, MD Richard Gray, MD Richard Jones, MD Mohammad Khan, MD Carol Kimball, MD Charles McDonnell, MD
Leena Mehta, MD Sandra Mendez, MD Tom Ormiston, MD Sen. Richard Pan, MD Neil Parikh, MD Hunter Pattison, MD Paul Reynolds, MD Ernesto Rivera, MD J. Bianca Roberts, MD James Sehr, MD Christian Serdahl, MD Ajay Singh, MD Lee Snook, MD Tom Valdez, MD John Wiesenfarth, MD
At-Large Alternates Christine Braid, DO Angela Crans Yoon, MD Lucy Douglass, MD Rachel Ekaireb, MD Karen Hopp, MD Arthur Jey, MD
Steven Kmucha, MD Sam Lam, MD Taylor Nichols, MD Ashley Rubin, DO Alex Schmalz, MD Ashley Sens, MD
CMA Trustees, District XI Adam Dougherty, MD Robert Oldham, MD
AMA Delegation Barbara Arnold, 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 Glennah Trochet, MD Lee Welter, MD
Executive Director Managing Editor Webmaster
Aileen Wetzel Ken Smith Melissa Darling
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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 membersâ&#x20AC;&#x2122; 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. ÂŠ2021 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.
| FEATURED CONTRIBUTORS |
Carol Kimball, MD
Caroline Giroux, MD
This month, we welcome Dr. Kimball to SSV Medicine. In her first column as SSVMS President, she looks forward to what everyone hopes is a better year ahead and her priorities for 2021.
Every six months, Dr. Giroux spends a weekend on call. She saw the usual array of psychiatric patients, but this weekend was unlike any other in the past. Spoiler alert: It didn’t end well for her pager.
Bob LaPerriere, MD
Faith T. Fitzgerald, MD
Millie Kahane was a force of nature at SSVMS. She passed away in September but left a lasting legacy as a museum supporter and primary funder of the new Honoring Wishes end-of-life program.
When she turned 50, Faith Fitzgerald, MD had more of a mid-life reflection rather than a crisis, even when her students suggested she should be having one. Turns out, she was pretty darn happy.
James Schlund, MD
Sean Deane, MD
CMA’s Janus Norman recounts the legislative victories and battles in a very chaotic 2020. Scope of practice, surprise billing, flavored tobacco and more were on the CMA’s radar.
Public health officers have been in the spotlight and under the microscope during the pandemic. Ken sat down with three in our region to listen to what their lives have been like in a most unusual year.
Comments or letters, which may be published in a future issue, should be sent to the author’s email or to SSVMedicine@ssvms.org.
James Schlund, MD of the Butte-Glenn Medical Society and Sean Deane, MD of SSVMS are the chair and vice chair, respectively, of District XI. They report on what was accomplished at CMA’s first virtual House of Delegates meeting, the success of moving debates online, and how CMA met the challenges of holding one of its biggest and time-honored events of the year in a pandemic.
| PRESIDENT’S MESSAGE |
Looking Forward to a Brighter Year in 2021 O
n an autumn day, I was at a 3-year-old’s outdoor birthday party, wearing a mask, staying socially distant, lying on a picnic blanket. The deep fall blue sky was cut into shapes by golden leaves and as I looked up, just gazing, I was not thinking, just enjoying. Tension dissolved, allowing my soul to be touched by the beauty. It has been five years since I joined the SSVMS Board representing Yolo County. At the time I was recovering from burnout, trying to figure out what could bring me joy, as that autumn day did. We know that there are several things necessary to prevent or resolve burnout, including belonging to a community, having a purpose and having a sense of agency. Stepping up and becoming active in our medical society has been crucial to my recovery. Now I am honored to step into the role of President of our SSMVS Board, and I hope to facilitate and guide our continued work. 2020 was probably the toughest year in many of our memories. I am hoping for less adventure but many opportunities to serve in the year ahead. I applaud SSVMS’s ability to step into a morass of unknowns and dire needs without fear and with a determination to serve our communities. Our mission is to help our members provide high quality care. In 2020, this involved SSVMS supplying vital PPE to physicians, a process that required sourcing face shields, raising the needed funds and becoming involved in their manufacture. This allowed many private practice physicians to safely continue providing care to their patients. In addition to the PPE, SSVMS was also a trusted source of information about the corona virus and helped to minimize misinformation. Since joining the board, I have watched this amazing organization develop the Joy of Medicine program. It started with just an idea that physician burnout was a growing problem and that we could probably figure out a way to support physicians in our area. We began asking physicians if they were burned out, then developed the Joy of Medicine seminars that have been held 4
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By Carol Kimball, MD firstname.lastname@example.org
annually in some form ever since. We now also have meetings where we can join together and support each other, and professionals are available to us through our society website. The first six sessions are free and it is completely anonymous. A colleague of mine told me Joy of Medicine saved their career. Beyond the Joy of Medicine program, SSVMS has worked to streamline the evaluation process in emergency departments for mental health patients, increased the availability of free colonoscopies for the uninsured, and increased the availability of Narcan while offering training for its use in the field. Looking forward, health disparities and systemic racism in medicine will be prime topics in 2021. It is fairly undeniable that people of color have worse health outcomes than white people. Look at the higher maternal death rate, higher preterm birth rate, and higher COVID death rates. As W.E.B. Du Bois first suggested over 100 years ago, “race” is a social construct rather than a term with biological meaning or one that describes a significant genetic diversity. So that means that being Black, in a perfect world, should not result in worse health outcomes. So what explains the difference? In most cases it is not an overt personal prejudice—by this I mean a physician intentionally providing inferior care because of skin color—that leads to a poorer outcome. Nor is it necessarily the patient; even Black women physicians, including Black obstetricians, have an increased risk of preterm labor. These are educated women who know the optimal care yet still suffer similar results. So if biology, personal bias or economic status are not reasons for poorer outcomes, I believe that there are systemic forces causing the disparity. We need to define and understand the root causes so we can develop solutions. I heard one physician state this year that there is no systemic racism in health care. How do we help physi-
cians understand that there is a problem and agree on a shared vision of what our health care system should produce so that we can change the reality? Only by recognizing the problem can we begin the process of solving it and delivering greater equity in health care. My goal is that we produce the best possible outcomes for patients regardless of race, gender, economic status, the type of insurance they have or even if they have any at all, or their religious or political beliefs. I agree with the statement in White Fragility that we must always question ourselves and look to see if our actions produce the outcome we desire. There are many examples in medicine where what was once considered to be the best approach to care turned out not to be the best at all (think 100% oxygen in premature infants, or the insulin sliding scale). This requires us to question and probably re-question the algorithms and formulas that we have come to assume are accurate. For example, should we even report the calculated African American GFR? Is there really a difference in treatment options based on race? There are many layers to the differences in care we
give our patients. We talk frequently about not having enough physicians of color, and I believe we need more diversity among physicians, advanced practice clinicians and nurses. Much of this has to do with the trust patients have of the physician and staff involved in their treatment, but as Dr. J. Bianca Roberts wrote in the September/October issue last year, it also is essential to physicians having a more thorough understanding of their patients. The more alien to the physician the circumstances of living are for the patient, the less likely we are to ask the right questions. Just as a patient may not know to ask why a provider chose one medication over another, we may not know to ask if they have access to the food we suggest, or if they have refrigeration for the medication, or even if they believe we are experimenting on them. Over the next year, I will be working with you on figuring out what questions to ask and how to find the sometimes difficult answers we need to help us, the physicians in the community, provide better care for our patients. Iâ&#x20AC;&#x2122;m looking forward to 2021, and I know that with your help we will accomplish great things.
| EXEC UTIVE DIRECTOR’S MESSAGE |
Honoring Wishes SSVMS Launches End-of-Life Planning Program
he COVID-19 pandemic has reminded us time and time again that we must always be prepared for the worst-case scenario, no matter how awkward or uncomfortable it may be to discuss or to plan. Helping patients and their loved ones plan for and document end-of-life wishes to avoid unnecessary suffering and assist families through a tremendously difficult time can greatly enhance a physician’s role as a healer. This fall, SSVMS launched our new end-of-life planning program we’ve named Honoring Wishes. A steering committee chaired by SSVMS board director and pulmonologist Dr. Vanessa Walker has convened that includes physicians from different specialties practicing in a variety of health care settings including critical care, emergency care, hospice, geriatric, and family medicine. Under the guidance of the committee, SSVMS is developing tools and resources to educate physicians so that they can better educate patients and families on the importance of advance care planning. Conversations about death and dying can be difficult but are essential to ensure that an individual’s wishes at the end of life are clearly documented, communicated, and adhered to by those providing care. An advance directive can provide more certainty that physicians and families have a clear understanding of what the patient desires when it comes to resuscitation and other treatments. Perceptions of death are nuanced by culture, religion, and many other factors that should be considered when talking with families. A 2011 report by the California Health Care Foundation and the Coalition for Compassionate Care of California found that 82% of Californians believe it is important to have end-of-life wishes in writing, but only 23% had done so. The report also found that 60% of Californians believe it to be extremely important to discuss these wishes with their loved ones to avoid burdening them making decisions 6
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By Aileen Wetzel email@example.com
on their own, but 56% had not discussed it. Many of us have lost a loved one, an acquaintance, or a patient during the current pandemic, which reminds us all how important it is to talk about and document our end-of-life plan. Through Honoring Wishes, SSVMS is developing support materials to help physicians and patients approach this difficult subject in a compassionate but thorough manner. An online resource center will soon be available that will include toolkits, guidelines, forms, checklists and other important documents to facilitate the planning process. The resource center will guide physicians on approaches to use when discussing end-of-life planning with patients and their families, and educational information will also be available on the site that can be provided to patients and families. Our goal is for all residents of the Sacramento region to have their end-oflife wishes documented and followed. As we introduce this program for our members, our own hearts at SSVMS are heavy. For many years, the SSVMS community has benefited greatly from the work and support of Dr. Albert and Mildred Kahane. Millie, as she was known, was a nurse, educator and a pioneer in hospice care. She was also a tireless advocate for end-of-life-care planning who gave generously to SSVMS charitable programs. Her contributions are the primary funding source for Honoring Wishes and enable us to make resources available to the medical community and the community at large. Unfortunately, Millie passed away during the planning process. You can read more about her incredible life on page 22. SSVMS will continue her mission to ensure that everyone can exit this life on their own terms, with dignity and as comfortably as possible. We’re proud that with this program, Millie’s legacy and her passion will live on by helping patients and families through their most difficult times.
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Lif e Coa c hes
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With increasing stress and pressure physicians are facing, SSVMS is committed to providing all physicians a place to turn during these difficult times. SSVMS will sponsors up to six wellness sessions with vetted psychologists and/or life coaches for physicians in Sacramento, El Dorado, Yolo, and Placer Counties. Members and non-members may utilize this service. To schedule a virtual appointment, contact a Vetted Provider directly, ask what virtual platform they support, and mention that you are accessing the SSVMS Joy of Medicine Program.
Steve Seay (916) 715-9252 firstname.lastname@example.org
| OPINION |
A Psychiatrist’s Weekend On Call Amid COVID-19 It’s Enough to Make Your Head—and Pager—Swim
call weekend, which for me at this stage in my career based on the pecking order of my institution is a twice-yearly occurrence, starts way before Friday at 5 p.m., when the dreadful pager must be turned on. It usually starts months in advance, in my head, as I apprehend the inability to have a reboot break with my family during the 12 consecutive days of work (five at the clinic, two at the emergency room and the hospital floors, and five more at the clinic). I don’t look forward to it because I know that in my specialty, the concept of call or glorification of our duties in life-or-death issues is such BS. What do we really accomplish for these people, brought in by police or ambulance, on an involuntary hold because of bizarre speech, disorganized behavior, yelling, “resisting” arrest, threatening, or being kicked out of their board and care? Once they are “stabilized,” we just return them to their awful life circumstances: danger ous neighborhoods, a crowded shelter, under a bridge, etc. And even if we provide a decent, available resource for respite, this is only a temporary solution, the chances are they will end up on the streets again. They will do drugs because, as we were dizzy from all the beep-beeps, we 8
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didn’t have enough time to listen to their stories, what led them to want to escape or destroy themselves. The only tiny bit of meaning in such a weekend is when I make sure I revisit and question each person’s serious diagnosis (such as schizophrenia, bipolar disorder, schizoaffective disorder) and dig for trauma. Patients of color are disproportionately and often erroneously diagnosed with such severe conditions compared to white patients, while in fact their
By Caroline Giroux, MD email@example.com
cases that arrived overnight and that must be evaluated along with the “5150 rewrites” (the involuntary hold has a precise clock and I abhor feeling so pressured by fragments of time… as if a form, a piece of paper could expire within seconds). They also share the evolution and disposition plan of the others who arrived earlier: previous diagnoses, current symptoms, who is not eating, who is not sleeping, who yells. So many elements of stories dance before my eyes as my mental
The only tiny bit of meaning in such a weekend is when I make sure I revisit and question each person’s serious diagnosis and dig for trauma. manifestations, even if they seem “psychotic” in nature, are traumarelated (from oppression, racism, transgenerational trauma and so forth). Perceptual disturbances and paranoia are frequent experiences in people who have lost a sense of safety due to trauma. It is important to break the cycle of misdiagnosis and mistreatment to empower the survivors, shift their trajectory and reduce the risk of revictimization (iatrogenic, societal, stigma-related). A wave of despair always sweeps over me as the rounds start and the nurse, discharge planner and social worker tell us about the new
space quickly overloads with too many acute tragedies. Stories that suddenly sound all the same because they are relayed by health professionals who have seen similar cases so many times, rather than the patients. The labels and behaviors might differ, but the common denominator of psychosocial misery and pervasive injustice is unmistakable. This weekend is a little different than my past shifts. On top of the stressful circumstances mentioned above (and likely to have gotten worse since my last on-call weekend given the poor living conditions,
Photo by Caroline Giroux, MD
social inequities, and racism that persist), there is something else, a looming thought terrifying me: an invisible threat that will make me spend extra time and energy shielding myself against it. On Friday, a few hours before I must turn my pager on and kiss my freedom goodbye, I not only ask for the ritual AAA battery that has gone dead after six months, I must also ask for PPE. Face mask, face shield, gloves, accompanied by washing hands like a surgeon after touching anything: chair, keyboard, telephone. I also need a 4”x6” picture of me for both an ID badge and to help alleviate patients’ paranoia since my facial expression and features are hidden behind a mask. At home, I put clothes in a bag to take to the office so that I can change from my contaminated ones after the shift, a process that will be followed by extensive hand washing, of course. I wonder what kind of lunch should I have? Not at the cafeteria, and not a homemade sandwich, as I should avoid touching what will end up in my mouth, even if I disinfected my hands until they feel like sandpaper. No microwavable dish either, as this box is publicly used. And where do I store my lunch? All surfaces must be considered contaminated until proven otherwise. What a strange existence saturated with micro-details, this reality of plexiglass, hand sanitizer, wipes and barrier methods. It is not as if the hospital setting was a healing environment (from a soul standpoint) to begin with—no beauty, no room with musical instruments to do drumming meditations, no art studio to purge the crap out of one’s life and transcend it. It seems like our dystopian reality is taking us even further away from that idyllic vision. Two days before the dreaded duty, I had decided to schedule a Zoom call with a colleague who does inpatient work to rehearse and be proactive (it is called self-efficacy). I took notes. That is how insecure I have become in this pandemic. I am anxious at the thought of having to learn a new sequence. I am afraid that my legendary distractibility will make me neglect precautions. I don’t think I can go through a day without eating, sitting down or going to the bathroom. I happen to have a nose that likes to itch so I worry about not being able to indulge in scratching. Above all, I am afraid of not being mentally present enough to perform my duties, the ones I enjoy the most, including listening to painful stories (when I can actually hear them, muffled by a surgical mask), generating
ideas for recovery for people I want to help, and teaching my trainees. These things necessitate relaxation. Tension will interfere with all those processes. Other questions arose as I was evolving in a new routine. How does one deal with patients refusing to wear a mask? For some, it comes from a delusional belief that this is not real. For others, refusal or omission comes from shutdown of cognitive functions and judgment. But trainees, generally more used to this kind of environment and not irremediable digital migrants like myself, usually come to the rescue and make the experience rather smooth. Initially resisting the way they preferred to communicate, texting, I had to step out of my comfort zone after the inevitable, embarrassing, or inevitably embarrassing occurred and sent me some kind of divine message. After my shift on Saturday, before leaving work, well… my technologically ancient paging device of eight years got a little wet. Ok, more soaked than that— immersed for a few seconds, the duration of my shock as I processed the sight of it swimming. It then occurred to me that maybe this Tiger Thing— TigerConnect—that made my pager look prehistoric wasn’t something that I needed email or a computer for, just a phone, and might not be so bad. Many years ago, this misadventure would have January/February 2021
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distraught me. But now I can easily laugh about it, because in a way, it dissolved some of my resistance to tame hard-to-keep-up-with technology. I felt liberated from this obsolete, uncomfortable vibrating creature that created a negative association, not to say a form of PTSD, originating from my 24-hour calls during internship. At the end of Saturday and Sunday, as I write notes and review and co-sign the residents’ notes, I experience the euphoric relief of having made it all in one piece. So at first, once I can shift gears, it is always with renewed gratitude that I go back to outpatient settings, where I feel the most comfortable. But of course, sooner or later, I find some other aberration to fiercely complain about. The latest story, which is unfortunately too frequent in our health care system, concerns a young woman who is a survivor of polytrauma, including sex trafficking, who has a plethora of health conditions. Because of her disabling symptoms (some of which are treatable), she lost her employment, and guess what?…yep, with it, her health insurance. This is the type of tautologically absurd scenario that makes me want to Bang. My. Head. Against. The. Wall. For the time being, I figuratively shake it in despair, in the hope that someday this unbelievable damage will be undone so we can continue to do our job: offer care—regardless of gender, race, religion, property ownership, pre-existing conditions, technological literacy level, or employment status—to those in need.
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| CMA’S 2020 LEGISLATIVE WRAP-UP |
California’s Completely Unpredictable, Totally Chaotic Legislative Year
s 2019 concluded, reasonable assumptions about 2020 began to emerge. The year was expected to be busy and more polarizing due to the presidential election occurring in November. Large-scale issuebased campaigns calling for new state programs supported by the expected state budget surplus were being announced. State legislators were finalizing their legislative packages. And lastly, the California Medical Association (CMA) was preparing to defeat yet another attempt to eliminate the cap on non-economic damages incorporated in California’s long-standing professional liability reform law, the Medical Injury Compensation Reform Act (MICRA). In March, the world changed, and California politics and the legislative process went through an unprecedented transformation. On March 19, Governor Gavin Newsom issued the nation’s first statewide stay-at-home order in response to the arrival of the novel coronavirus (SARS-coV2, the virus that causes COVID-19) in California. All nonessential businesses, such as restaurants, entertainment centers/activities, etc., were immediately shut down until further notice. The State Legislature was forced to take multiple extended recesses, and all in-person lobbying was prohibited, leading to the cancellation of CMA’s annual Legislative Advocacy Day. The legislative process was completely upended. CMA staff worked diligently to adjust to ever-changing dynamics, as both houses of the Legislature scrambled to implement social distancing guidelines and condense their calendars. In the end, CMA successfully maintained state funding for physician services, defeated proposals to increase or add new administrative burdens onto physicians, and secured a number of executive orders to protect medical practices as they faced a pandemic unlike any seen in the past century.
However, CMA did not escape the legislative session unscathed. The Legislature passed, and the governor signed, AB 890 (Wood), which created two new classifications for nurse practitioners. While this measure was passed into law, this matter is far from settled as the fight to ensure patient safety now moves into the regulatory process. All of CMA’s advocacy centers have prioritized this issue, developed an action plan, and are coordinating with the American Medical Association as well as various specialty associations to ensure the bill is implemented in a manner that protects patients and physician practices.
Budget and Access to Care
California began this year with a strong economy, historic reserves and a projected surplus of $5.6 billion. Due to the COVID-19 pandemic, the state’s economy took a significant hit, which meant the governor had to make several difficult decisions when revising his proposed budget in May. The Governor’s May Revision was a complete redrafting of the state budget proposal released on January 10, 2020. In January, the budget proposal increased our state’s investment in health care, which included growing California’s physician workforce. The May Budget Revision, however, sought to reverse course, proposing to cut Proposition 56 funding for increased physician reimbursements, reduce patient benefits in Medi-Cal and strike all investments seeking to expand the physician workforce. Through the budget process in the Legislature, CMA was able to protect: • $1.2 billion in Proposition 56 (tobacco tax) funding, which provides supplemental payments for physician and dental services, family health services, developmental screenings, non-emergency medical transportation and value-based payments. This includes the continuation of all future cohorts of the Proposition
SSVMS Forms Health Equity Advisory Committee
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By Janus Norman email@example.com
56 Physician and Dentist Loan Repayment Program (years 2-5 of the 5-year program). • $1.5 million in General Fund monies to maintain the Proposition 56 Graduate Medical Education program at an ongoing total of $40 million. • $33.3 million in ongoing General Fund monies for the continuation of the Song-Brown Healthcare Workforce Training Program. • The expansion of post-partum mental health services for individuals diagnosed with a maternal mental health condition. In addition, the revised budget proposal included a 47% increase to the Medical Board of California’s physician and surgeon licensing fee. Through CMA’s advocacy, the Legislature rejected that proposal. Still, the Legislature could revisit the discussion in 2021 when the Medical Board is subject to a review of all of its operations through the sunset review process. It is anticipated that the Medical Board will seek a license fee increase in the context of that process.
Surprise Billing: AB 72 Fix
Since the implementation of AB 72 (Bonta) related to surprise billing, CMA has been working with the Legislature to mitigate the negative impacts on the physician community. This year, AB 2157 (Wood) was introduced to address the issues surrounding the independent dispute resolution process (IDRP). Along with several specialty societies, CMA was able to secure amendments that allowed physicians to provide more substantial evidence to better defend their claims during an AB 72 payment dispute. Through CMA’s advocacy in the legislative process and with the Department of Managed Health Care (DHMC) directly, an IDRP determination has been in the physician’s favor, a first since the law became effective. However, our work on this issue does not end there. CMA continues to work with regulators and legislators to further ensure a process that is fair and accessible to any physician needing to use it.
Flavored tobacco products are often the entry point for young people who use tobacco. Over the last several years, a spike in e-cigarette use among the nation’s youth has been linked to targeted advertisements of flavored tobacco. Menthol cigarettes, sweet cigars, candy vapes
and other flavored tobacco products serve one purpose: to mask tobacco’s harshness and get users hooked to a dangerous life-long addiction. In 2020, CMA combined forces with a large coalition of health care, youth and community organizations to support SB 793 (Hill), which prohibits tobacco retailers, or any tobacco retailers’ agents or employees, from selling, offering for sale, or possessing with the intent to sell or offer for sale, a flavored tobacco product or a tobacco product flavor enhancer. This ban includes e-cigarettes and vaping products, as well as traditional tobacco products. SB 793 crossed the legislative finish line and was quickly signed by Governor Newsom once it reached his desk. The new law will take effect on January 1, 2021.
Decreasing Administrative Burdens
CMA worked with Assembly member Lorena Gonzalez on AB 2257 to further address challenges for physician practices resulting from a bill passed last year (AB 5) that made significant changes to the definitions of independent contractors and employees, in an attempt to be consistent with the court decision in the Dynamex case. Last year, AB 5 included an exemption for physicians, but there continued to be a need to address business-to-business and referral agency arrangements. CMA successfully secured amendments to address those outstanding concerns, and the bill was signed into law. CMA also helped lead a coalition to defeat SB 977 (Monning), which sought to expand the California Attorney General’s existing authority related to mergers and acquisitions in the health care industry. Although CMA policy supports governmental actions designed to ensure hospital market competition, this broadly drafted legislation established a wide definition of health care transactions, which included leasing and other medical contracting arrangements. SB 977 ultimately failed to move off the Assembly floor. CMA worked with Senator Dr. Richard Pan to exempt independent medical practices from the mandate, and secured physician involvement in future rulemaking and guidance on this issue and supply chain sustainability. In addition to the above, CMA worked with multiple legislative offices to stop the creation of new administrative burdens related to the COVID-19 pandemic. AB 685 (Reyes) requires employers to provide written notifica-
tion within 24 hours to their employees if they were potentially exposed, at the workplace, to a person who has COVID-19. As this would have required physician practices to report this information daily, CMA secured amendments that exempted employees who conduct COVID-19 testing or screening or that provide direct care to individuals known to have tested positive for COVID-19. This approach balanced CMA’s support for notifying employees of possible exposure and protecting physician practices from being overburdened. Senator Pan introduced legislation requiring the state and health care employers to procure a stockpile of personal protective equipment as a means of addressing future equipment shortages like the one experienced at the outset of the pandemic. As introduced, the bill would have created a significant burden on independent physician practices. CMA worked with Dr. Pan to exempt independent medical practices from the mandate, and secured physician involvement in future rulemaking and guidance on this issue and supply chain sustainability.
At the onset of the statewide public health emergency, CMA worked to build upon AB 744 (Aguiar-Curry, 2019), which required commercial health plans to implement payment parity for services provided via telehealth. An association-wide advocacy effort allowed CMA to secure widespread payor coverage across the entire health care system that required all commercial, Medi-Cal and workers’ compensation payors to immediately cover telehealth services at the same rate as in-person services. To achieve this outcome, CMA worked with each independent agency and department to ensure consistency between the DMHC and the Department of Health Care Services (DHCS) as well as the California Department of Insurance and employers under the Department of Workers’ Compensation. Each agency continued to post updated guidance consistent with CMA’s input, and often referenced CMA’s sponsored telehealth legislation (AB 744) as their models. CMA also advocated for the governor to waive existing laws requiring consent prior to providing telehealth services. During the COVID-19 state of emergency, these waivers ensure that no enforcement action would be authorized against covered health care providers
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providing telehealth services via remote communication technologies that may not fully comply with these privacy laws. CMA was successful in receiving these waivers at the state and federal levels.
Decreasing Liability For Medical Practices
CMA worked with a coalition of health care and other business organizations to defeat AB 2570 (Stone). This bill would have exposed physicians and their practices to frivolous lawsuits, making it more difficult for physicians to maintain the viability of their practices.
Scope Of Practice
As discussed earlier, Assemblymember Jim Wood’s AB 890 creates two new categories of nurse practitioners, who would be allowed to provide services without standardized procedures. Despite the fervent work of CMA, the AMA and numerous specialty societies, the bill passed the Legislature and was enacted into law. The bill does not eliminate physician supervision and leaves room for interpretation regarding the role supervision can still play in the physician-NP relationship. It should also be noted that existing NPs are not impacted by AB 890 and must continue practicing under standardized procedures. In addition, the measure includes a delayed implementation of three years to allow for the completion of the regulatory process. A detailed factsheet on this bill can be found on the CMA website at cmadocs.org. Despite this setback, the fight to protect patient safety will now roll into the regulatory process. CMA will continue to work in tandem with AMA and our grassroots network to keep physicians engaged on this issue. CMA will always be in the midst of every critical political and legislative battle, utilizing our resources to advance an agenda that protects physician practices and empowers the physician voice. In other scope developments, CMA and the American College of Obstetricians and Gynecologists resolved a long-standing issue with the certified nurse-midwives through SB 1237 (Dodd). This bill creates a framework for CNMs to perform certain functions within the scope of midwifery independently while maintaining a collaborative relationship with a physician and surgeon. The measure also includes a requirement for informed
patient consent as well as patient outcome reporting requirements.
Budget a Bright Spot
On December 7th, the California Legislature reconvened for the beginning of the 2021-2022 legislative session. Following social distancing protocols and utilizing telecommunications, the members of the Legislature accepted the oath of office and acknowledged that the legislative process, along the state, has yet to return to normal. While COVID continues to create chaos, state revenues have been a bright spot. Thus far, state revenues are outpacing revenue projections adopted in the state budget, leading the Legislative Analyst’s Office to predict
a $26 billion windfall in 2021-22 despite an operational deficit that must be addressed. While the State Capitol has yet to re-open its doors, the CMA, in partnership with SSVMS, will utilize every resource available to ensure physicians’ voices are heard. The priority of the year will be the pursuit of an aggressive agenda that seeks to provide physician practices relief from the economic challenges created by the pandemic, ensure science and data are at the forefront of public health decisions and protect state resources dedicated to increasing access to care. Janus Norman is a senior vice president of the California Medical Association. He handles government relations and political operations.
CMA Successfully Holds First Virtual House of Delegates Meeting
andemic. No longer will that word conjure mental images of black-and-white photos of Dr. Salk leaning over an inexplicably grinning child being vaccinated, or warehouses of retching Great War soldiers, or ghoulish woodcarvings of plague doctors roving the fetid avenues. In their place are the sights and sounds of empty schoolyards, deserted concert venues, and the
By Jon Davids, MD firstname.lastname@example.org
The command center for CMA’s first virtual House of Delegates session.
By James Schlund, MD email@example.com
By Sean Deane, MD firstname.lastname@example.org
ever present glowing screen and clicking keyboard. What a difference just one year makes. Every member of society has had to adapt in some way, or fail in the attempt. The essential work for the essential workers the CMA House of Delegates represents was no different. On October 24, 2020, for the first time, the House was convened in a virtual format. In many ways, this year’s event was a pioneering test to demonstrate that the House is able to convene, debate, and vote on policy with members attending virtually from every far flung corner of the state. Until very recently, the House of Delegates has crafted and approved policy through vigorous in-person debate on the House floor. In 2013, changes were made to the CMA governance structure such that much of the policymaking power was transferred to the Board of Trustees and the House was shortened to a two-day format limited to addressing major issues. Resolutions were permitted to be submitted electronically yearContinued on page 28 January/February 2021
| PROFILE |
COVID-19 Puts the Spotlight on Public Health Officers
Drs. Olivia Kasirye, Aimee Sisson, Nancy Williams Express Hope, Frustration, and How Physicians Can Help
he COVID-19 pandemic has shined a spotlight on public health officers across the country. Most had worked in relative obscurity to protect the public from disease, improve the accessibility of low-cost or free health care to underserved populations, address addiction issues within the community, and generally promote wellness in their communities. The combination of a once-in-a-century pandemic and divisive politics in an election year has led to new attention to their jobs that has often been unwelcome and made the job of reducing the death and number of infections associated with the virus more difficult. Nationwide, according to the Associated Press, at least 181 state and local public health leaders in 38 states have resigned, retired or been fired since April 1. As a result, one in eight Americans lives in a community that has lost its public health department leader during the pandemic. For their dedicated and vital work, the SSVMS Board
of Directors is recognizing the public health officers in four counties —Dr. Olivia Kasirye of Sacramento County, Dr. Nancy Williams of El Dorado County, Dr. Aimee Sisson of Yolo County, and Dr. Rob Oldham of Placer County (the interim officer who is also director of Health and Human Services)—at the 2021 SSVMS Honors Medicine event. This year’s event will be a virtual affair held Saturday, February 27 via Zoom. These public health officers will be honored for the “bold and courageous work you do every day to keep our communities safe, often in the face of political pressure and personal attacks.” Through Zoom, SSV Medicine managing editor Ken Smith sat down with Dr. Kasiyre, Dr. Williams and Dr. Sisson, the public health officers in the counties served by SSVMS, to discuss what they’ve faced during the pandemic and what they expect on the road ahead. The questions and responses have been edited for length and clarity.
SSV Medicine: It’s almost the end of November as we speak. Do you want to give me your predictions for what we’re going to see by the time the new year arrives? Dr. Olivia Kasirye, Sacramento County: I can tell you what I hope will happen, that our numbers will start going down, that we’ll peak and that we will have gotten our first shipment of the vaccine and we’ll be shifting to vaccination mode. Dr. Nancy Williams, El Dorado County: I’m maybe a little bit less optimistic. I think we’ve got a whole string of indoor season and holiday gathering type things coming up, and I feel like people are just tired of doing anything to comply anymore. My county has still a little bit of a kind of Wild West mentality (where) we
do our own thing and freedom trumps everything else. I still feel like people aren’t believing it. So that part is is frustrating. I’m hoping for a peak (but) we’re still on a rise. I think Thanksgiving is going to add to that. Dr. Aimee Sisson, Yolo County: I’ve been referring to it as a Dickensian paradox. To quote the first line of A Tale of Two Cities, “It was the best of times, it was the worst of times.” Olivia’s captured all the reasons to be hopeful that we have vaccine coming. There’s two now, it looks like three highly effective vaccines are getting close to FDA authorization. But we’re still looking at spring for the general population having wider availability to the vaccine. As Nancy pointed out, we’re heading into winter with colder, hopefully wetter weather pushing
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people indoors. I’m probably more on the pessimistic side than the optimistic side, thinking that we’re going to have a hard winter to get through before a very hopeful spring. SSV Medicine: Do you think it’s most likely that there is going to be there’s going to be a rise in cases, but maybe a decrease in the incidence of death or the percentage of death? Dr. Sisson: I think we’re going to see a decrease in the case fatality rate, but there are already so many cases that we’re going to see a total increase in the number of deaths compared to the peaks that we had this summer and spring. But I do think the average person who gets COVID is less likely to die now. Dr. Kasirye: The amount of the antibody treatment, for example, that we’re getting is nowhere near what the need is. Dr. Sisson: Today, we have 10. Dr. Kasirye: We’ve got a total of maybe 200, and we would use that up in just one day because just yesterday we had over 900 cases. It’s a drop in the bucket. I’m hopeful that things will continue to improve as it becomes more available, but I also agree with my colleagues that we still have a difficult period, especially with the holidays ahead of us. Dr. Williams: I think the huge gain in treatment occurred already. What happened on the East Coast in the beginning—before they really even knew basic things to do—that’s been learned and applied. The death rate dropped so much from that, I don’t think we’ll see as much dramatic improvement going forward. And there’s always concern about what would happen if the hospitals really are overflowing and we don’t have enough health care workers to serve those patients. In that case, we could have increasing death rates just by virtue of not being able to get to them. SSV Medicine: It wasn’t too long ago we were all talking about the curve flattening and everybody was sort of congratulating each other. Then all of a sudden we’re heading up. Was that a surprise at all or expected? Dr. Kasirye: At least for Sacramento, especially around the end of October, we were actually doing really well. We were getting towards turning Sacramento
Dr. Olivia Kasirye orange and everything was hopeful. But of course, we had been hearing what Dr. Fauci was saying that, look, there is another surge coming and we needed to be ready. So it was disappointing when everything came to a screeching halt and then all of a sudden, like almost overnight, within a two-week period our case rate tripled. Dr. Sisson: I don’t think we were surprised by another wave, I think the timing surprised us a little bit. I think everyone thought we had a little bit longer, until after Thanksgiving, when people thought we would see this surge, not after Halloween. In my mind, this is all happening about a month earlier than I thought it would. Dr. Williams: I agree with that. Public health understands what’s going on and we know what the forces are that are creating things that will make (cases) rise. But even though we know that and we convey that information to the public, we can’t get them to to take it seriously and change their behaviors. I knew we were at risk because my county didn’t have very much COVID activity in the early wave. Now we’re finally really getting hit. I won’t say people don’t care, but I don’t think they understand the cause and effect still, even though we do. SSV Medicine: I’ve noticed that the vast majority of people that I encounter in my area wear masks in public. That’s not always the case elsewhere. What do you think it is that causes that difference, and is there a way to increase compliance? Dr. Kasirye: Right from the start in the U.S., unfortunately, the public health response was politicized. It was also being perpetrated by all of the online outlets and social media that people can go to, where there were a lot of conspiracy theories. I think that really made it very difficult. I hear from colleagues in different countries
and you don’t hear about the pushback that we are having to deal with in the United States. There was always the impression that the U.S. would be able to handle anything and that the CDC is top of the line. And yet here we are. It’s been difficult to witness and to also deal with the kind of pushback and hostility that some parts of the community have had towards just asking them to wear a face covering. I think the most success we’ve had is with businesses; if you don’t wear a mask or do social distancing, don’t bother coming in. Dr. Sisson: I’m hopeful. I think part of the issue with masking is that in the beginning there wasn’t really any evidence to support mask wearing and then there was a shortage of any type of mask, let alone N95 respirators. That combination led to the message of, “You don’t need masks.” Then there was research and evidence from other countries that cloth face coverings could be used, so we started recommending those. But people pointed out that the message changed and really struggled with the idea. It doesn’t mean we were lying to you before, just that this is how science works and a good communicator and a good leader will change their message as the evidence changes. Instead, I think the public saw that as a sign of weakness and that we didn’t know what we were doing. I’m now hopeful because the evidence has shown that masks can, in fact, protect the wearer, not just everybody else. I think our very rugged individualism in the United States has meant, “I’m not going to wear a mask if it doesn’t help me.” Dr. Williams: I’ll go back a little bit to the different forces at play and maybe how we can get more compliance. My county has three distinct regions: There’s the Lake Tahoe region, which is very tourist oriented and on the political spectrum, a little more left-leaning; the west end is the Sacramento suburb of El Dorado Hills, which is a little more right-leaning, but at least adjacent to a metropolitan area, which I think has an influence; and then the central part of our county is definitely more right-leaning and more interested in personal freedoms, (where) they don’t think of it as really affecting us because we’re rural. In the beginning, I don’t think Tahoe was as compliant as they became. And I think the thing that really helped that area was the visitors coming from other areas where masks can have become standard.
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Dr. Aimee Sisson SSV Medicine: The Board of Directors is commending you for the “bold and courageous work you do every day to keep our community safe, often in the face of political pressure and personal attacks.” What has it been like? Dr. Sisson: I’ve received threats. It’s interesting because I’m a new health officer. I started in Placer County in October of 2019 and hardly anybody knew what a health officer was, who I was, what health officers did. And then all of a sudden we were thrust to the forefront. I’m on the news. And it was fun at first and then not so fun when everybody got my cell phone number and my email address and then found other ways to send not very nice messages to me. It was really unexpected for me. I think traditionally when public health is working, nobody knows who we are. And it’s been very different in the pandemic. The vast majority of people out there are supportive of the work we’re doing; I learned this when I resigned from Placer County and there was an outpouring of thank you messages from the community. I compiled the emails into a single word document and the cut and paste was more than 90 pages of “thank you’s.” It was really heartening. That sentiment had been there all along, but I didn’t hear it. But that being said, the vocal minority can be quite intimidating. I’ve received multiple threats, some of them more veiled than others, some quite direct and some, I would call death threats. And that’s something that I never expected. Dr. Kasirye: I agree with Amy that the vast majority of the population does support what we’re doing. I think when they realized the onslaught that we were
is going to die down and those people will lose their reason for being there.
Dr. Nancy Williams under, some of those silent majority actually have been taking the time to send us thank you emails and just nice gestures of appreciation, like bringing us bagels for breakfast and sending us cards. So it does help to encourage us to get through the sticky points. But again, I agree with Aimee that there are some of those who have been very vocal in letting us know how displeased they were. Dr. Williams: I have to echo that it’s very similar where I am. We’ve got a relatively small group of very, very loud people who protest at our office, who speak at every board meeting, who basically belittle public health. They blame us for being the ones responsible for stopping everything (but) we aren’t doing any local orders, we’re only following what the state requires. It’s very wearing, it’s incredibly energy draining, it’s disheartening. I’m pretty worn out right now. We have one person who’s been leading the charge and hooked up with what was initially an anti-vaccination group. Now it’s kind of pro-freedom. They don’t believe any of the science we put out. They were begging for science. We held a town hall and they kept asking to meet with me. We did that a couple of weeks ago. I felt like we had a respectful communication, but within days the leaders were putting out some stuff that says we’re doing another protest, and Dr. Williams says this false thing and that false thing, and she wants us to wear masks in our own homes. Everything’s taken out of context, everything is just used to support their own beliefs. There’s just no winning, I guess. The only way to get through this is just to keep putting one foot in front of the other, knowing that someday this
SSV Medicine: How are the counties getting ready for a vaccine? Dr. Kasirye: We’re working with the hospital systems. Part of the challenge we’ve had is that there’s a lot of detail we don’t have, even at this time. We don’t know how much we’re getting or who it’s going to initially. The state is having separate talks with the hospitals, so it does make it a little more challenging for coordination. In general, we’ve had people (and) clinics emailing and saying, “Hey, I’m here to help.” We’ve had students, like student nurses, stating that they’re available to help. We’ve also been able to get a waiver for our paramedics so that they can also help with vaccinations. We have teams of on-call staff nurses that we’ve hired that would be ready to go, especially to places like the long-term care facilities. I think what we also need to work on is the messaging. I have had a few people ask me whether I will take the vaccine, and I said, of course, yes. There will be those people on either end who say they have no interest, but I think those are still a minority. The biggest challenge for us, I think, will be being able to get it out soon enough because people want to get back to their regular lives. Dr. Sisson: We’re taking a very similar approach to planning for the vaccine in Yolo County as well. The state and the feds are discussing a three-stage rollout. It looks like right now the first doses are going to health care workers, and then after that it will be high risk populations, including some essential workers, like first responders who aren’t health care workers, and potentially nursing home residents. We won’t see a general population vaccine for non-high-risk people until the spring. Dr. Williams: I agree with that. The only other related topic that comes to mind is some people have already expressed that they’re really concerned about whether the vaccine is to be mandated. We’re a long way from any kind of mandate because we don’t have enough vaccine to mandate anything. I don’t know that there would ever be a mandate, with the exception perhaps of health care workers. If anybody is saying there’s a mandate, there definitely is nothing in place at this time.
SSV Medicine: Communities of color have been hit disproportionately hard by this virus. What’s being done in the way of outreach or other actions to help mitigate that? Dr. Kasirye: In Sacramento, there are a couple of things that we’re doing. One is we were able to get CARES money and with part of that we set up testing sites in the community. The way we selected those test-
cally diverse, but we do have a significant Latinx population in the South Lake Tahoe area that primarily works in the tourism and restaurant industries. Like many other places, they have more people per square foot in their lodging and so we’ve seen that population more affected, particularly in early cases. We’ve offered things like extra lodging and providing food and that sort of thing.
I have had a few people ask me whether I will take the vaccine, and I said, of course, yes. — Dr. Olivia Kasirye, Sacramento County Public Health Officer ing sites was based on the demographics as well as the numbers that we were seeing of COVID. Disadvantaged communities were high priority areas. We knew that they would have more barriers to transportation and more barriers to access to health care. So being able to have testing within their neighborhoods was good in order to to be able to provide that service. In addition, we have contracts with the agencies that are housing the testing sites so that they’re also doing outreach in terms of finding out if there are any needs of the family, making sure that they get their results quickly and making sure that there aren’t any additional questions. That is, someone who can can take those questions and answers and then also conduct contact tracing. We do have staff, mainly nurses within the county, but then we also have a contract with community-based agencies so that we have contact tracers from those communities. An advantage of that is that they’re from those communities, so they are able to build rapport pretty quickly. We also put money in our budget for being able to have what we call wraparound services: food service, housing, even behavioral health support to address the disparities with COVID-19 in disadvantaged communities. At the last board hearing, the Board of Supervisors did vote to declare racism a public health crisis. That has provided us with an additional platform, even beyond just this recent crisis, to look deeper because these disparities were there before. And we know that it impacts these communities not only in times like a pandemic, but any other crisis that comes up hits these communities a lot harder. Dr. Williams: My county is not particularly ethni-
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The other main outreach we’ve done is with the homeless population. We do have a lot of people who live in encampments and housed communities, so we’ve been working with one of our hospitals. They have a nurse assigned to do a lot of field work. She has made an alliance with our homeless outreach team from the sheriff’s office and they go out and meet with some of these folks and find out if they have people that they feel are particularly vulnerable. Dr. Sisson: In Yolo County we have a large Latinx population. I will actually admit that I’m a little too new to Yolo County, having been on the job for just a couple of days over a month now, to know the full details of the expanded efforts that we’ve taken in that population. I do know that we’ve really expanded our language offerings. I think more so than in the past, we make sure materials are translated before the English version goes out, whereas I think in the past it was slow. SSV Medicine: How can the physician community support you in your efforts? Dr. Williams: We just had a town hall requested by one of our supervisors. I think it was really helpful to have the community hear from more than just me; they’re hearing from other respected experts in medicine who are supporting the same public health message. The availability of people to do that sort of support is really helpful. Maybe they can write more op-eds or something like that, where other trusted voices are speaking in the same language we are. Dr. Kasirye: I agree with that. At the last meeting that I attended for the (SSVMS) Public and Environmental Health Committee, they did discuss being able to do
some pieces or having people available to talk so they are hearing it from the medical community in addition to public health. Dr. Sisson: When we have physicians, members of the medical society, echoing our messaging around gatherings and face coverings, all the preventive actions, that’s really helpful in addition to vocalizing their support. And then in their encounters with patients, what could be really helpful is education, especially around isolation and quarantine. I think that’s where maybe the health department in Yolo County hasn’t done the best job of communicating with providers. We have blanket or mass isolation and quarantine orders, and our hope with those is that physicians would pick up the ball and sort of run with it. So when a test result comes back, instead of just saying, “You’ll hear from the county health department,” sometimes we get overwhelmed and we aren’t able to keep up with the cases. Please educate your patients while they’re waiting for their test results that they need to isolate. If they have symptoms, give them a copy of the isolation order. If they’ve been exposed, give them a copy of the quarantine order. Also give them copies of the isolation or quarantine instructions. We really need to see physicians helping us with that because we aren’t able to keep up with our contact tracing when the cases get as high as they are right now. SSV Medicine: Are there one or two distinct action steps that you would like to see from physicians? Dr. Kasirye: What I mentioned about them promoting the message is helpful. Dr. Williams: I would like for people to take the time to think about the potential public health consequences of some of their actions. People are going to their physicians and asking for mask waivers. There are no consequences like there are with vaccinations where if you don’t have a vaccination, you don’t get into school. But there are consequences at the other end. So I’m sure it’s easy for a provider to say, “Well, I can’t think what the harm is in this, I’ll just write this thing and tell them they need to take precautions anyway.” But if kids go to school and they have a waiver, they’re in a different position than everybody else. So they have to sit in a different place or they’re just going to be the only ones in a room wearing a face shield, posing some more risk
to the kids around them. If it’s done just for appearance, it’s not really a medical exemption and it actually causes some harm to the whole masking messaging. Dr. Sisson: Especially with the increased evidence that the mask protects the person wearing it, so they’re putting themselves at risk as well as everybody else. SSV Medicine: Is there a specific message you would like to deliver to the physician community? Dr. Kasirye: This morning I was reading Medscape and there was a story about the increase in interest in MPH degrees from the general public. That was actually really encouraging, to hear that even with all of the challenges we’ve had people are seeing the value of getting a master’s in public health. Dr. Sisson: I would have two messages. One is thank you. Sometimes people talk about me as being on the front lines of COVID and I’m like, I’m not! I get to sit in an office, I don’t have to wear an N95 and a gown and gloves and eye protection and worry that I might bring COVID home to my family every day after work. And so, my biggest message is thank you to all of our physicians for the work that they are doing in testing and treating and messaging to COVID patients and suspected patients in the community. And then I think my second message would be asking them to continue to serve as role models for behavior for patients. Dr. Williams: I will say, for everybody’s sake, it’s hard to be the model all the time. I think we have it maybe a little bit easier as health officers, because (we know) the consequences for us slipping up are huge. We recognize that other physicians don’t have as much pressure on them to be perfect but it’s just as important. Eyes from the community are on all of us. So we really do appreciate the extra effort. Talk to patients about the importance of things like general protections, why you shouldn’t travel unnecessarily, why you should wear masks, that it’s not a weird thing and please consider doing it. I’m sure they get tired of saying it, just like we do. But we really, really appreciate it because it helps strengthen our public health message. Ken Smith is managing editor of Sierra Sacramento Valley Medicine.
| APPRECIATION |
Caring to the End Honoring Wishes A Fitting Tribute To Millie Kahane’s Legacy
here are a lot of words to describe Millie Kahane: successful, impactful, influential, innovative, and philanthropic are just a few of them. If you have visited the Medical Museum in the past two years, you have been touched by Millie’s generous donation that allowed us to double the museum size. Millie was also a leading advocate for the development and training of nurse practitioners in the 1970s. More recently, she was the primary funder of the new SSVMS end-of-life program, Honoring Wishes, which had been a major interest of hers and which she was excited about starting. SSVMS Executive Director Aileen Wetzel said that despite her formidable presence, Millie was a compassionate caregiver and advocate for patient rights. “I visited with her several times in her home after Al passed away,” she said. “We talked about love and loss and our mutual desire to increase awareness of end of life care planning. I shared with her my vision for what eventually became SSVMS’s Honoring Wishes program. “I learned shortly after she passed that one of Millie’s end-of-life wishes was to ensure the Medical Society had the funding needed to launch this important program. It will be a wonderful addition to Millie’s legacy.” Mildred Dorothea Loughlin Kahane, RN, passed away on September 13, 2020 at the age of 93. In her memory, our room of nursing history is now the Mildred Kahane, RN Nursing History Room. It joins the display room at the Museum named in honor of her late husband, Albert. Mildred, known to her friends and family as Millie, was born in Tarrytown, New York on August 2, 1927. She was the first in her family to go to college and a trailblazer from the time she set foot on the campus of Adelphi University on Long Island, where she graduated with a B.S. in nursing in 1949 thanks to receiving the Peggy Ann Burleigh scholarship, which allowed her to 22
Sierra Sacramento Valley Medicine
By Bob LaPerriere, MD email@example.com
finish her degree. This single event guided her lifelong interest in supporting education and scholarships. She was known as one of the most successful, impactful and influential alumni in the history of that university and was a longtime member of its advisory board. She later did graduate work at Columbia University. Millie had an early passion for nursing, and especially public health, that continued throughout her life. “Millie would diligently check the expiration dates on the bags of chips placed on the lunch counter,” Wetzel recalled. “She never let staff forget the day she discovered a bag of chips that had expired seven days prior to the day of the meeting. From that day forward, whenever the Kahane vehicle would pull into the parking lot, there would be a burst of activity as staff rushed to check expiration dates on each and every bag of chips.” After graduation from Adelphi, she spent the next eight years at the Meadowbrook County Hospital in New York, gaining hands-on experience in bedside care. At the time, there was practically no nursing care outside of hospitals. Millie met Dr. Albert (Al) J. Kahane in 1956 at Meadowbrook Hospital, where Dr. Kahane was doing his internship, and they were married four years later after he completed his residency. The Air Force sent the Kahanes to Alaska, where she expanded her nursing skills at the local hospital and, because of her interest in public health, she became Anchorage’s first school nurse. That work led to being named the first executive officer of the newly created Alaska Board of Nursing when Alaska became the 49th state. She was also involved in opening a new hospital in Anchorage, where she served as director of nursing. The Kahanes moved to California from Alaska in 1964 and settled in Fairfield. From there, she commuted By and Eric Williams, MD to UCSF and earned her Master’s degree certificate firstname.lastname@example.org in public health in 1965. Later that year she and Dr.
initially intimidated—and somewhat fearful—by the very professional Mrs. Kahane. “As I evolved in my role as a student nurse, I expressed great interest in becoming a nurse practitioner. Millie was there as a powerful influence and guide and a champion for me. She helped to mold my career of over 45 years as a nurse practitioner.” In addition to her contributions to SSVMS, Millie was a very generous financial supporter of her alma mater, Adelphi University. Her generosity there will benefit generations of students to come. Millie and Al traveled all over the world and she road tripped with fellow nurses across the U.S. and Mexico. “Discipline yourself to travel, see the world,” she said. “Don’t let goals get lost.” An avid bridge player, she was a proud member of the 70-plus ski club and the Ski Patrol. With her husband, she established the Rocklin branch of the Bach to Rock music school a few months before her 89th birthday. She felt that many of her accomplishments were “a matter of opportunities, being at the right place at the right time, and learning to take risks in life.” That attitude was likely responsible for her being featured in the 1974-1975 edition of Who’s Who of American Women. Millie, who is survived by her sister-in-law Jacqueline, two stepchildren and a multitude of good friends, was interred at a private graveside service at East Lawn Sierra Hills Memorial Park. In her remembrance, donations may be made in her name to the Honoring Wishes end-of-life program at SSVMS, the Mildred and Albert J. Kahane Scholarship for Nurse Practitioners through the UC Davis Foundation for the Betty Irene Moore School of Nursing, or Adelphi University. She became a legend in her own lifetime and left this world on her own terms, in her own home, which is exactly what she wanted. Millie had kept her handwritten speech that she gave at her late mother’s graveside service. In it, she called her mother: “A vital, unique, very proud and fiercely independent lady with a tough exterior which concealed, albeit poorly, a great sensitivity, love and consideration for and of others. A devoted wife… a real lover of LIFE. She cared. She brought cheer and encouragement to others without asking or even accepting anything in return.” Millie couldn’t have described herself any better.
Kahane moved to Sacramento, where he became part of the first group of physicians to open the Kaiser facility and was later named its physician in chief. Meanwhile, Millie became an assistant professor of nursing at Sacramento State and was appointed to the California Board of Registered Nursing by Governor Ronald Reagan, serving one year as president. She also worked with Congressman Robert Matsui in the field of hospice care. The destiny of nurses, she believed, was to rise above the traditional hospital bedside role and to take on more responsibility in an outpatient setting. She believed that her students could learn new skills that could eventually be included in a bachelor’s of science nursing program, and that those advanced nursing capabilities would provide the core content upon which to build clinical specialties. “In 1972 as I was starting my nursing program at Sacramento State College, I was hired as a medical assistant at Kaiser,” said Sue Elam, a former student of Millie’s. “I had no idea what I was getting into working with ‘nurse practitioners,’ a new and exciting role. I was
| ESSAY |
The Mid-Life Crisis That Wasn’t
By Faith Fitzgerald, MD email@example.com
Sierra Sacramento Valley Medicine
Photo: Everett Collection / Courtesy Everett Collection - stock.adobe.com
ne day, a quarter-century ago, my house staff, some a time when women were less likely than men to be faculty colleagues, nurses, hospital workers and received into medical school and women more likely to medical students surprised me by setting up an outdoor be told to go into nursing or motherhood. birthday party for me the day before my 50th birthday. My desire to be a doctor may have begun when I was I was led by a senior student to an outside grassy area in the the fourth grade. I was witness to four indelible close to the hospital and saw multiple tables covered things: with paper plates, soft drinks, birthday cards, and well 1) A classmate’s mother got polio, and was in an iron as a whole bunch of people wearing black T-shirts with lung. I was shocked and afraid that my mother might “FFF” (Faith Fitzgerald’s Fiftieth” printed in red on the have the same terrible fate. front. 2) Some of my classmates also Most welcomed by all, there got polio, evidenced by empty was a lot of food and a sunny day. chairs at school. That seemed very As I approached, they all started very wrong to me. singing “Happy Birthday to You”… 3) Jonas Salk, a doctor-scientist, to me. created polio vaccine! I was deeply touched. However, 4) My mother signed up my the creator of this wonderful brother and me as two of the surprise party, a senior student, national group of “Salk’s Kids” then suggested that since I was trials in 1953. Three doses and no now at a half-place in my life, I polio for either of us. had to have a midlife crisis. I had wanted, ever since then, “What?” to be a doctor and I got into college “You know, a midlife crisis,” my and medical school! From day one student said. “It’s where you think on, I knew absolutely that it was about what you have done and the right thing for me. Dr. Jonas Salk (above) and the are still doing, then wonder if you This exercise in midlife crisis development of the polio vaccine might be better off, from this time brought memories of all the other influenced Dr. Fitzgerald’s early desire to on, to choose another activity.” people (in addition to patients) go into medicine. “I like what I am doing now who tried to help me be a better very much,” I said, and you are very optimistic about doctor and teacher and showed me their generosity: my getting to be a hundred years old.” colleagues, students, residents, fellows, staff, nurses, “Still—you think about it!” he said as he helped me faculty, administrators… in all fields of medicine and put on the FFF T-shirt. all over the world. I went to meetings to give talks, So, when I woke up the next morning on my actual hear talks, meet the doctors, see the patients and make 50th birthday, I could not help but wonder if a midlife rounds with younger internists and students. I worked crisis were to occur what I would do. This segued into with and learned from doctors as a medical student, wondering why I got into medicine at all. intern, resident and faculty; not only in the United There were no doctors in my family, and it was in States, but also in the jungles of Malaysia as well as
Singapore, Thailand, Hong Kong, Russia, Mexico, Japan, France, Italy, England, Scotland, The Netherlands, Chile, Bolivia, Canada, Australia, Germany, the Balkans, Saudi Arabia, Pakistan, and every state in the Union. The best and most enduring memories, however, were with patients both here and abroad. What I did not remember, in retrospect, were the contents of many lectures, texts, papers, or technology and procedures of the past, or the “right answers” on tests, as many were found to be the wrong answer over time—and they still are. There is now an increasing rapid turnover in “knowledge” in medicine: data change, studies change, medicinals change, procedures change, “best pathways” change. What did I remember best? Patients and teachers who gave me witness of tragedy, triumph, joy, hope, despair, fear, courage, belief and unbelief, culture, language, good and evil, failure and redemption. They also gave me a great gift: a life of challenge, adventure and worth… and a rich treasure trove of memories. The answer to diagnosis and therapy are, very often, in the questions we ask and the stories that patients tell us, augmented by the keen observational skills of the
clinician as the story is told and the physical findings sought for. We now spend more time on computers than we do with our patients. We order studies and procedures to tell us what we might have gleaned from careful listening and observations. We are increasingly given little time for contemplation. We are imitative in our written work (cut and paste here, acronyms there). Physical examinations are less skillful than they were in the past, which is even more important when we consider that physical examination is also the event that allows us to lay on hands, a caring and often therapeutic act. And how did this affect my midlife crisis decision? Well, I decided to do what I thought was best and tried to be the best doctor I could be, hoping that others would have as much joy in the work as I have had for the last half century. So, though in midlife then, I had no crisis. I decided to stay on doing what I was doing for as many years as I could and so long as I was able, and now—over 25 years later—I have never regretted that choice.
| BOARD BRIEFS |
Board Briefs December 14, 2020 THE BOARD: Received an update from Dan Cavanaugh, Vice President of Membership for Membership Development, Cooperative of American Physicians (CAP). CAP is an SSVMS Business Partner. Received an update regarding the COVID-19 vaccination distribution from Alicia Sanchez, CMA Chief Strategy Officer and Dustin Corcoran, CMA Chief Executive Officer. Approved the 2021 Committee Appointments. Approved the Financial Statements Ending November 30, 2020.
MD; Mohan R. Karki, MD; Rajasekhar Kolla, MD; Sharon X. Li, MD; Joe A. Lin, MD; Stacey W. Lockard, MD; Matthew Y. Luk, MD; Michel Medina, MD; Alexander J. Menze, MD; Samantha A. Montgomery, MD; Christopher K. Nguyen, MD; Lan Giao T. Nguyen, MD; Chinwee C. Onu, MD; Sydney L. Orokunle, MD; Joshua A. Ostrue, MD; Namrita D. Prasad, MD; Suhanki Rajapaksa, MD; Kristina V. Raveendran, MD; Ran G. S. Sandhu, MD; Aimee C. Sisson, MD; Bryan D. Sloane, MD; Bradleu C. Smith, MD; Hilary K. Stevens, MD; Samuel J. Tate, MD; Justin J. Teng, MD; Claire J. Tobias, MD; Nicolae Andrey V. Torres, MD; Mackenzie S. Treloar, MD; Leigha J. Winters, MD; Jeren M. Wong, MD; Bruce X. Xu, MD; Cindy X. Zhang, MD; William H. Zhu, MD.
Approved the following Membership Reports:
For Reinstatement to Active Membership — Nikki H. T. Pham, MD.
December 14, 2020
For Resignation — Muhammad A. Gill, MD (left area); Henry Chen, MD (left area); Robert B. Lurvey, MD (left state); Mirna Lechpammer, MD (left state).
For Active Membership — Erin J. MacDonald, MD; Lester C. Pan, MD; 49 new Sutter Medical Group physicians. For a complete list of the 49 new Sutter Medical Group members, see SSVMS New Members.
For Acceptance of Transfer of Membership — R. Keith McAfee, MD (to Yuba-Sutter-Colusa); Piangwarin Phaosawasdi, MD (to Napa); Billy T. Hour, MD (to Napa).
For a Change in Membership Status from Active Regular to Active 65/20 — Stephen K. Parkinson, MD; Gordon A. Wong.
For Retired Membership — William Vetter, MD.
For Resident Physician Active — Behnam Bagheri, MD, CAL-DHS Fellowship; Mohayed Mohayed, MD, CAL-DHS Fellowship.
For Retired Membership — Larry W. Bowen, MD. For Resignation — Joyce A. Eaker, MD.
November 9, 2020 Received a legislative update from Janus Norman, Senior Vice President, CMA’s Centers for Government Relations and Political Operations. The update focused on AB 890 (Wood), the Nurse Practitioner Bill.
For Acceptance of Resident Transfer — Kristine C. Meade, MD (to Solano).
Approved the 2021 proposed budgets for SSVMS, the Building Fund and the Community Service, Education and Research Fund (CSERF).
November 23, 2020
Approved the appointment of Resident Physician Active member, Ashley Rubin, DO to the SSVMS Delegation to the CMA House of Delegates representing Alternate-Delegate At-Large Office 7.
For Active Membership — Ranjita Adjolara. Claire C. Baranov, MD; Alexander J. Becka, MD; Ren Bernardo, MD; Erika T. Blaikie, MD; Heather C.Y. Chou, MD: Steven F. Cocciardi, MD; Michael G. Cook, MD; Peter Czobor, MD; Auva Davoodi, MD; Aelia Fatima, MD; Adam B. FlamerCaldera, MD; Dipika J. Gopal, MD; Harry H. Hatasaka, Jr., MD; Christine E. Hsu, DO; Viola Huang, MD; Viola Huang, 26
Sierra Sacramento Valley Medicine
Approved the 3rd Quarter 2020 Financial Statements, Investment Reports and Recommendations. Approved an amendment to the Employee Pension Investment Policy.
| NEW MEMBERS |
APPROVED THE FOLLOWING MEMBERSHIP REPORTS October 26, 2020 For Active Membership — Arielle Gire-Dumas, MD; Charlene Hansen, MD; Tasnim Khan, MD; Vijaja Reddy, MD. For Probationary to Active Membership — Maninderjit K. Atwal, MD
For Retired Membership — Lawrence Bass, MD; Jose Cueto, MD; Michael Klein, MD; Michael Murphy, MD. November 9, 2020 For Active Membership — Victoria Anne Ryan, MD; Alberto Russell, MD; Anuradha Shanmugham, MD. For Retired Membership — Scott Budd, MD
For Resident to Active Membership — Amy CY. Zhou, MD
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. — J. Bianca Roberts, MD, Secretary.
New Active Members
*Physician specialty abbreviated following name. Ranjita Adhikari, MD, FP, The Permanente Medical Group
Lance D. Edmonds, MD, DR, Sutter Medical Group
Robert A. Jesinger, MD, DR, Sutter Medical Group
Terah J. Allis, MD, OTO, Sutter Medical Group
Arfa Faiz, MD, AI, Sutter Medical Group
Jane A. Alston, MD, GS, Sutter Medical Group
Mehwish Farooqi, DO, R, Sutter Medical Group
Mohan R. Karki, MD, FP, The Permanente Medical Group
Claire C. Baranov, MD, OM, The Permanente Medical Group
Aelia Fatima, MD, HOS, The Permanente Medical Group
Tasnim Khan, MD, FP, One Community Health James M. Kim, MD, AN, Private Practice
Alexander J. Becka, MD, HOS, The Permanente Medical Group
Adam B. Flamer-Caldera, MD, EM, The Permanente Medical Group
Rajasekhar Kolla, MD, FP, The Permanente Medical Group
Robert C. Benzl, MD, R, Sutter Medical Group
Kimberly H. Fok, DO, HOS, Sutter Medical Group
Allen Li, DO, R, Sutter Imaging Sacramento
Ren Bernardo, MD, FP, The Permanente Medical Group
Jeffrey S. Fountain, DO, DR, Sutter Medical Group
Sharon X. Li, MD, HNS, The Permanente Medical Group
Harchitwant S. Bhinder, MD, IM, Sutter Medical Group
Arielle J. Gire-Dumas, MD, OBG, Mercy Medical Group
Joe A. Lin, DO, FP, The Permanente Medical Group
Erika T. Blaikie, MD, EM, The Permanente Medical Group
Dipika J. Gopal, MD, IM, The Permanente Medical Group
Stacey W. Lockard, MD, FP, The Permanente Medical Group
Vijay K. Bodukam, MD, HOS, Sutter Medical Group
Kathleen J. Gouvea, DO, UC, Sutter Medical Group
Matthew Y. Luk, MD, FP, The Permanente Medical Group
Mekhala Chandra, MD, HOS, Sutter Medical Group
Jonathan M. Gusdorff, DO, NRN, Sutter Medical Group
Erin J. MacDonald, MD, OBG, Mercy Medical Group
Heather C. Chou, MD, PD, The Permanente Medical Group
Charlene A. Hansen, MD, IM, One Community Health
Stephanie H. Mai, MD, GE, Sutter Medical Group
Steven F. Cocciardi, MD, IM, The Permanente Medical Group
Harry H. Hatasaka, Jr., MD, OBG, The Permanente Medical Group
Michael G. Cook, MD, AN, The Permanente Medical Group
Aaron H. Healy, MD, CD, Sutter Medical Group
Ramya Mallareddy, MD, HOS, Sutter Medical Group
James R. Cooney, MD, AN, Sutter Medical Group
Stephen S. Henrichon, MD, R, Sutter Medical Group
Katie K. Crean-Tate, MD, OBG, Sutter Medical Group
Nathaniel B. Hodoba, MD, NSP, Sutter Medical Group
Peter Czobor, MD, IM, The Permanente Medical Group
Jason D. Hoskins, MD, IRDR, Sutter Medical Group
Sina Dadfarmay, MD, OBG, Sutter Medical Group
Christine E. Hsu, DO, IM, The Permanente Medical Group
Auva Davoodi, MD, PD, The Permanente Medical Group
Viola Huang, MD, GS, The Permanente Medical Group
Ramandeep S. Dhaliwal, MD, HOS, Sutter Medical Group
Zahid Iqbal, MD, HO, Calif Correctional Health Care Svcs
Kathryn C. Dimiceli, MD, OPH, Sutter Medical Group
Anna Sophia R. Irvin, DO, FP, Sutter Medical Group
Christa L. Dominick, MD, GO, Sutter Medical Group
Amrith Jamoona, MD, NS, Sutter Medical Group
Lavina Malhotra, MD, GS, Sutter Medical Group
Stephen J. Malutich, MD, NM, Sutter Medical Group Genieve M. Martinez-Hernandez, MD, HOS, Sutter Medical Group Micheal A. Massoud, DO, HOS, Sutter Medical Group Conor W. Mclaughlin, MD, OTO, Sutter Medical Group Michel Medina, MD, P, The Permanente Medical Group Alexander J. Menze, MD, N, The Permanente Medical Group Myles M. Mitsunaga, MD, R, Sutter Medical Group Continued on page 28
House of Delegates (From Page 15) round and delegate testimony offered online in essentially a message board format. This year, the CMA House of Delegates and its component delegations converted to an entirely online format in an adaptation that was largely successful thanks to heroic efforts by CMA staff. The House was tasked with voting to change our articles of incorporation to codify our commitment to health equity and justice, provide input on policy to address current and future pandemic preparedness, and advise the Board on approaches to the future of medical practice after COVID-19. Although the formal session of the House was limited to just four hours, verbal debate was functionally moved to an auxiliary Town Hall meeting on the day preceding the formal meeting of the house. Written testimony and opportunities to extract reports were made available online in the month preceding the final virtual meeting. Verbal testimony and debate proceeded virtually, with tools of the digital platform easily lending themselves to parliamentary procedure. In addition to the rapid changes in basic House procedures, the toll of the pandemic on physician practice was evident at one of the meetingâ&#x20AC;&#x2122;s traditionally most joyous moments: celebrating the work of the
outgoing president and inaugurating a new president and president-elect. The pandemic caused the position of president-elect to be vacated midyear, but Dr. Peter Bretan met the challenge and offered to continue service to CMA for a second year as president to fill the gap. Dr. Robert Wailes was elected to the position of president-elect, and Dr. Tanya Spirtos and Dr. Jack Chou were elected to continue in 2021 as speaker and vice speaker, respectively. The authors were honored to have been elected to continue to lead our delegation. At the House of Delegates this year, we saw that we could get it done, no matter the obstacle. The pandemic has been a source of incalculable adversity, but as a profession, as an organization, and as a people, we have adapted. Some of those adaptations may be of ongoing benefit, part of a silver lining that we are all trying to find in this darkest of clouds. One thing is certain: as we emerge from these tribulations and head into unforeseen new challenges, the House of Medicine will be there to help our patients and our society overcome them. James Schlund, MD and Sean Deane, MD are chair and vice chair, respectively, of District XI.
New Members (From Page 27) Samantha A. Montgomery, MD, FP, The Permanente Medical Group
Anne E. Ray, MD, UC, Sutter Medical Group
Phyllis E. Napoles, MD, GS, Sutter Medical Group
Vijaya L. Reddy, MD, FP, Reddy Urgent Care/ Reddy Medical Services
Christopher K. Nguyen, DO, HOS, The Permanente Medical Group Lan Giao T. Nguyen, MD, IM, The Permanente Medical Group Rosemary Nunez-Davis, DO, PD, Sutter Medical Group Braden R. Oâ&#x20AC;&#x2122;Shaughnessy, DO, FP, Sutter Medical Group Chinwe C. Onu, MD, EM, The Permanente Medical Group Sydney L. Orokunle, MD, FP, The Permanente Medical Group Joshua A. Ostrue, DO, FP, Woodland Clinic Medical Group John C. Perlegos, MD, HOS, Sutter Medical Group Nikki H. Pham, MD, FP, Mercy Medical Group Namrita D. Prasad, MD, HOS, The Permanente Medical Group Shalvin S. Prasad, DO, HOS, Sutter Medical Group Suhanki Rajapaksa, MD, IM, The Permanente Medical Group Kristina V. Raveendran, MD, FP, The Permanente Medical Group
Sierra Sacramento Valley Medicine
Subhash Reddy, MD, GS, Sutter Medical Group
Jay S. Robertson, DO, GS, Sutter Medical Group Samuel J. Robinson, DO, FP, Sutter Medical Group Gerardo D. Rodriguez-Gomez, MD, NSP, Sutter Medical Group Alberto Russell, MD, HOS, Mercy General Hosptial Victoria A. Ryan, MD, FP, Mercy Medical Group Mahwash Saeed, MD, IM, Sutter Medical Group Christopher D. Sanders, MD, R, Sutter Medical Group Rana G. Sandhu, MD, NEP, The Permanente Medical Group Maninder S. Sanghera, MD, IM, Sutter Medical Group Karen E. Schultz, MD, CD, Sutter Medical Group Anuradha Shanmugham, MD, IM, Marshall Medical Center Aimee C. Sisson, MD, MPH, Yolo County Health and Human Services Agency David M. Skeehan, DO, GS, Sutter Medical Group Bryan D. Sloane, MD, EM, The Permanente Medical Group
Bradley C. Smith, MD, EM, The Permanente Medical Group Hilary K. Stevens, MD, FP, The Permanente Medical Group Teddy J. Su, MD, DR, Sutter Medical Group Emma C. Swan, MD, HOS, Sutter Medical Group Samuel J. Tate, MD, EM, The Permanente Medical Group Justin J. Teng, MD, AN, The Permanente Medical Group Claire J. Tobias, MD, OBG, The Permanente Medical Group Nicolae Andrey V. Torres, MD, FP, The Permanente Medical Group Mackenzie S. Treloar, MD, OBG, The Permanente Medical Group Leigha J. Winters, MD, EM, The Permanente Medical Group Ely A. Wolin, MD, NM, Sutter Medical Group Jeren M. Wong, MD, EM, The Permanente Medical Group Bruce X. Xu, MD, HOS, The Permanente Medical Group Cindy X. Zhang, MD, HOS, The Permanente Medical Group Amy C. Zhou, MD, PD, Woodland Clinic Medical Group William H. Zhu, MD, P , The Permanente Medical Group
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