Winter 2023

Officers and Board Staff

President

Lauren Simon, MD, MPH, FAAFP

Immediate Past President

Shannon Connolly, MD, FAAFP

President-elect

Raul Ayala, MD, MHCM

Speaker

Alex McDonald, MD, FAAFP

Vice-Speaker

Anthony "Fatch" Chong, MD

Secretary/Treasurer

Brent Sugimoto, MD, MPH, FAAFP

Chief Executive Officer

Lisa Folberg, MPP

Foundation President

Ron Labuguen, MD, FAAFP

AAFP Delegates

Jay Won Lee, MD, MPH, FAAFP

Lee Ralph, MD

AAFP Alternates

Michelle Quiogue, MD

Lisa Ward, MD, MPH, FAAFP

CMA Delegates

Kimberly Buss, MD

Felix Nunez, MD

Sumana Reddy, MD, FAAFP

Kevin Rossi, MD, FAAFP

CMA Alternate Delegates

Raul Ayala, MD, MCMH

Noemi Doohan, MD, PhD

Adia Scrubb, MD, MPP

David Tran, MD

Lisa Folberg, MPP Chief Executive Officer lfolberg@familydocs.org

Karen Alvarado Advocacy Assistant kalvarado@familydocs.org

Anita Charles Program Assistant acharles@familydocs.org

Morgan Cleveland Manager of Operations & Governance mcleveland@familydocs.org

Jerri Davis, CHCP Vice President, Professional Development, CME/CPD lisenberg@familydocs.org

Laurie Isenberg Director of Education and Professional Development jdavis@familydocs.org

Christine Lauryn Manager, Member Communications clauryn@familydocs.org

Josh Lunsford Vice President, Membership & Communications jlunsford@familydocs.org

Pamela Mann, MPH Executive Director, CAFP Foundation pmann@familydocs.org

Catrina Reyes, Esq. Vice President, Policy and Advocacy creyes@familydocs.org

Jonathan Rudolph Manager, Finance jrudolph@familydocs.org

Tiyesha Watts Legislative & Policy Advocate trwatts@familydocs.org

Brent Sugimoto, MD, Editor

Josh Lunsford, 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.

Brent K. Sugimoto, MD, MPH, FAAFP, AAHIVS

Navigating the Dobbs era after the end of Roe

This was supposed to be the golden anniversary. January 22, 2023 would have marked fifty years since the Supreme Court ruled in Roe v. Wade that the Constitution protected the right to an abortion. Instead, this January marked Roe’s undoing when a realigned court found in Dobbs v. Jackson Women’s Health that no such right existed.

In just months since the Dobbs ruling, fourteen states now have a ban on abortion, scrambling the rules of life for 20 million women, who now live without the right to privacy affirmed in Roe and must now live with the state’s interdiction on the most personal of decisions. However, we are not reverting to a pre-Roe era. Alongside these restrictions on women, states are now moving to criminalize physicians who would provide abortion services. Relatively rare prior to Roe v. Wade, punishing physicians as coconspirators is becoming a more common tactic of intimidation to diminish the availability of abortion. Our colleagues throughout the country must now practice with the state’s increasing intrusion into the relationship with their patients—previously privileged and sacrosanct—perhaps because legislators know many physicians see this prohibition as contrary to our duty to our patients.

Civil enforcement measures in states like Idaho allow abortion providers to be sued by immediate or extended family members. Arizona has a law, currently blocked by its Court of Appeals, that carries a prison sentence of two to five years for anyone who assists in an abortion. Although it has no chance of becoming law with a Democratic Senate, the House of Representatives passed a law on January 11, 2023, that would subject abortion providers to criminal penalties. While the fight for reproductive justice casts a shadow on the practice of medicine, it poses a particular peril to our own specialty of Family Medicine. In her essay, Dr. Chris Henneberg, family physician and abortion provider, insightfully connects abortion care with our specialty’s ethos of caring for the whole

person: another example of how we provide medical care with an appreciation of our patients as people, rather than their component organ systems.

What does it mean, then, to be a family physician when we may be barred from helping a patient address one of the most meaningful decisions in their life: the question of whether, when and how to become a parent? Treating the whole person is our prime directive as family physicians. It is why we consider the prevention and treatment of disease not as an end, but as an objective serving a vision where patients can live their lives to their fullest potential.

The Dobbs ruling—that the right to an abortion was different from other privacy rights—nonetheless invited the debate over the presumption that decisions between physicians and patients are private and personal. This is likely to add fuel to the fire to efforts to intrude on what family physicians do for their patients. Specialties are partly defined by what skills they bring, so when we are restricted from providing our skills in whole person care, how does that affect the identity of Family Medicine?

What would it mean to be a family physician when we can longer help patients live in bodies that suit their gender? What would it mean to be a family doc if we cannot help patients make choices about their end of life? What is family medicine if addressing gun violence is declared not in our “lane” (e.g., physician gag laws)? In what other ways will our care become a political hot topic and subject to criminalization?

In California, these questions feel far away in our political climate, but we are far from insulated. We care for patients from other states seeking services they cannot obtain elsewhere, and the validity of our state laws is subject to a politically unstable federal government.

In truth, California family docs are on a different front of the same fundamental fight of family physicians throughout the country: maintaining the integrity of how we care for our patients, maintaining the integrity of our relationships with them, and by doing so, maintaining the integrity of our specialty.

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Lauren Simon, MD, MPH, FAAFP, CAFP President

Green Wind is in the Air

The excitement in the air was palpable as I showed my children a new book to read during nightly story time. The book was about the wind farms like the San Gorgonio Pass Wind Farm, the oldest wind farm in the United States, which we saw on top of the hills as we drove east from San Bernardino towards Palm Springs and the deserts in the Coachella Valley. The children’s book was a gift from a patient who worked in the energy industry and knew all about the giant windmills which glistened in the sunlight swirling around like giant pinwheels. He saw the choregraphed motions of the huge wind turbines sending power to communities and understood the injury risks to the windfarm workers. The book for my children reminded me of how thoughtful our patients are and how fortunate we are as Family physicians to hear about the details of our patients’ home and work lives, how those details help us care for them and how much we learn from our patients. In turn, that book stimulated many conversations about renewable energy, ideas for school science projects and Scouting experiences for my children and friends in the years that followed, fostering a keen sense of responsibility for our Earth.

In California, our family physicians, staff, residents, medical students, patients, populations, and pets know too well the impacts of climate change such as the fires and floods which have damaged or destroyed homes, medical clinics, residency teaching sites and equipment, businesses, towns, food supplies and livelihood in Santa Rosa, Santa Barbara, Ventura, San Bernardino and San Diego to name just a few. Our hearts grieve for our friends, family members, patients, and other individuals we have lost in these environmental disasters. Throughout these devastating events, our California family physicians have used our comprehensive medical training to respond to the needs of our communities. Our CAFP members have shared our experiences and lessons learned with Family Physicians in other states to help them prepare for such events and care for their communities.

The California Academy of Family Physicians has policy which addresses the environment, our impact on it and medical issues which also affect the environment. CAFP members have diligently testified at the American Academy of Family Physicians Congress of Delegates on these topics and, fortunately, AAFP has adopted some of our CAFP policies as

its own. One example of CAFP policy which AAFP adopted is regarding fire preparedness. In 2022, the CAFP Board of Directors adopted policy that the CAFP “distribute educational materials to prepare members for wildfires, such as creating evacuation and meet-up plans, preparing fire preparedness kits and prevention of wildfires” and as other states also face wildfires, directed CAFP to send our resolution to AAFP where AAFP adopted this resolved clause. Additional portions of CAFP policy include that the CAFP support both local and state legislation that addresses wildfire prevention” and that” the CAFP continue to support and advocate for legislation that overall decreases the effects of climate change, including the impact of the healthcare system on carbon emissions."

As I thought about the impact CAFP and its members have on our environment, I was struck by some of the factors outlined in “Project Drawdown” (working toward a point in future when the atmospheric greenhouse gases will stop climbing and start reducing thereby stopping catastrophic climate change) which affect us in our personal and professional lives. Some of these factors include information we routinely provide to our patients promoting more plant-based food consumption (fewer animal proteins) and increased physical activity such as walking and cycling in our patients and populations to improve health and reduce risk for noncommunicable diseases, and reduction of fossil fuels (such as use of energy efficient public transportation) which can help improve air quality and reduce lung disease. The photos pictured here from Redlands, California which include the new Arrow commuter train line and the bicycle at the Herngt ‘Aki’ Preserve, part of the green space surrounding Redlands (named the “Emerald Necklace”) reflect these lifestyle suggestions in my home region.

As we move forward, some of our CAFP plans to reduce environmental impact include the installation of rooftop solar at the new CAFP headquarters in Sacramento, with decreased staff commuting days with utilization of remote technology and more use of shared space; plus reduction of food, paper and plastic waste at our professional and educational meetings and meeting venues. Working together with our Academy, our California Family Physicians, are taking steps (aiming for at least 10,000 steps per day per individual) towards a “healthier” and “greener” future for all.

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Political Pulse –A Look Back at 2022

California legislators, who were elected during the November 8th General Election, were sworn into office on December 5, 2022. This being California, there was not much question about which party continues to hold onto a majority of the seats in the state Assembly and state Senate. Democrats continue to hold roughly 3 out of 4 seats in both the Senate and the Assembly, enough to keep super-majorities.

Even if the partisan balance remains roughly the same, there are still some big changes in Sacramento. The Legislature saw a surge in retirements and early exits this election cycle resulting in nearly a 30 percent turnover in the Legislature. The freshman class will now have a record number of women and LGBTQ members. Included in that freshman class of women is our very own Jasmeet Bains, MD. Dr. Bains is the first family physician and first Sikh American and woman of Indian American descent to be elected to the California Legislature. Dr. Bains won her first campaign for public office with an overwhelming margin. The November 21, 2022, results from the Kern County Registrar of Voters showed Dr. Bains leading with 60.5 percent of the vote, while her challenger reported 39.5 percent.

There will also be a change in leadership in the state Assembly. After a protracted battle that split the chamber’s Democratic caucus, Assembly Democrats voted unanimously to make Assembly Member Robert Rivas, D-Salinas, the next Speaker, but he will not assume the role until June 30, 2023. Current Speaker Anthony Rendon, D-Lakewood, was re-elected to open the legislative session wherein he will serve as Speaker and facilitate the transition until June 30. The Assembly Speaker is one of the most powerful jobs in California politics. The leader determines committee assignments, sets policy priorities, and has a major role in negotiating the state budget.

Aside from legislative members, California also voted on seven statewide ballot propositions in the 2022 General Election. Four ballot measures were defeated and three were approved, including the two CAFP-supported propositions - Proposition 1, the Constitutional Right to Reproductive Freedom, and Proposition 31, a Referendum

on the 2020 Law that Would Prohibit the Retail Sale of Certain Flavored Tobacco Products.

Proposition 1 was the most popular measure statewide, winning two-thirds of the vote. Support for Proposition 1 was mostly concentrated in the Democratic coasts, where it received a higher share of the vote in those counties than any other measure on the ballot. Approval of Proposition 1 means the California Constitution would be changed to expressly include existing rights to reproductive freedom—such as the right to choose whether or not to have an abortion and use contraceptives.

As for the law that would prohibit the retail sale of certain flavored tobacco products in California, the tobacco industry has been fighting it since it passed in 2020. They first went through the Courts to prevent enforcement of the law. CAFP signed onto an Amicus Curiae (“friend of the court”) brief opposing their efforts. The tobacco industry, however, gathered enough signatures to qualify a referendum – Proposition 31 - that blocked the law from taking effect until voters could decide whether to uphold or overturn it. That allowed tobacco companies to continue selling the products in question for another two years — likely earning them at least $1 billion in profits. Fortunately, the approval of Proposition 31 means inperson stores and vending machines in California cannot sell most flavored tobacco products and tobacco product flavor enhancers.

CAFP advocates for family physicians and patients in a number of arenas, including through legislation, regulations, administrative action, ballot propositions, and legal measures. CAFP will continue to advocate on issues within CAFP’s legislative priorities:

1. Advancing payment reform and system transformation, including transforming current payment models; reducing system complexity and administrative burden, including not legislating the practice of medicine; and creating new care models that promote better health outcomes, health equity, and access to care.

continued on page 12

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2. Promoting the growth of the primary care physician workforce, including guiding financial and policy changes in medical education that support primary care, and creating a more diverse workforce.

3. Defining and raising the profile of family medicine, including through conducting public education and awareness; leadership development; and

supporting full spectrum family physicians.

4. Supporting physician wellness, including alleviating burnout and supporting efforts that promote physician mental and emotional health.

5. Promoting Justice, Equity, Diversity, and Inclusion (JEDI), including through advocating for policy changes that improve health equity and advancing a more diverse family medicine workforce.

In the legislature, CAFP will have a particular focus on JEDI, system transformation, and raising the profile of family medicine, hence the theme for the 2023 AMAM will be health equity. There will be a presentation on evaluating policy with an equity lens by Courtnee Melton-Fant, PhD, Assistant Professor, Division of Health Systems Management and Policy at the University of Memphis. In addition, the Family Physicians Political Action Committee (FP-PAC) will continue to support candidates who promote issues important to family medicine and to educate current legislators on the importance of family medicine. Though not all CAFPsupported candidates get elected, we continue to have strong champions in the Legislature.

As we saw with Dr. Bains, we know family physicians are remarkable advocates and leaders. To further promote family physician advocacy and leadership, we will have two advocacy training tracks at AMAM – the first is on crafting your message, telling your story, and meeting with your legislator, which will be presented and facilitated by Nina Surya, who is an expert speech and leadership coach and executive partner at MediaWorks. The second training track is on running for office and serving on advisory committees, which will be presented and facilitated by experienced political consultant and partner at the Strategy Group, Danielle Cendejas.

AMAM is your chance to make change in health care policy! Come join us at AMAM and please also contribute to the FP-PAC. Find more information and to register today at familydocs.org/ amam!

(L to R): Vice President of Advocacy and Policy, Catrina Reyes, Esq., Assembly Member Jasmeet Bains, MD, CAFP CEO, Lisa Folberg, and Advocacy Assistant, Karen Alvarado, on election night at the Jasmeet Bains Watch Party.

(L to R) Melissa Campos, MD, Maria Carriedo-Ceniceros, MD, Assembly Member Akilah Weber, CAFP’s Vice President of Advocacy and Policy Catrina Reyes, Esq. and David Bazzo, MD, FAAFP in attendance at an in-district private dinner.

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Be More Like Jasmeet

During my first year as a resident at UCSF-Fresno, I entered a contest to write on the importance of physicians in leadership roles. My resident colleague and I were chosen to attend the National Conference of Constituent Leaders (NCCL) in Kansas City. Accepting a CAFP dinner invitation turned into a 10-year journey that started for me as a resident member to the board, then as Fresno-Kings-Madera President, Regional Director to the Board, and currently the CAFP President-elect. What a wonderful journey to have experienced through the years that has included: advocacy, CME, leadership, practice transformation, and the joy of medicine. I have had the honor to take this journey with a group of family doctors who love their patients, their communities, and one another. I’m especially proud to have seen the journey of the recently elected Dr. Jasmeet Bains from when I first met her as a resident to now as the first family physician and first Sikh American in California’s legislature, representing the Central Valley in Assembly District 35. I was struck by the authenticity and energy Jasmeet gives when you first meet her, connecting with you on just about any interest you may have. I have gotten to know Jasmeet in the last 3-4 years and understand the force behind her decision to run for office. She grew up in Delano, a rural town in the Central Valley where the hurdles she faced growing up are still present today. We have spent time discussing barriers people still face in the Central Valley in access to care, physician shortages, social determinants of health, homelessness, mental health and substance use disorders, affordable housing, water drought, and air quality.

Growing up in a small town myself and living in the Central Valley, I can relate with Jasmeet and our conversations on needs that are vital for any town to thrive. I have had the privilege to serve as the medical director for our rural clinic system, from the entrance to Yosemite down the oil fields of Taft. Every one of the towns in the valley is unique and special all together. Jasmeet understands this as a family physician rooted in her community.

My experience in visiting the various clinics and talking to patients, clinic staff, medical providers, and local government officials is that everyone living in that town wants to succeed, to grow, and are looking for ways to thrive. The pandemic forced us to think and act differently, from the care we provide in our health systems, to the education of our children, and most importantly how we value the gift of time. Jasmeet was on the frontlines, establishing field hospital sites to treat COVID patients. She leveraged her experience, talents, and community connections to make a difference. We can all do the same in our own communities.

As family physicians, we are in a unique and trusted position in our communities to make an incredible impact. We have the ability to contribute to society in additional ways, whether we volunteer at the local food bank, join a nonprofit board, or like Jasmeet, run for public office. We can make a difference. We need to look at our community in a solutions-based way, turning to our neighbor and asking how we can help or collaborate. One thing to highlight is the power of community and the ability for gifted and talented people to come together and fix complex issues. That is exactly what Jasmeet did. Jasmeet serves as a volunteer with Global Family, an organization dedicated to combating human trafficking and child abuse, on the San Joaquin Valley Air District’s Environmental Justice Advisory group, working to improve our Valley’s air and water quality and on the Taft College Foundation, fighting to expand access to higher education.

As family physicians, we are well trained and best positioned to lead any community in need. We must continue the #FMRevolution to support physician wellness, combat mental health and substance use disorder, and fight for equitable health care and reproductive rights. Jasmeet saw the shortcomings of the health care system in California and she knew family physicians needed to be at the table to make changes in order to improve access to quality healthcare. It is because of her authenticity that her community came out in full support of her. As her family physician community, we must continue to support her in her efforts to improve our healthcare system as the only family physician and one of three physicians in the legislature.

We can all take pride in Jasmeet’s victory as it has shown us that we are all able to amplify our voices for our patients, our colleagues, and our specialty. The future is in our hands and we must grasp every moment to make the changes we want to see in our communities.

About Raul Ayala, MD, MHCM:

Dr. Ayala is the President-Elect of the California Academy of Family Physicians. He was born and raised in South Texas, in the great city of Mission, a small town of about 20,000 where everyone knew everyone, and known for its citrus and great people. Dr. Ayala completed his Family & Community Medicine Residency at UCSF-Fresno where he met his wife Kelly, who was an OB-GYN resident. The Ayalas decided to stay in Fresno to start a family and their careers serving the communities of the Central Valley. Dr. Ayala and his wife now have two children: Grace (7) and Raul III (5).

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POV: A Resident and First Timer at AMAM

I could feel my heart pounding in my ears and the perspiration collecting under my armpits as I stood at the microphone in front of a room of over a hundred medical students, residents, attending physicians, and staff. Our CAFP Student-Resident Council’s Advocacy subcommittee had submitted two resolutions for CAFP’s All Member Advocacy Meeting (AMAM), and I was up there to speak in support of our resolutions. This was the first time we had submitted resolutions as a subcommittee, and the first time many of us had gone to AMAM in person. Despite our nervousness, several of us, including one of our fourth-year medical students, spoke and successfully defended our resolutions.

The 2022 AMAM, the first in-person event in over two years, was so refreshing after two years of AMAM on virtual platforms. I was beyond excited to see my fellow CAFP Student-Resident Council members in person, and even more amazed at how inspiring the entire conference was. Hearing how passionate our community felt about various resolution topics, how some physician members became involved in advocacy and ran for elected office, and how many people donated to FP-PAC to support political action on behalf of family medicine physicians made me feel invigorated about the future of family medicine.

Many medical students and family medicine residents are interested and want to learn how to advocate. For 20222023, the largest sub-committee of the Student-Resident Council is focused on advocacy. We want to learn how to push for progress for our patients and for ourselves. We want to be involved in effecting widespread change and fixing problems that we see in the system. While we often have the desire, we do need guidance and mentorship in how to effectively advocate. We may not know how to write a resolution or how to call into town halls to support a piece of legislation. Dedicated time set aside for advocacy is also crucial for trainees, when so much of our time and energy is required just to learn medicine.

As a first-year resident, I felt like AMAM was the perfect starting point for me to dive into the world of advocacy through organized medicine. For example, at the end of the 2022 AMAM, all the attendees practiced our spiels for talking to our legislators. Prior to that, I had never thought about the details of meeting with a legislator. After this practice, and most certainly after joining one of the virtual legislator meetings later that week, I had a much better idea. These small opportunities give trainees the ability to build our confidence. With each bit of practice or involvement, we learn that speaking up does not have to be so scary, and we feel empowered to be more involved.

By the end of AMAM, I not only desired to further my own involvement in advocacy, but also to encourage other residents and medical students to learn and become more involved. I am very much looking forward to AMAM this year and hope to see many of you there!

About Dr. Wang

Susan Wang is a resident physician at UC Irvine Family Medicine. She grew up in the Bay Area and absolutely loves being a Californian!

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Students & Residents - The CAFP Foundation is pleased to offer 15 scholarships in the amount of $500 each to support medical student and family medicine resident participation in the All Member Advocacy Meeting & Lobby Day, March 25-27, 2023. This is a great opportunity to get involved in CAFP’s legislative advocacy efforts. Apply soon, these go fast!

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Lisa Folberg CEO

Family Medicine POPs

I hope you had an opportunity to take a break and get some well-deserved rest over the holidays. I always enjoy the beginning of a new year as it provides a great opportunity to reflect on the previous year. As you have read in the advocacy and education updates, 2022 was a great year for CAFP and for family physicians. Thank you to all of you who made 2022 a success, including our dedicated Board of Directors and President Dr. Lauren Simon. The achievements of 2022 could not have been accomplished without the engagement of our members across the state who continue to serve your patients with the intelligence and compassion that is family medicine.

I cannot reflect on the achievements and hard work of family physicians in 2022, without talking about Dr. Jasmeet Bains, the first family physician to serve as a member of the California legislature. She ran for office to address the issues that her Central Valley patients face, from the economy and education to health care. She was not expected to win against her seasoned politician opponent but she used her family physician determination and hard work for a decisive win. Politics can feel transactional and insincere. Her constituents saw the antidote in Dr. Bains.

As a new member of the California Legislature, Dr. Bains will face new and continuing challenges. We can expect challenges in 2023 outside of the legislative process as well, including an uncertain economy and continuing threats to public health, immediate and ongoing, like climate change.

There will also be many new opportunities in 2023. Through media, legislative and regulatory advocacy there will be opportunities to make sure family physicians are leading conversations around health system change, payment and workforce. Your CAFP is well situated to raise our political profile in our new Sacramento location. Through advocacy and coalition building, there will be opportunities to promote primary care and with it, family medicine training, as well as to protect full spectrum

family medicine and address social determinants of health. Empowering, educating and connecting family physicians will be essential in navigating the challenges and opportunities in 2023.

Much like you as family physicians must put your own proverbial oxygen masks on before helping others, CAFP needs to make sure that as an organization we are healthy and strong in order to help our members weather challenges and embrace opportunity. In 2022, CAFP was able to hire new staff members in the areas of education and advocacy. We have made leadership opportunities more transparent and are looking at our internal structures to make sure we are reflecting the values of family medicine, including working toward a just, equitable, diverse and inclusive environment.

CAFP has also been looking at improving member experience. I am excited to announce that CAFP will be launching our new CAFP e-platform, which will be a device, phone or computer based app that will allow members to access education, advocacy, and policy information all in one place. The app will allow you to keep up with changes in state and federal law, clinical medical education opportunities, register for events and programs, and network with colleagues all in one convenient place.

In 2023, we will continue to honor the traditions of CAFP while making changes that serve changing member needs. As part of that effort, we will be combining the Student & Resident Summit and the Clinical Forum into one exciting event, Prism of Practice (POP). Family Medicine POP will bring together current and future family physicians to provide the latest clinical information and residency program information, as well as to learn and be inspired by each other.

No matter what 2023 brings, I look forward to facing the challenges and opportunities together.

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Primary Care Physician Needed at Visalia Family Practice

107 N. Hall St. Visalia, CA 93291

If you’re looking for the perfect place to live and work, we invite you to consider Visalia Family Practice Medical Group in Visalia, California. Established over 35 years ago we have a built-in-patient base with a cohesive group of providers that will help you thrive in your career and achieve a balance in todays practice environment.

• Start immediately, looking for 2 positions, established and new providers encouraged to apply

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• $220,000 to $240,000 per year*

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Visalia Family Practice prides itself in being a traditional family medicine clinic. We’ve created a very down to earth, family oriented, and congenial atmosphere. We’re the perfect fit for doctors who want low stress, a low cost of living, high satisfaction, and a happy, healthy environment for raising a family and enjoying your free time.

To apply and for more information visit : www.vfpmg.com/career-listings/family-physician

You may contact Breana Bergdorf, Administrator by phone at 559-625-9200 or email at bbergdorf@vfpmg.org

WellSpace Health is hiring for Family Practice Physicians

WellSpace Health is now hiring physicians! WellSpace Health is a non-profit community health system providing comprehensive medical, dental, behavioral health and supportive services to individuals and families since 1953. As a Federally Qualified Health Center, we believe that everyone deserves to be seen, no matter who you are, where you come from, where you work or what place you call home - we see you!

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To view the application scan the QR code to the left with your phone camera.

Health Impacts of Climate Change

Jerry P. Abraham, MD Director & Chief Vaccinologist, KEDREN Mobile + CDU Street Medicine

Declaring Climate Change A Public Health Emergency –We Need Climate Health Action Now!

Climate change is the most pressing existential crisis of our lifetime. The climate crisis will have long lasting adverse impacts on health, and further exacerbate health disparities including reducing access to care. With a constant lens and focus on advancing racial justice and achieving health equity in my daily clinical duties, I can say first-hand that addressing the health harms due to climate change is about so much more than saving polar bears, planting trees in wealthy communities, and tax rebates for Teslas. Low-income, poorly resourced, underrepresented, and underserved communities have the most at stake and the most to lose when it comes to their health.

For example, my clinical practice as a family physician is geographically based in South Los Angeles, where my patients are currently living with the health consequences of our dependence on fossil fuels and the subsequent greenhouse gas emissions daily. From rising temperatures and extreme heat, to worsening air quality and water quality, to raging wildfires and so much more, my patients have the most to lose as they suffer the brunt of these worsening conditions. The lack the resources and funding to mitigate and adapt to the changing climate as other, wealthier communities are able and, unfortunately, it is they and their families who will suffer the repercussions. As family physicians, I wholeheartedly believe it is our responsibility to acknowledge climate change as an existential threat to public health and patient wellbeing, and to do all we can to declare the climate crisis a public health emergency, reduce our dependence on fossil fuels, limit global warming to 1.5°C or pre-industrial targets, achieve a zero-carbon emissions economy by 2050, including decarbonizing the health sector. The medical field is so incredibly heterogeneous – with all its varied specializations and modes and types of practices, all-consuming different quantities and forms of energy in their unique ways. Between clinics and hospitals, we burn fossil fuels at staggering rates. The healthcare industrial complex is responsible for 20% of carbon-combustion within the United States – as a profession that entirely

centers around patients and improving their health and wellness, we are actively working against our goals by letting these levels of dependence and consumption continue creating health harms for the very people we serve. It is important for every physician to pivot some of their advocacy and energies to address the climate crisis.

I recently co-authored a resolution to the American Medical Association (AMA) regarding this issue in collaboration with my California Primary Care colleague Dr. Ashely McClure and other physician leaders from across the country. The AMA resolution passed on the floor of the AMA House of Delegates and declared Climate Change a Public Health crisis and committed AMA resources to taking action to limit U.S. emissions and support the rapid implementation of clean energy, as well as investments in mitigation, adaption, and patient and clinician education. Importantly, our resolution also emphasizes the significant investments in climate resilience through a climate justice lens. The AMA not only passed this action but they also committed to developing a strategic plan for how they will enact this new advocacy priority.

This is a huge step forward in preserving the health and prosperity of the public that we serve, but one action will not be enough, and our efforts must not end there. Beyond this resolution, I want to encourage my health professional colleagues to work toward similar commitments across organized medicine and beyond. It’s so important that we get involved within our specialty and state societies at the county, state, and federal levels. Although climate advocacy may be intimidating – for example, there were many people who said we would never get this resolution passed through the AMA — but in the end, over 90% of physician voting delegates in the AMA House of Delegates voted to support us. With persistence and passion, it is possible.

Regardless of how daunting a task it may seem, as a physician who cares for underserved patients each day, I am certain that this work is absolutely a necessity, and not a luxury. The climate crisis continues to worsen and

continued on page 22

Fact:

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If you are 30 or older, ask your health care provider about getting an HPV test with your Pap test. Learn more at www.healthywomen.org/hpv.

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continued from page 20

disproportionately impacts marginalized and vulnerable communities – these impacts will not be felt equally. Those who need the most aid and resources will surely receive significantly less than those with the ability to manage the issues to come. This is not a controversial issue; it is a bipartisan issue with growing generalized consensus – we can all agree that this is a matter of survival for all persons but especially for those most neglected by society. It is our role as healthcare providers to ensure the health and prosperity of all people regardless of sex, gender identity, ethnicity, race, sexual orientation, religion, and socioeconomic status situation. I would like to call upon my peers to take initiative and lead and to be deliberate with their efforts in combating the Climate Crisis. Let’s educate ourselves and become more involved the many ways that we can work together to limit the health harms due to the changing environment. We need to become part of the solution and stop contributing to the problem. Working together and by not giving up, we will achieve a cleaner and healthier future for all – after all, we only have 1 planet and 1 life to live.

Ways you can join the Physicians Climate Change Movement:

1. Join the National Academy of Medicine Grand Challenge to Decarbonize the Health Sector

https://nam.edu/programs/climate-change-andhuman-health/action-collaborative-on-decarbonizingthe-u-s-health-sector/

2. Join the President Biden & Vice President Harris’s call to join the HHS Pledge to Decarbonize the Health Sector

https://www.whitehouse.gov/briefing-room/ statements-releases/2022/06/30/fact-sheet-health-

sector-leaders-join-biden-administrations-pledge-toreduce-greenhouse-gas-emissions-50-by-2030/

3. Join the growing community of California Physicians addressing Climate Change https://docs.google. com/forms/d/e/1FAIpQLSdZXxl7pGT9hSK_H2YG60pm_80cu-oxwHkeKG3iMUMuhsdCA/viewform

4. Consider a Fellowship or Additional Training in Climate Health: https://www.healthequity.challiance.org/choffellows

5. Medical Society Consortium on Climate Health & Equity https://medsocietiesforclimatehealth.org/ members-in-action/june-2022-champion/

6. AMA Climate Change as a Public Health Emergency Resolution https://www.washingtonpost.com/ politics/2022/06/14/climate-change-is-increasinglyviewed-public-health-crisis/

https://www.ama-assn.org/house-delegates/annualmeeting/highlights-2022-ama-annual-meeting

https://medsocietiesforclimatehealth.org/latest-news/ consortium-statement-ama/

https://www.medicaleconomics.com/view/amaclimate-change-is-a-public-health-crisis

About Dr. Abraham:

Dr. Abraham, a practicing Family Physician in Los Angeles County, completed a Climate Health Fellowship at Harvard, continues to lead the physician climate change movement at the American Medical Association (AMA) including authoring the AMA Resolution Declaring the Climate Crisis a Public Health Emergency, and serves as a Climate Champion at the California Medical Association organizing education and advocacy for Health Professionals and being a resource for California Gov. Gavin Newsom's Office on Climate Health with a particular lens on Health Equity & Racial Justice. He is the Director & Chief Vaccinologist at KEDREN, a FQHC.

California Climate & Health resources:

https://ww2.arb.ca.gov/educational-resources

https://calepa.ca.gov/climatedashboard/#Community_Health

https://www.cdph.ca.gov/Programs/OHE/pages/ CCHEP.aspx

https://www.apha.org/-/media/Files/PDF/topics/ climate/CC_Factsheet_California.ashx

https://climatehealthnow.org/learn

Christine Henneberg, MD, MS

Family Physicians in Abortion Care

programs that offered robust abortion training, eventually choosing one that participated in the TEACH (Training in Early Abortion for Comprehensive Healthcare) program. At that time the center of TEACH’s mission was to train residents to provide “integrated” abortion care, equipping us to incorporate medication and procedural abortion into our primary care practice.

Integration. The word shares a root with “integrity”: the state of adhering closely to moral and ethical principles, but also a state of being whole, undivided.1 It is a core tenet of what it means to be a family physician—not just a philosophy, but an ethic: understanding and treating each patient as a complete human being, rather than a problem list or a compilation of organ systems. Through our training, the benefits of integrated care become obvious to family doctors, even though the challenges are manifold, particularly in abortion care. Any procedure has the potential to disrupt a busy clinic day, requiring time, staff, medications and equipment. Additionally, stigma surrounding abortion may lead support staff and colleagues to object to primary care doctors offering officebased abortion services.

“How long have you been doing this?” a patient recently asked me. She was shivering on the edge of the exam table, her lower half covered by a paper drape. Unfazed, I answered, “About ten years.” She nodded, then asked another question I hear often: “Do you like it?”

I answered her carefully but honestly, knowing that I could never imagine or intuit the range of her emotions in that moment. “Yes,” I said, “I do.”

As a family doctor, I’ve never taken my abortion training for granted. In medical school I applied only to residency

These barriers meant that even in California, very few residents go on to actually provide integrated abortion care. My TEACH trainers presumably knew this. But they also knew that only clinicians who have been trained to think about abortion as part of the care of a whole person are equipped to provide truly compassionate, competent care for all pregnant patients. A doctor who never performs or even observes an abortion during her training will likely come to see abortion itself as a fragment of something broken—care provided “somewhere else,” by a different type of doctor—rather than a piece of an integrated whole.

Despite my TEACH training (and following national trends), my practice has become increasingly fragmented over the past ten years. I provide first- and second- trimester abortions in a dedicated high volume setting, and primary women’s healthcare in a separate office. Nevertheless, my training in integrated care means that all my patients get the benefits of my empathy and expertise. I can discuss pregnancy options

continued on page 24

with any patient, in any setting; and I can seamlessly counsel my abortion patients on a host of primary care concerns, from hypertension to HPV vaccines.

Meanwhile, amidst the dramatic political changes of the past several years, family doctors are helping to rethink the meaning of “integrated” abortion care, and to re-envision our role in it.

We are collectively moving away from the focus on individual choice and toward an emphasis on reproductive justice: the right of all persons to have children or not to have children, and to parent the children we have in safe and sustainable communities. We also recognize that as physicians in California, we have a unique duty to help circumvent barriers to abortion access for all patients. Sometimes this means drastically minimizing our own role. In the “new normal” of abortion care, instead of coming into an office, many pregnant persons will complete a brief health screening, order pills over the internet or by phone, then manage their own abortion at

home, with only minimal involvement of a clinician. For some this is the safest, most affordable way to end a pregnancy, and family doctors are working to make it more widely available. This is integrated abortion care, and it belongs squarely in the work of family medicine. It is a commitment to treating all pregnant persons as complete human beings, with their own goals, values, and priorities. It is a commitment to wholeness, to justice, to integrity.

1. I owe this etymologic observation, particularly in the context of clinical practice, to Dr. Lindsay Mazotti’s essay, Integration. JAMA. 2010;303(1):15-16.

2. More information on Reproductive Justice, a movement founded and led by Black women, can be found at sistersong.net.

3. Dr. Michele Gomez, a TEACH faculty member and family doctor, is one of the founders of the MYA (Manage Your Abortion) network, one of a growing number of efforts to empower patients to safely manage their own abortions.

Opportunities exist with Tidelands Health for our health system-owned primary care practices in Horry and Georgetown counties. We cover a growing primary service area of more than 320,000. Inpatient services are provided by system-employed hospitalists; full specialty support for referrals including a relationship with Medical University of South Carolina, Charleston. New providers will be busy from the start in growing practices. Practice locations span from Georgetown to Myrtle Beach. We offer fair market value compensation, production and quality bonuses, relocation assistance and a lucrative benefits package. Our coastal communities offer an endless amount of outdoor recreation and a pleasant lifestyle. Please reach out to Lydia Smith, Provider Recruiter at lsmith@tidelandshealth.org

Primary Care Clinic & Hospitalist positions available for FM or IM Physicians

Monterey County, California

Natividad Medical Center is a 172-bed acute care hospital owned and operated by Monterey County. We are a teaching hospital with a UCSF af liated Family Medicine residency program as well as rotating medical students and physician assistant students. We pride ourselves on having a supportive and collegial environment. We treat a medically underserved population and seek mission driven colleagues.

Must be Board Eligible in Family Medicine or Internal Medicine. Spanish language skills are welcome, but not required.

Position Highlights:

• Teaching hospital with residents and medical students

• Nocturnist positions available for procedurally trained Hospitalists

• Eligible for PSLF and CalHealthCares loan repayment programs

• California Public Employees Retirement System and County Bene ts

• Paid malpractice

• CME reimbursement and paid time-off

The Monterey Bay Area is an amazing place to live. We are located a short 20-minute drive from the coast, near Big Sur, Carmel and Monterey, and less than 2 hours south of San Francisco. The County hosts annual events including the Monterey Jazz Festival, IndyCar Grand Prix of Monterey, Sea Otter Classic bike race, Monterey Car Week, and the California Rodeo.

Salary and bene ts are competitive and commensurate with skills and experience. For more information, please email CV to: CVReview@natividad.com.

EOE/M/F/H/V.

Erika Roshanravan, MD, FAAFP

Trauma-informed Care for Every Body (Part 2)

In the last issue, we started talking about weight stigma as a form of trauma with detrimental effects on health, and our role in perpetuating and worsening weight stigma with practices such as weighing at every visit, frequent reminders to lose weight regardless of the problem patients present with, and largely ineffective, often shame-inducing advice for self-guided “diet and exercise”. We also explored the inaccuracy of assumptions that thinness equals health, what a flawed proxy BMI is for health, and BMI’s origins in an entirely white European population. We will now talk more about weight and trauma, disordered eating, and some starting points to reduce weight stigma in our practices.

Trauma has long been recognized as a contributing factor to increased body weight. The original study on Adverse Childhood Experiences (ACEs) in 1985 was born out of Dr. Vincent Felitti’s observation in a weight loss clinic that among women who dropped out of the program, a majority (55%) had experienced sexual abuse. Several studies since have confirmed an association between trauma and heavier weight (e.g., Richardson et al. 2014, Wiss et al. 2020).

In addition to trauma leading to higher weight, higher weight in turn also commonly leads to toxic stress and trauma from weight discrimination and weight stigma. Health At Every Size (HAES) and others have posed an important question: to what degree are adverse health outcomes caused by the toxic stress from weight discrimination and weight stigma, rather than by the fat itself?

There is ample evidence of the adverse effects of weight stigma on health and well-being. Internalization of weight bias has been shown to be a link between weight bias and poor health outcomes. Weight bias internalization refers to the degree to which a person has started directing weight stigma at themselves and can be measured with the Weight Bias Internalization Score (WBIS).

Pearl & Puhl (2013) showed that a higher WBIS were associated with body image disturbance, poor self-esteem, anxiety and depression, and, in particular, disordered eating. Contrary to common belief, most individuals with disordered eating do not have low, but high BMIs. Binge eating disorder rates are especially high among patients at higher weights and are associated with poor mental health and poor quality of life.

It is easy to see how our incessant highlighting and focusing on our patients’ need for weight loss reaffirms patients’ internalized weight stigma and thus reenforces disordered eating. To make things worse, when we tell people to “diet”, we are basically telling them to adopt eating patterns we know to be harmful in thin people: restricted eating, feeling guilt and shame about eating, being overly preoccupied with eating, etc.

There is overwhelming evidence of the detrimental harm eating disorders cause, and we as healthcare providers are part of the problem. Additionally, evidence shows that the most detrimental cardiovascular health outcomes are associated with weight cycling, which is often a consequence of self-directed dieting.

How can we do better? How do we reduce healthcare’s contribution to internalized weight bias, disordered eating, and other poor health outcomes? The 4R’s of traumainformed care (i.e., realize, recognize, resist, respond) provide a helpful framework for this (see table, page 28). This is a very complex topic, and there is much to unpack from what we were taught. Ultimately, as with other biases, fighting weight bias means to see the individual for who they truly are, in all their complexity, personality, beauty, strengths and weaknesses, unpretentiousness, vulnerability and totally badass-ness.

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continued from page 26

REALIZE (the impact of trauma and stress and paths to recovery):

- High weight can both result from and result in trauma.

- Weight stigma, including in healthcare, is experienced by most individuals at high weight, and is a form of toxic stress and trauma.

- Internalized weight stigma is very common (even in individuals with normal BMI!) and associated with disordered eating and other poor health.

- Thin does not equal good health, fat does not equal poor health, and BMI is a poor proxy for health.

RECOGNIZE (signs and symptoms of trauma and stress):

- Ask your patients about weight bias, prior experiences in healthcare, internalized weight stigma, disordered eating, and trauma history to the degree the patient feels comfortable talking about.

- Learn to recognize if your audience is in “learning brain” or in “survival brain” (stress response, flipped lid). A brain in “survival mode” cannot learn at that moment. Focus instead on addressing the toxic stress.

RESIST re-traumatization:

- Give patients a choice if they want to be weighed at a visit.

- Ask permission to talk about weight.

- Use body-positive language.

- Stop blaming patients and individual lack of effort for weight. Recognize weight is complex, multifactorial.

- Do not encourage self-directed “dieting” due to both its ineffectiveness and general worsening of internalized weight bias and feelings of shame and guilt when it does not work.

- Empower them to develop a positive relationship with food.

- Enlist the help of a nutritionist familiar with body positivity, cultural humility and disordered eating if the patient would like that.

- Know available resources for medically supervised non-surgical or surgical weight loss programs if a patient desires that and find out which weight loss programs/ providers in your area include an emphasis on self-compassion, body positivity and cultural humility.

- Stop simply advising “exercise”. Explore what movement individual patients may find enjoyable, what they would like to and be able to engage in. Strongly discourage tying “exercise success” to weight loss. Physical activity generally improves the sense of well-being, reduces stress and improves cardiorespiratory fitness, but does not necessarily result in weight loss.

RESPOND (by integrating knowledge of trauma and stress):

- Create welcoming spaces: seating areas, gowns and equipment that accommodate a variety of sizes.

- All interventions must be patient-driven. Explore what “health” means to them.

- Openly address cultural and historical issues around the white-centric roots of creating the BMI norms, white supremacist roots of the thinness ideal, and the extremely important paradigm shift that “eating healthy food” does not mean “eating white people food”.

- Empower them with tools for self-compassion and body positivity. Enlist the help of a therapist if the patient would like that.

- To the extent the patient desires that, manage stress, mental well-being, sleep quality, ability to move and engage in life activities.

- Consider alternatives to weight-gain causing medications.

- Reflect on your own weight bias towards others as well as towards your own body and weight. Consider doing the Harvard Weight Bias exercise and take the Weight Bias Internalization Score (Modified) WBIS-M questionnaire yourself. As with other forms of trauma and toxic stress, consider exploring this with the help of a therapist. We need to take care of ourselves in order to be able to be our best selves in this work.

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