Summer 2018 by California Academy of Family Physicians

VO L . 69 N O. 3 S u m m er 201 8

APRIL 2018

CAFP HONORS MEMBERS AND SWEARS IN NEW PRESIDENT AND OFFICERS

Opening the Dialogue about #MeToo in Medicine

1520 Pacific Avenue • San Francisco, California 94109 • www.familydocs.org Phone (415) 345-8667 • Fax (415) 345-8668 • E-mail: cafp@familydocs.org

Officers and Board

Staff

President Lisa M. Ward, MD, MScPH, MS

Susan Hogeland, CAE

Immediate Past President Michelle Quiogue, MD President-elect Walter Mills, MD Speaker David Bazzo, MD Vice-Speaker Shannon Connolly, MD Secretary/Treasurer Lauren Simon, MD, MPH Executive Vice President Susan Hogeland, CAE Foundation President Marianne McKennett, MD AAFP Delegates Jeff Luther, MD Carla Kakutani, MD

Executive Vice President shogeland@familydocs.org

Conrad Amenta Director, Health Policy camenta@familydocs.org Morgan Cleveland Manager, FP-PAC and Membership mcleveland@familydocs.org Jerri Davis, CHCP Director, CME/CPD jdavis@familydocs.org Jonathan Rudolph Manager, Finance jrudolph@familydocs.org Adam Francis Director, Government Affairs afrancis@familydocs.org Shannon Goecke

Director, Membership and Marketing sgoecke@familydocs.org

AAFP Alternates Carol Havens, MD Jay W. Lee, MD, MPH

Pamela Mann, MPH

CMA Delegation Ashby Wolfe, MD, MPA, MPH (Chair) Mark Dressner, MD Sumana Reddy, MD Kevin Rossi, MD Lauren Simon, MD, MPH Felix Nunez, MD, MPH

Elizabeth Lukrich

Program Manager pmann@familydocs.org

Manager, Communications and Social Media elukrich@familydocs.org

Looking for a job? Go to www.fpjobsonline.com Questions? Call 888-884-8242 and a HEALTHeCAREERS representative will help you.

Shelly Rodrigues, CAE, FACEHP Deputy Executive Vice President srodrigues@familydocs.org

Brent Sugimoto, MD, Editor Shelly Rodrigues, CAE, Managing Editor The California Family Physician is published quarterly by the California Academy of Family Physicians. Opinions are those of the authors and not necessarily those of the members and staff of the CAFP. Non-member subscriptions are $35 per year. Call 415-345-8667 to subscribe.

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California Family Physician Summer 2018

California

Summer 2018

FAMILY PHYSICIAN st ro n g

me di ci ne

f o r

C al i f o r n ia

On the cover, counter-clockwise from the upper left: Jay Lee and Michelle Quiogue; 70th Birthday cake; Lisa Ward and John Cullen; Susan Hogeland; and Isabel Chen. Above: Susan Hogeland and Nancy Mazza; Karrin Allyson.

features 14 Celebrating 70 Years and 10,000 Members! 18 #MeToo ... The Movement is New, But the Experiences are Not

Gil Solomon, MD

20 Sexual Harassment in Medicine is Not Only Wrong, It Erodes Medicineâ&#x20AC;&#x2122;s Credibility

Conrad Amenta

22 Family Medicine Match Rates Continue to Increase

Pamela Mann, MPH

24 CAFP and CAFP Foundation Honor Four Incredible Family Physicians With 2018 Awards

departments 6 Editorial

Family Medicine Can Lead the Healing in #MeToo

8 Presidentâ&#x20AC;&#x2122;s Message

#MeToo Allies

10 Political Pulse

In Advocacy, Flexibility Is Key

12 Membership News

Introducing Our 10,000th Member

30 EVP Forum

If Not for Yourselves, for Others!

Brent Sugimoto, MD Lisa M. Ward, MD, MScPH, MS Carla Kakutani, MD Shannon Goecke Susan Hogeland, CAE

For upcoming CME activities visit familydocs.org/cme California Family Family Physician Physician Summer Summer 2018 2018 California

editorial

Brent Sugimoto, MD

Family Medicine Can Lead the Healing in #MeToo I would like to start my article by saying that I hope you are enjoying reading this issue of the California Family Physician as much as issues past. I am honored to serve as your new editor, taking the reins from Dr. Nathan Hitzeman, who very capably brought you this magazine these past four years. Please join me in thanking Nate for his service and skill in helping our voices be clarion, relevant and heard. In that tradition, this issue will feature a discussion of #MeToo in Family Medicine. Although the media have reported #MeToo in medicine – cases such as Dr. George Tyndall from the University of Southern California – medicine as a whole has not demonstrated much self-reflection, perhaps treating cases as anomalies. When 30 percent of women and four percent of men in academic medicine are reported to have experienced sexual harassment in their jobs (Jagsi et al, 2016), however, medicine is no different from any other profession. This may be surprising to some. In the area of sexual harassment and assault, “[s]ome expect [medicine] to be better, given the compassion and altruistic impulses that lead people to pursue medicine,” (Jagsi, 2018). This may be one reason #MeToo has not yet disrupted medicine in the way it has shaken entertainment, business and government. Physicians may be given the benefit of the doubt because of our reputation for caring.

Consider a study by Gartrell et al. (1992), which found that of those physicians who had been involved with their patients, nine percent believed it was “always appropriate” to have sexual contact with their patients. These data suggest something perhaps more disturbing than the conduct of someone entrusted to care for others – many physicians who violate the sexual boundaries of another have no idea that what they are doing is wrong, best encapsulated in the following perspective of a study participant: A 60-year-old family practitioner wrote that he learned about the negative effects of physician-patient sexual contact through personal experience: “This [relationship] was disturbed; I didn’t understand how or to what depth until years later when she [the patient] committed suicide.” (Gartrell et al., 1992) When physicians speak aloud for zero tolerance of sexual assault and harassment, it helps those with a wobbly compass find their moral North, if not through empathy, then by conforming.

It could be true that some can hide in the shadows of the bright glow of caring service we give to our communities. If so, it will be our conversation – our honest and perhaps painful discussion – that can be the light that illuminates these dark crevices of our profession. As Justice Louis Brandeis remarked, “Sunlight is said to be the best of disinfectants.”

I would like to express my profound gratitude for the contributors to the feature on #MeToo in this issue of California Family Physician. Their courage in speaking out in such a personal way puts a face on something we cannot ignore. This is a complex subject, and this feature cannot begin to touch on all the facets of #MeToo in medicine. What I hope results from this issue is a conversation. Family medicine is a specialty rooted in justice and equality. Family physicians are natural leaders to take on #MeToo. If we want to improve health care for all, this is one of the quintessential targets of the quadruple aim – making medicine safe for all is the ultimate form of well-being.

Beyond exposing past wrongs, the real promise of #MeToo in medicine is the refashioning of professional norms: to incontrovertibly state sexual harassment and assault will never be tolerated; to help the powerful understand that unscrupulously using their position to demean and hurt others is a losing proposition; to convince those who are victimized to know that they can speak out without jeopardizing their careers; to help institutions remove conflicts of interest so that they do not choose between justice and the predatory star academician. Finally, I would argue that this discourse will have one final effect: to mark clearly what is right and wrong.

References 1. Gartrell NK, Milliken N, Goodson WH, Thiemann S, Lo B. Physician-patient sexual contact. Prevalence and problems. Western Journal of Medicine. 1992;157(2):139-143. 2. Jagsi, R. Sexual Harassment in Medicine - #MeToo. N Engl J Med. 2018 Jan 18;378(3):209-211 3. Jagsi R, Griffith KA, Jones R, Perumalswami CR, Ubel P, Stewart A. Sexual harassment and discrimination experiences of academic medical faculty. JAMA 2016;315: 2120-1.

California Family Physician Summer 2018

p r e s i d e n t ’s m e s s a g e

Lisa M. Ward, MD, MScPH, MS

#MeToo Allies I remember the day quite clearly. My calendar was blocked to meet with one of my staff and I struggled to anticipate the agenda. I couldn’t make the connections to any current projects, I hadn’t asked for anything in particular … She walked in right on time which may have been my first clue that this was a tremendously important meeting. I greeted her warmly as she was someone I knew well, someone who had been growing in her role and responsibilities, thriving. As we sat together around the table in the corner of my office, her story unfolded. While she attended a conference fully sponsored and endorsed by our organization, another member of our staff attending the conference propositioned her in an unwelcome and unwanted way. My insides churned with a mix of emotions as I listened to her story. I sobbed with the woman in front of me, who was hurt and ashamed, embarrassed and also quite courageous. I was insulted and disgusted that one of my own people would act with such base behavior. And, somehow, I felt as if I shared in the culpability, as these events occurred at a conference I sent them to attend as part of their professional development. And, I was pissed … defensiveof-my-people-mama-lion, not-in-my-house-will-this-stand-PISSED. I did a few things that very day. I probably did a few things wrong, but I did a few things right. I listened and I believed this woman and what she brought at face value. I asked how she was being supported and offered some other resources put in place by the foresight of the organization’s leadership. I let her know I would look into the matter immediately and get in touch with her again at a specified time. I assured her that her experience was confidential between us and the few people in the organization with whom I would work with to investigate the circumstances. I was an ally. The house of medicine is complicit in its discrimination against women and other groups in its tolerance for ongoing sexual, physical and emotional abuse. Perhaps gone are the days when women medical students got the used, previously studied cadavers in anatomy. It was not worth the investment in their learning to buy them a new study tool when they were surely going to get married and have children soon … Surely, women could not sustain the difficult physical and mental toughness it takes to

California Family Physician Summer 2018

perform the hours-long, complex surgeries required in the surgical subspecialties and women continue to be underrepresented among these specialties of medicine to this day. And surely, that surgeon who cursed at the staff and threw instruments around the surgical suite during my third-year residency surgery clerkship has been sanctioned for the abusive and unprofessional behavior he displayed. Surely … People and organizations have the great potential to act as allies in eliminating discrimination and harassment in our world. While I would argue that everyone comes with the tools to be a strong and supportive ally, family physicians are especially practiced at the skills to listen, to console, to integrate resources and to document the information provided by victims. The medical record is a valued aid to provide objective histories of patients’ experiences. Organizations also are becoming more and more resourced to serve as allies on behalf of employees.State law in California requires mandated training each year on sexual harassment for all supervisors, from your medical assistant lead to your office manager to your chief executive. This elevates the importance of the information and lets no one avoid the expectations that lie within its content. Policies are clear and actionable. Organizations provide free and confidential mental health services in the form of Employee Assistance Programs (EAP). Universities have ombudsman roles and diversity officers who are empowered to serve as safe, confidential resources to medical staff. And as leaders become younger and more diverse, the culture of accepted harassment and discrimination is receding from its former prevalence. I wasn’t her only ally that day. It was her husband who listened to her story and felt her anguish. He insisted she report her experience to her boss, to me. He was an ally. My human resources director, whom I called directly after she left my office, also was her ally. Together we made a plan to collect information from each of the staff members involved; we assessed the reports collected; and we determined the consequences. How can we all position ourselves to be an ally? The resources are all around you.

California Family Physician Spring 2018

political pulse

Carla Kakutani, MD Chair, CAFP Legislative Affairs Committee

In Advocacy, Flexibility Is Key One of the most important things I’ve learned in my years helping to steer CAFP’s advocacy activities is that you have to play the long game, but always be open to taking quick advantage of opportunities to move the ball forward. Nothing reminded me of this lesson more than the past few weeks and what transpired with CAFP’s sponsored bill, AB 2895 (Arambula and Bonta), and the State Budget.

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the bill explicitly states that primary care spending would be measured, it moves us a long way toward setting a foundation for achieving CAFP’s goal. Another provision in the proposed state budget funds the creation of an APCD. This makes three avenues CAFP can take advantage of to further our objectives. As of this writing, it is looking very likely that this budget provision will be included in the final version signed by the Governor! Flexibility is key. In even better news on our long term goals, for more than a decade, CAFP has fought to improve the primary care physician workforce, informing legislators about the Song-Brown Physician Training Program and urging adequate funding for family medicine residency programs. The hard work paid off last year when CAFP and others secured a $33 million/year appropriation for Song-Brown for 2017, 2018 and 2019. It was the first time the State Legislature had made that kind of investment in primary care residency programs.

As of 2017, at least 18 states had enacted APCDs, 16 of which are operational. California is not one of these states.

The bill is modeled on an Oregon law. To help Oregon gather the data needed to report on primary care spending, the state uses its All Payer Claims Database (APCD), a statewide information repository that collects health insurance claims information from all health care payers. As of 2017, at least 18 states had enacted APCDs, 16 of which are operational. California is not one of these states. This is why CAFP is supporting a bill THAT DID pass out of the Appropriations Committee, AB 2502 (Wood), to create an APCD in California. While nothing in

California Family Physician Summer 2018

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Unfortunately, AB 2895, which would have required health plans to report on the percentage of premium dollars they spend on primary care, was held in the Assembly Appropriations Committee and appears dead for this year. The Committee staff estimated that the bill would cost roughly $1 million/year to administer. This is by no means the end of the story for primary care transparency.

Persistent and flexible advocacy pays off. It often takes years before seeing your work come to fruition, but if you’re flexible, patient and persistent, you may be surprised at what family medicine can accomplish when we all work together toward a common goal. Want to get involved in CAFP’s advocacy efforts and help make a positive change for primary care and patients? Visit our website and learn more: http://www.familydocs. org/advocacy/get-involved.

California Family Physician Summer 2018

membership news

Shannon Goecke Director, Membership and Member Services

Introducing Our 10,000th Member I’m excited to add another chapter to our year-long celebration, 70 Years…10,000 Stories. This spring your Academy achieved a very special milestone – for the first time in our history, we reached a membership of more than 10,000 family physicians, residents and medical students. To help mark this special occasion, we thought it would be fun to identify the 10,000th person to join CAFP and share that individual’s story with you. I recently had the pleasure of chatting with Ms. Martha Vargas, a third-year medical student at UC Davis-PRIME. Beyond her academic achievements and clinical service, I was especially impressed with Martha’s maturity, humility, compassion and commitment to service. I know you will be, too. I also hope you will be inspired to add your story to our ongoing celebration. Stories can be in the form of written narratives, audio or video recordings, photographs, illustrations, poems – anything that fires your imagination. Send your story to myfmstory@familydocs.org and add your voice to our narrative. Martha Vargas was born in Sacramento County but spent her early childhood between two very different cultures. Both of her parents were born in a small village in Michoacán, Mexico, and her father was a migrant farmworker. The family went where the work was. When another daughter was born and it became impractical to take the girls out of school for months at a time, the family set down roots in Sacramento. Martha has been there since.

During her undergraduate studies, Martha began volunteering with Clinica Tepati, which serves the medically underserved Latino populations of Sacramento with health screenings, health education and treatment of chronic conditions. In addition to providing Spanish interpreting during appointments, she recorded patient vitals, took histories, assisted doctors with patient triage and prepared blood and urine samples for testing. When it came time for medical school, Martha chose UC Davis’s RuralPRIME program. Rural-PRIME is part of the University of California’s “Programs In Medical Education,” which is designed to produce physician leaders who are trained in and committed to helping California’s underserved communities. Rural patients have poorer outcomes than their urban counterparts: higher levels of chronic conditions, higher rates of hospitalizations and higher rates of cancer deaths. Instead of completing clinical rotations at UC Davis Medical Center, students in RuralPRIME go to underserved communities in places such as Stockton, Salinas and Quincy. “Through my family, I am emotionally tied with rural underserved communities,” Martha said. “With the help of Rural-PRIME, I hope to return to these communities and serve as a physician leader.” In medical school, Martha expanded her role at Clinical Tepati, serving as a medical student officer. In this role, she had the opportunity to examine

The experiences of her early childhood exposed her to deep poverty and desperate social conditions – factors that she would eventually understand are directly related to a person’s health. But even as a child, she expressed a sense of duty and responsibility, that “you go where you are needed.” Though her parents weren’t educated, it was always assumed that their girls would be. “It wasn’t ‘if’ you go to college, it was ‘when’ you go to college,” Martha laughed. But the seriousness with which she received that message and the gratitude she has for her parents are no joke. After graduating from Natomas High School in Sacramento, she completed her undergraduate degree in biological sciences, with honors, at UC Davis. She is now enrolled in UC Davis School of Medicine. She likes to joke she stays at UC Davis so she can keep her same email address. Her younger sister now attends UC Davis as an undergraduate, with plans of becoming a teacher. 12

California Family Physician Summer 2018

Martha and her husband Juan Carlos Rodriguez.

patients independently and present her findings to attendings, conduct EKGs and draw blood for labs and work with undergraduate volunteers to coordinate patient care. Martha is currently preparing to apply to residency programs soon. She hopes to match in California but has not decided for certain whether she will pursue a residency in family medicine, family medicine and psychiatry or psychiatry alone. While we certainly hope she will stay with us in the Golden State and pursue some form of family medicine, we know she will excel as a physician and a champion of the underserved wherever she ends up. Martha says, “The status and power that being a physician grants you also comes with a responsibility to give back. When you have the capacity to help, you must help.” Until next issue, I hope you have a terrific summer. As always, please reach out to me if you need membership assistance – sgoecke@familydocs.org.

California Family Physician Summer 2018

Celebrating YEARS

and

10,000 MEMBERS! Nearly 300 CAFP members came together in Monterey in April to learn about important family medicine clinical topics, network with peers and celebrate our specialty! Highlights included the impactful keynote session with stories from family physicians directly involved in recent traumatic events (natural disasters, mass shootings), Hobart Lee’s popular Family Medicine Update, the launch of two new curricula, a celebration of CAFP’s 70th birthday and 10,000th member, the incoming and outgoing

presidential addresses of Drs. Lisa Ward and Michelle Quiogue, Fellows conferral, award presentations and a special event in honor of retiring CAFP EVP Susan Hogeland where CAFP and the CAFP-Foundation endowed a new student and resident health policy fellowship. We will be finalizing the date and location of next year’s meeting soon and hope to see you there!

We celebrated with cake!

CAFP past presidents Jay Lee, Michelle Quiogue and Lee Ralph.

California Family Physician Summer 2018

Residents presented their case or research posters.

Small group discussions helped attendees answer practice inquiry questions.

Karrin Allyson, Grammy-nominated jazz artist, sang for Susan.

Table Talk breakfasts were popular this year.

Attendees spent time discussing cases.

Our inaugural Fund Runners enjoyed the 5K.

continued on next page >

California Family Physician Summer 2018

Remember foosball? Alex McDonald, Raul Ayala and Lizzy Lukrich sure do.

Susan Hogeland, flanked by President Lisa Ward and Immediate Past President Michelle Quiogue.

AAFP Fellowship was conferred at the Forum.

Your 2018-1019 Officers were sworn in.

Our social media influencers rocked! 16

California Family Physician Summer 2018

edicine # M e To o i n M

Gil Solomon, MD

#MeToo … The Movement is New, but the Experiences Are Not Forty years after the event, it’s clear to me that performing a weekend physical in your deserted office on a medical student applying to your residency is not appropriate, even if you are the associate director of the program, you are trying to help the student, and you are doing the visit for free. Forty years later, it is clear to me that performing a vigorous prostatic massage to check for gonorrhea in a 25-year-old monogamous male with no symptoms of a sexually-transmitted infection is wrong. The 25-year-old student was me. At the time I felt sick and numb, and I drove home in a daze. My wife did not ask me about the appointment, and I didn’t say anything until six months later. She immediately recognized what happened. At first, I protested her interpretation, because I had trouble believing that a physician, particularly one I looked up to and respected, could have done such a thing. It was only years later, after reading a Los Angeles Times article about a woman sexually abused by her gynecologist, that I decided to say something to make sure others weren’t victimized as I had been. But, when I told my story to the residency program director, he did not pursue it. He told me the physician wouldn’t have done that and did not take any action. When I went to pursue it with the Medical Board, I learned my victimizer had committed suicide. As I began my clinical rotations, I realized some patients and some patient encounters engendered feelings, even erotic feelings. Fortunately, we had an excellent psychiatrist and therapist training us in my residency. We had scheduled supervision that included observation through a one-way mirror. They explained that these feelings were the result of countertransference. They talked about the importance of boundaries and the harm that would come to patients by crossing them. This training was crucial in helping me manage these encounters through my career and maintaining clear boundaries. An article by Joh O. Neher, MD, a family practice residency associate director, courageously describes an encounter with a young coed that engenders similar feelings. The accompanying editorial in the Archives of Family Medicine discusses how to manage such feelings and describes how Dr. Neher was scrupulous in observing those boundaries. It points out that sexual misconduct is often a later step in a series of boundary violations.

California Family Physician Summer 2018

The article contrasts this with physicians who have not maintained boundaries, describing the progression. According to the editorial, it often begins with excessive self-revelation (based on the physician’s, rather than the patient’s, needs), followed by more frequent and/or extended appointments, hugging or physical contact to “comfort” the patient and then progressing to a sexual relationship. The editorial describes a common offender as a middle-aged physician with some disappointments in his or her life or career, who becomes over-involved with a patient. This fits the profile of two colleagues, one who ultimately lost his license, and one who is currently in state prison, convicted of sexual battery. Both called me before I read the summary of their actions online; one to help with an appeal and one for a review job with my health plan. The discrepancy between what they told me on the phone and what I read online was remarkable. Like Dr. George Tyndall, the University of Southern California student health physician who maintains that he did nothing wrong when multiple medical assistants/ nurses reported him along with students, my colleagues could not see how egregious their actions were and how they were viewed. Others may weigh in, but here is my advice: 1. Access and read Dr. Neher’s piece and the editorial about maintaining our boundaries in the clinical setting. 2. Advise patients to report any questionable encounters, even if it is a close or respected colleague to whom you are loyal or who you believe has to be innocent. It is the job of the medical board to investigate and pass judgement. 3. If you are in the small group of physicians who have crossed a boundary with patients, you likely will be found out. However you may justify your actions, that view will not be shared by your patients, colleagues or the legal and regulatory system. Now is the time to stop. References 1. Luber MP. The management of troubling feelings toward patients. 2. Arch Fam Med. 1999 May-Jun;8(3):272-3. 3. Neher, JO. Time and tide. Arch Fam Med. 1999 MayJun;8(3):270-1.

#MeToo Experience I was in med school, my last year, a few weeks before graduation, with finals looming. Made it this far without major incidents, the usual derogatory sexist comments and put downs aside. I thought I wanted to be a surgeon, and with surgery exams fast approaching, I was stressed. My attending noticed and offered to go over topics with some other students – I thought I’d be safe. But I wasn’t. No one else showed up, and I was alone. I should have run out the door, but I didn’t. I worried about my grade, whether he’d grade me lower on my rotation if I didn’t want to learn. But he wasn’t interested in teaching me surgery, more like anatomy. I managed to leave, but not before feeling violated and incredibly upset at the lack of respect, the overreach of power and control this attending had over me, plus the incredible shame that I’d allowed myself to get into that situation. I cried inconsolably after running out of that room and made it back to the cafeteria, where my classmates and friends helped me find myself again. The strength to say no. Not to be afraid. Took me a long time to recover, and thankfully I made it through finals and graduated. But I didn’t choose surgery. That part was irrevocably cut out from my being that day. All this is part of my #MeToo story. I know I am not alone. Can we change this culture? I hope, and I pray, together, one day, we will. – Anonymous FP California Family Physician Summer 2018

# M e To o i n M e d i c i n e

Conrad Amenta, CAFP Director of Health Policy

Sexual Harassment in Medicine Is Not Only Wrong, It Erodes Medicine’s Credibility In a 1992 article in The Western Journal of Medicine, authors Gartrell, Milliken, Goodson and Thiemann found that nearly 10 percent of physician respondents to their survey acknowledged sexual contact with one or more patients. They reported that 89 percent of those contacts occurred between male physicians and female patients, and 42 percent of respondents had sexual contact with more than one patient. This occurred despite 94 percent of respondents opposing sexual contact with current patients.

This last passage is especially important. Standing up against sexual harassment is not only timely in the era of #MeToo, but is also essential in safeguarding the legitimacy, autonomy and sustainability of the profession itself. Physicians enjoy a position of privilege and trust imbued by their patients, a position that both defines and helps to make possible the care a physician provides. To exploit that privilege and trust is not only unethical ... it also erodes the basis of the profession’s authority. A physician who abuses patient trust for personal gain erodes trust in the profession as a whole.

Sexual contact and harassment can also occur between colleagues. A muchdiscussed 2016 article in the Journal of the American Medical Association titled, “Sexual Harassment and Discrimination Experiences of Academic Medical Faculty” found that 30 percent of US academic medical faculty women reported harassment during their careers. This compares to only four percent of men reporting harassment. These findings were summarized in a Los Angeles Times article titled, “Will medicine be the next field to face a sexual harassment reckoning?”

Every physician has a responsibility to ensure that sexual harassment in medicine is stamped out. A Medical Economics blog post of March 2018 lays out “7 keys to a strong sexual harassment policy.”

The American Medical Association’s (AMA) Council on Ethical and Judicial Affairs (CEJA), which “provides practical ethics guidance on timely topics,” defines sexual harassment as “unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature.” This definition can extend to include interactions between physicians and patients, colleagues and staff. CEJA also points out that, “Sexual harassment exploits inequalities in status and power, abuses the rights and trust of those who are subjected to such conduct,” and that it “is likely to jeopardize patient care.” 20

California Family Physician Summer 2018

First and foremost, it’s important for medical practices to take the time to review their policies to prevent sexual harassment. These steps include being clear and unequivocal about what constitutes sexual harassment, stating emphatically that it will not be tolerated. Next, everyone in the workplace should understand that it is safe to report sexual harassment and how to do so. Finally, a transparent investigation process and thorough documentation will ensure rigor and fairness. Medical practices should also consider retaining legal advice about how to draft and implement a sexual harassment policy. Without taking steps to provide clarity of both purpose and process, patients who experience harassment in the course of care may avail themselves of the services of the Medical Board of California, which may investigate claims (at great expense to the physician) and take disciplinary action as necessary. The moment calls on all physicians to consider what they are doing to ensure safe, professional spaces in which to provide and receive patient care, to

Kaiser Permanente is proud of our long history of diversity and providing a safe and respectful work environment for our employees. In fact, Kaiser Permanente Santa Rosa Medical Center is enjoying its 12th straight year of being named one of the “Best Places to Work” in the North Bay by the North Bay Business Journal. The #MeToo Movement exemplifies the importance of having a culture where being able to speak up is imperative. teach and train the next generation and to work as a team. It is the ethical thing to do, not only to provide the best possible patient-centered care, but also for the sake of the profession itself. https://jamanetwork. com/journals/jama/ fullarticle/2521958 http://www.latimes. com/business/hiltzik/ la-fi-hiltzik-medicineharassment-20180110story.html http://www. medicaleconomics.com/ medical-economicsblog/7-keys-strong-sexualharassment-policy

On the first day of employment, every Kaiser employee receives a copy of our Principles of Responsibility which embody the Kaiser Permanente culture. One of the most important principles is to Foster a Harassment-Free Environment which states that “we do not tolerate harassment of any kind by anyone in violation of Kaiser Permanente policies, whether it involves an employee, physician, dentist, executive, vendor, contractor, contingent worker, member, patient, or anyone else. We believe in personal dignity and respect for one another. Whether or not an offense was intended, harassment — or the perception that it exists or has occurred — is harmful and creates a less effective work environment.” In the event that any employee feels that harassment has occurred, Kaiser Permanente provides multiple ways to report it, including speaking to any member of management, reporting to the Human Resources Department and/or utilizing the compliance hotline. All complaints are thoroughly investigated and acted upon. Our strict retaliation policy ensures that employees who have a complaint can speak up without consequence. We are proud that the diversity of Kaiser Permanente’s culture permeates all levels of the organization, allowing for an inclusive environment where all voices can be heard. Patricia Hiserote, MD Program Director, KP Santa Rosa Family Medicine Residency Program

California Family Physician Summer 2018

Pamela Mann, MPH CAFP Program Manager

Family Medicine Match Rates Continue to Increase On March 16, 2018, I was delighted to share the Match Day milestone with fourth-year medical students from the University of California Riverside School of Medicine (UCR SOM). The Riverside Convention Center was crowded with family, friends, faculty and staff counting down as students waited to rip open match envelopes. How thrilling (and nail-biting) – all medical students across the country discovering their next phase of training at the same time on the same day – the excitement in the room was electric! According to UCR’s SOM dean, Dr. Deborah Deas, “Eighty-nine percent of the 49 graduates matched in California; 38 percent will remain in the Inland Empire to complete residency training, and 58 percent of those remaining in the region will train in primary care.” This is an exciting start to the county’s bold initiative to recruit, train and retain medical talent and primary care clinicians, mainly by offering free medical education to those agreeing to practice in the area.

Drs. Deborah Streletz and Kenneth Ballou pose with their new intern, Dr. Timothy Vu.

California Family Physician Summer 2018

Across other California medical campuses, including UCLA, USC Keck and UC Davis, programs reported primary care as the highestranking field among their graduates, with internal and family medicine being the most popular specialties.1,2,3 While the number of California medical student graduates who will remain in-state to complete family medicine residencies is still to be finalized, we do know family medicine is seeing an upward trend nationwide and throughout the state. The 2018 National Resident Matching Program (NRMP) marked the ninth consecutive year of increasing matches to family medicine residency programs (FMRPs). National data show 3,654 family medicine positions were offered, an increase of 276 from 2017, and 3,535 medical students and graduates matched to the specialty, an increase of 298.4 California has mirrored this growth. Since 2013, the number of positions available in California family medicine residency programs has grown by 116. In 2018, programs offered 445 slots, 47 more than in 2017, and filled 439 (98.7 percent). This summer, the state will welcome the launch of three new FMRPs totaling 20 new slots for family medicine residents: Charles R. Drew University of Medicine and Science Family Medicine Residency Program, Kaiser Permanente San Jose Family Medicine Residency and Kaiser Permanente Santa Rosa Family Medicine Residency Program. In addition to these slots, four existing FMRPs (Loma Linda University, PIH Family Medicine, Shasta Community Health, San Joaquin and Valley Family Medicine) have increased their number of available training positions from 2017. Finally, two osteopathic programs (Chino Valley and Community Memorial Health) became dual Accreditation Council for Graduate Medical Education- (ACGME) and American Osteopathic Association- (AOA) accredited, together matching nine family medicine residents. Kimberly Vu, a rising intern at Kaiser Permanente Los Angeles FMRP and an outgoing co-chair leader of the CAFP student council, reflects on her match moment, “It’s surreal to think that all my education has culminated in this, but at the same time, I know it’s also only starting! I am beyond excited and deeply grateful to be able to join the family medicine revolution and help make a difference in our communities!”

More training sites and more family medicine residents are certainly something to celebrate, but our work is far from over. Despite the growing workforce numbers, California still doesn’t have enough primary care physicians in most regions of the state. In fact, only two regions (the Greater Bay Area and Sacramento) have ratios of primary care physicians per population above the minimum ratio recommended by the Council on Graduate Medical Education.5 As we continue to fight for funds that support primary care training, we must also fight to keep our graduates at home. On September 8, 2018, medical students and residents from across California are invited to attend CAFP’s 10th annual Family Medicine Summit (FMS) in Los Angeles. Since 2008, CAFP has provided an unprecedented opportunity for California medical students, residents, program directors and thought leaders in family medicine to convene for a day of learning, leading, reflecting and connecting. The Summit is a unique chance for attendees to network, develop leadership skills and advocacy acumen and to explore programs in a fun and engaging setting at the Residency Fair. It is our hope not only to build a strong pipeline of family physicians, but also to showcase the talent and opportunities unique to California.

So, class of 2019, before you hit “submit” on your Electronic Residency Application Service (ERAS) in the fall, we encourage you to come to LA, hang out with us, talk to our programs and consider staying a while. References 1. Student Life Match Day. n.d. Retrieved from http://medschool. ucla.edu/current-match-day 2. Day, Brian. (2018, March 16). Match Day 2018 brings joy as USC med students celebrate residency news. Retrieved from https://news.usc.edu/138556/its-a-match-graduating-medicalstudents-celebrate-residency-news/ 3. Soon-to-be physicians celebrate Match Day 2018. 2018, March 16. Retrieved from http://www.ucdmc.ucdavis.edu/publish/ news/newsroom/12745 4. AAFP. n.d. 2018 Match Results for Family Medicine. Retrieved from https://www.aafp.org/medical-school-residency/programdirectors/nrmp.html 5. California grapples with ‘severe’ doctor shortage, study shows. 2017, March 02, 2017. Retrieved from https://www.cmanet. org/news/detail/?article=california-grapples-with-severe-doctor

California Family Physician Summer 2018

CAFP and CAFP Foundation Honor Four Incredible Family Physicians with 2018 Awards Isabel Chen, MD, MPH was selected as the 2018 Resident of the Year. Isabel has served as a student and resident leader

at the CAFP, actively engaged in advocacy, planning for the Family Medicine Summits, serving as a delegate at the National Conference for Residents and Students and encouraging her peers to get involved. Isabel’s remarks at the Forum were so inspiring that we’ve elected to reprint them for all to read. “Thanks, CAFP; it has been an incredible honor to be involved with CAFP this year. I’ve served on the board getting to know leaders and change agents in the organization and am especially grateful for the opportunity to co-lead the Resident Council with Blair Cushing, DO. Meeting and collaborating with residents across the state who are passionate about furthering the mission of family practice is very, very special. My first thank you is to my program director, John Yu, and my Kaiser Permanente Los Angeles colleagues and peers, to my mentors, my family, including my mother, who is here with me, my friends and all of you.

Isabel Chen, MD, MPH 2018 Resident of the Year

I have been asked why I chose family medicine … and I easily answer: to advance equity, human rights through health, healing and wellness. I originally imagined myself in human rights law, persecuting criminals at the Hague.

I spent last week at the Beyond Flexner Alliance national conference in Atlanta. This is an organization dedicated to reforming health profession education so that all of our missions, values and teachings are aligned with the health equity lens and goal. The week was especially timely as we marked the 50th anniversary of MLK’s (Martin Luther King) death … and what an immense responsibility we all have as physicians, healers and advocates to honor his legacy. Even in a time of political vitriol, hate, divisiveness, I am always able to find peace with Dr. King’s words, “Darkness cannot drive out darkness; only light can do that. Hate cannot drive out hate; only love can do that.” 24

California Family Physician Summer 2018

If there is one thing that grounds family medicine, it is that love. Love to hear the patient story, love to heal suffering and pain, love for human connection. And it is this love that guides our field, the advocacy work that we do at CAFP, in the ultimate search for justice, fairness and equity. A mentor of mine once told me that “change is slow, except when it’s fast.” This is a fast moment. Fast moments can be fraught with danger, but also with opportunity. Inconvenient truths must be faced, the galloping inequality of the last 30 years has come due; race, gender and class differences cannot be overlooked, and a democracy cannot work for some unless it works for all. This is our opportunity to turn the urgency, anger and motivation of this moment into a movement that meets those challenges. I am so filled with optimism, energy and confidence that not only will my generation be ready for the change, but will actually be the change needed to advance the needle of health equity. CAFP is certainly setting an incredible precedent for progress and activism. I am so glad to be in your company today and for the rest of my career. Thank you again for this incredible honor and CAFP’s investment in the future of this profession and our health care system.

Jay W. Lee, MD, MPH was presented the 2018 Hero of Family Medicine Award at the All Member Advocacy Meeting

in Sacramento in March. Dr. Lee practices family medicine in Los Angeles and is Chief Medical Officer at Venice Family Clinic. Serving in various capacities with CAFP over the past decade, Dr. Lee has worked

Jay W. Lee, MD, MPH, 2018 Hero of Family Medicine Award

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for advertising information, contact

MICHELLE GILBERT 501-221-9986, ext.120 mgilbert@pcipublishing.com California Family Physician Summer 2018

to address the primary care physician shortage, ensure access to care for all patients, increase the voice of family physicians in health policy and improve physician workforce diversity. The Hero of Family Medicine award is given annually to a CAFP member who has gone above and beyond the call of duty to advocate for patients, colleagues and the family medicine specialty. Dr. Lee’s efforts to strengthen the family physician community through education, advocacy and leadership make him a true family medicine hero. Dr. Lee was the first Korean-American president of CAFP (2015-2016). He also served on the board as speaker, secretary-treasurer, new physician director and a member representing the Los Angeles district. He has been a member of the CAFP Audit Committee, Medical Student and Resident Affairs Committee and Workforce Taskforce and currently chairs the Member Engagement Committee. He also has served as a media spokesperson, representing CAFP’s views on family medicine issues. Following several years of advocacy on family medicine’s behalf, Dr. Lee recently became Chair of CAFP’s Family Physicians Political Action Committee. He also has served as a legislative Key Contact with California Senators, Assemblymembers and Congressional representatives and as a member of CAFP’s Legislative Affairs Committee. In addition, Dr. Lee is co-founder of the popular social media and outreach campaign Family Medicine Revolution (#FMRevolution), which links family physicians, residents and medical students state, nationwide and globally to increase their advocacy clout and strengthen their bonds as physicians in the specialty of family medicine. “He’s an unstoppable force fighting to improve care for patients and moving family medicine forward,” Dr. Michelle Quiogue, then-CAFP President, said. “As a supportive colleague and leader, he ensures that family medicine’s voice continues to grow for all of us and the

California Family Physician Summer 2018

patients we serve.” Dr. Lee has his own take on Newton’s Second Law of Motion: “Force is mass times not acceleration, but amplification, so the Family Medicine Revolution is the mass of all of us advocates times the amplification of our collective voices,” he said. For more than 25 years, Dereck De Leon, MD, selected as the 2018 Barbara Harris Award for Educational Excellence Award, has taught and mentored several hundred medical students, residents, staff physicians and others in health care disciplines. Colleagues say he’s also an outstanding, compassionate and popular physician to his patients, some of whom have been with him for more than 20 years. Dr. De Leon also is playing a key role in developing the Kaiser Permanente School of Medicine, which will be located in Pasadena, California. After Dr. De Leon began practicing with the Southern California Permanente Group in San Diego in 1992, he began teaching medical students at the University of California, San Diego, where he currently holds a volunteer Associate Clinical Professor position. He has served as Director of Education for the Kaiser Permanente San Diego (KPSD) Family Medicine Department, Director of Continuing Medical Education (CME) for KPSD, and CME surveyor for the State of California.

impoverished areas of San Diego. This year-round program provides high school students with exposure to the health professions and mentoring about how to get accepted to college and navigate once there. More than 90 percent of the students in this program have gone on to four‐year universities.

The CAFP Family Physician of the Year is presented annually to

a physician who exhibits the finest qualities of family physicians and who goes above and beyond in service to patients and community.” “Selected from among CAFP’s 10,000 members,” said CAFP President Lisa Ward, MD, MScPH, MS, “The 2018 CAFP Family Physician of the Year is Tipu Khan, MD.”

Dr. Khan serves as faculty at the Ventura County Medical Center (VCMC) Family Medicine Residency Program, where he provides patient care and trains the next generations of family physicians. He is an Addiction Specialist and runs VCMC’s Addiction Medicine Consultation Clinic. He also is the Site Detox Medical Director for Prototypes and Changing Tides in Oxnard and Founding Former Medical Director and Board President/CEO at Crescent Clinic of Orange County, a free clinic that serves the Anaheim area. continued on next page >

He also is the Founding Director of the KPSD Family Medicine Residency Program. In 2008, he advocated to KPSD leadership to start KPSD’s sixth family medicine residency. After gaining approval, he led the process of faculty recruitment, curriculum development, accreditation and more, and opened the program to the first class of residents in 2012. The program has achieved a 100 percent pass rate for physicians seeking American Board of Family Medicine certification after completing the training. Under Dr. Leon’s leadership, the program has increased the diversity of family physicians in training and expanded its work in underserved communities. In fact, in 2014 the KPSD Family Medicine Residency Program received the R.J. Erickson National Diversity and Inclusion Award. Dr. De Leon is passionate about creating a pipeline to help mentor and support students from underrepresented backgrounds who have an interest in family medicine. Five years ago, he created and since has overseen the Summer Urban Fellowship Program based in the Otay Mesa/San Ysidro community, one of the most

California Family Physician Summer 2018

Tipu Khan, MD, 2018 CAFP Family Physician of the Year

He is dedicated to serving patients in underserved communities and practices the full spectrum of family medicine, including obstetrics, with a focus on care for pregnant patients addicted to opioid drugs and other substances. He also provides disaster care, homeless care and Hepatitis C care. He practices in a wide range of settings, including the primary care clinic, emergency departments, inpatient hospital medicine, urgent care clinics and homeless clinics. Dr. Khan also is widely known for his work in Haiti, where he volunteered in the catastrophic aftermath of the 2010 earthquake despite the imminent danger of more quakes and aftershocks. He has made numerous subsequent mission trips and authored a memoir titled Where’s Haiti? documenting his journey and narratives of Haitians’ survival after the quake.

California Family Physician Summer 2018

When wildfires hit Ventura last year and the Thomas Fire burned more than 600 homes, Dr. Khan provided medical care and spearheaded a GoFundMe campaign that raised tens of thousands of dollars for people who lost homes in the fire. He also helps plan the future of family medicine, mentoring younger physicians, training colleagues and advocating for patients and family medicine through his work with CAFP. This has included developing and leading medical education courses, serving on key committees, advocating with legislators, writing California Family Physician magazine articles and representing CAFP at the national level to the American Academy of Family Physicians. It has been written of Tipu that he is “on a mission to save both his community and the world at large. Numerous stories could be shared … like his work performing tattoo removal for formerly incarcerated gang members, or providing obstetric care for women with opioid addiction, but none of them fully capture the depth of his compassion. When the California wildfires hit Ventura this last year, we all worried for our colleagues, but also knew that Dr. Khan would be there to lead. Sure enough, we saw his face on television, rendering care despite ongoing fires in the surrounding community and again while fundraising for relief. His nomination for Family Physician of the Year is timely. We live in times of great sociopolitical instability when role models are few and far between, when the brave and the bold are needed more than ever. Dr. Khan is among the bravest, the boldest and the most compassionate members of our society. His voice will continue to be a source of inspiration for family physicians for years to come.” Congratulations to all our 2018 award winners, you are the heart of the Family Medicine Revolution.

California Family Physician Summer 2018

evp forum

Susan Hogeland, CAE

If Not for Yourselves, for Others! The last 20 months have been among the most politically difficult I can recall in my adult life. CAFP has had to fight, refight and fight again for gains made toward achieving universal health coverage. Attacks have been made on many principles family medicine holds dear and, while we have fought back hard, some ground has been lost. Continuing revelations about sexual harassment and abuse by some of the most wellknown individuals in the country have added to already abundant cynicism, but also have created hope that meaningful change can happen, even in what seems like a hostile environment. In the meantime, your Academy continues to advocate for payment reform, practice transformation and an increase in the family medicine workforce, as well as for public health issues such as the opioid misuse epidemic, gun violence and elimination of childhood diseases that long ago should have disappeared. One bright spot amid all the recent chaos was an article in The New York Times “The Upshot” series on January 17, 2018 entitled, “It Couldn’t Change Minds, So It Changed the Law.” As of a few months ago, California had experienced more than 70 deaths of individuals 65 and younger who contracted the flu – the large majority of whom were unvaccinated for one reason or another. News articles had admonished that wasn’t too late to get a flu shot and it was still a good idea, despite the low efficacy of the last vaccine (19-30 percent!). “If not for yourself, for others” is the battle cry, and a reasonable one, since immune-compromised individuals are at the greatest risk, which leads me to the bright spot: You may recall in December 2014, Disneyland was the site of an outbreak of measles that sickened at least 159 people; the Upshot article pointed out that was more than the typical number infected in an entire year in the United States. The outbreak was the impetus for legislation authored by Senator Richard Pan, SB 277, that was wholeheartedly supported by CAFP and our legislative advocate, Jodi Hicks. It called for the elimination of the personal and religious belief

California Family Physician Summer 2018

exemptions for vaccinations for school age children. At the time, both Dr. Pan and Jodi were subjected to vitriolic personal and online attacks as well as threats to their personal safety by anti-vaccination forces. Nonetheless, the two of them persisted heroically. The Upshot article credits this policy change with turning around California’s (regionally) low vaccination rates: “Data from a county-by-county analysis shows that in many schools with the lowest vaccination rates, there was an increase of 20 to 30 percentage points in the share of kindergartners vaccinated between 2014 and 2016.” In other words, the law changed behavior when public health officials and physicians couldn’t, no matter how hard they tried. Family physicians certainly are well-acquainted with herd immunity, which for measles is between a 90-95 percent vaccination rate. In 2014, California averaged 93 percent for measles, but that figure belied much lower rates in some locales. Up to 38 percent of California’s children resided in counties below the 90 percent rate; some individual school rates were shockingly low. For example, 13 percent of kindergartners at a Berkeley school were up to date on vaccinations – 87 percent of the kids had personal belief exemptions! Schools with average vaccination rates of 60 percent now are close to 90 percent, and even schools with strong resistance to vaccination moved up dramatically (although they still are under herd immunity levels). Threats to pull children out of school have not materialized, but as we know from other recent news articles, a few physicians still are willing to provide questionable medical exemptions. They are very much the exception. Work such as this by CAFP benefits not only your patients, but you and your family as well. It reduces the cost of health care by preventing unnecessary illness and deaths. It says everything about family medicine – that it’s in it for patients.

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