A recording of this presentation is available HERE.
Hooray for Generalism Finding Meaning and Purpose in a World of Hyper-Specialization (Gerlach, 4/15/26)
A recording of this presentation is available HERE.
Immigration Status and Negative Health Impacts (Yadira Raya-Cervantes, 4/1/2026)
A recording of this presentation is available HERE.
Northern California Center for Well Being: HeartWorks Cardiac Rehabilitation Program (Roosen, 3/25/26)
A recording of this presentation is available HERE.
Thanks so much to Erin Roosen, program manager for our local Center for Well-Being's Cardiac Rehabilitation Program, HeartWorks, located at 500 Doyle Park Drive, Santa Rosa 95405. She gave an inspiring presentation on the value of Cardiac Rehabilitation. She certainly inspired me to give a more robust bedside recommendation for my cardiac patients.
Cardiac Rehabilitation is an evidence-based intervention that literally saves lives. . .
HeartWorks offers:
- A 3 month focused exercise program for patients with heart failure, any cardiac procedure (valve replacement or repair, stent, CABG), and recent STEMI/NSTEMI
- Cardiac rehab
- decreases need for hospitalization by 25%
- helps people increase activity level
- improve quality of life (65% improvement on PHQ9)
- improves diet
- decreases mortality (47% decrease in mortality if you complete the program, compared to attending only 1 session)
- Cardiac rehab includes pre and post exercise vitals and 3 lead EKG monitoring
- Phase II is 36 sessions (2-3 days/ per week, depending on availability): goal is to improve aerobic capacity (by increasing the 6 minute walk test and/or improve MET levels). This is generally covered by Medicare insurance
- Phase III is an additional 3 month non-monitored program paid for by participants (24 sessions, 2/week)
- Once participants complete cardiac rehab, they are offered a 3 month voucher for our local YMCA
What was most moving about Erin's presentation was the improvement of patients' quality of life and mental health, as well as a recognition that decreasing loneliness (we are in an epidemic) improves mortality as well.
We are working with HeartWorks to ensure more of our patients complete cardiac rehab with a special personal focus on our Spanish speaking patients (Erin said they have both a Spanish speaking MA and physiotherapist).
Of note, referrals must be done through a patient's cardiologist!
OB and GYN update: highlights and practice changing articles from 2025 (Lund & Bacon, 3/11/2026)
A recording of this presentation is available HERE.
(late entry)
Many thanks to Drs. Allison Bacon and Erin Lund for an excellent review of important practice-changing literature from the fields of OB and Gyn in 2025. It's obviously important for us to keep track of practice-changing advances, but the task can be overwhelming and burdensome, particularly if it's an area you are not using on a daily basis.
Dr. Bacon started us off with 3 practice-changing OB papers:
1) Quality-Improvement (QI) Strategies for the Safe Prevention of Preterm Birth, ACOG Committee Statement 17, May 2025
Key take homes:
- current US NTSVD (normal term spontaneous vaginal delivery) rate is 25.6% but ranges 18.5-84.6%, and the WHO goal is 23.6%>> the variability represents opportunity for improvement through local QI projects
- in fact the CMQCC initiative in California reduced rates from 26% to 22.8% (from 2014 to 2019)
- suggested strategies to improve vaginal delivery:
- local policies and procedures to support vaginal birth
- labor support huddles
- team trainings for interpretation of fetal heart rate monitoring
- unit based policies for oxytocin and management of labor dystocia
2) FIGO good practice recommendations on preconception care: A strategy to prevent preterm birth, Int'l Journal of Gynecology/Obs 2025
- preterm delivery is responsible for most neonatal and infant deaths
- many risk factors for preterm birth can be targeted outside of pregnancy
- baby-centered assessment as a part of preconception care
- examples risk factors and interventions
- teen pregnancies>> preconception counseling
- optimize screening/treatment of chronic conditions (e.g. hypertension, DM, thyroid)
- mental health>> screen for mental health and eating disorders
- infectious disease>> HPV vaccination, screen for STIs, preserve oral health
- nurtitional status>> discuss BMI, dx/tx iron-deficiency
3) Air Pollution Linked to Risk of Spontaneous Preterm Birth, Celeste Krewson, 2025, Contemporary Ob/gyn
- talk to patients about PM2.5 as mechanism for for social drivers of health, use of air filters?
- solutions driven by housing, community, city planning
Dr. Lund presented the second half on the important gyn literature:
1) ACOG Clinical Consensus #9: Pain Management for in-Office uterine and cervical procedures
- healthcare professionals tend to underestimate the pain people with uterus may feel during a procedure, providers may deem pain management not needed and therefore not offer to patients
- despite discrepancy between level of pain between patients and providers, patients still do report high degree of satisfaction with in-office gyn procedures
- higher pre-procedural anxiety and anticipated pain are
- associated with higher pain scores
- THEREFORE options for pain management should be offered to all patients for in-office procedures
- IUD: topical anesthetic is more effective over placebo or misoprostol
- lidocaine spray>> lidocaine injection (?2017 RCT)
- no evidence to support pre-procedure NSAID, though may help for post-procedure pain
- use of ultrasound has been shown to decrease pain of IUD insertion
- EMB: 10% lidocaine spray (3 puffs before), naproxen 30 minutes prior reduced pain in one study, performing EMB with full bladder may reduce pain
- Uterine aspiration: paracervical block, NSAIDs pre-procedure (for post-procedure pain), oral benzos do not reduce pain but do reduce anxiety
- Colpo: topical/intracervical lidocaine recommended for biopsies and LEEP
- Trauma-informed care: universal trauma precautions, given patients control over procedure, ask permission to begin/continue procedure, careful with words used (e.g. not bed, table)
2) Management of Recurrent Bacterial Vaginosis, ACOG Clinical Practice Guideline Update 12/2025
- Recurrence is common! 66% of patients experience recurrence of BV within 12 months of initial diagnosis
- Recent RCT comparing partner therapy for recurrent BV (treating partner with oral and topical) showed marked decrease in recurrence (35% vs. 65% at 12 weeks), absolute risk was BIG -2.6 recurrences per person per year
- Increasing evidence that BV should be considered an STI: predominantly occurring in sexually active populations, associated with new/multiple sexual partners, there is microbiological evidence that sexual partners exchange bacteria
- Ideal people to partner treat: monogamous male/female partners (shared decision making for other scenarios)
- Coverage may vary-- CA extended partner therapy applies to STIs (GC/CT), MAY be applied to BV (pharmacy dependent)
- Note clindamycin gel can weaken latex condoms
- Also note, recent evidence based guidelines say it's okay to drink alcohol and take metronidazole!!
Slow Medicine: finding the balance between knowledge, care and humanity (Paul Nguyen, 3/4/26)
A recording of this presentation is available HERE.
Many thanks to Dr. Paul Nguyen, who gave a moving and important Grand Rounds this week, which he entitled "Slow Medicine: Reflections from a 3rd year resident". What was so compelling about his presentation was how he brought us back to the basics of why most of us came to family medicine in the first place and wove in his reflections on where the rub occurs, and how we might approach it to make it better for patients and for us.
I particularly appreciated his inclusion of two Vietnamese proverbs, which I will leave here for your consideration:
Translation: You only know you're hungry after eating.
Meaning: You may only understand the importance of something once you have experienced it yourself.
Translation: Keep grinding the metal, one day it will turn into a needle.
Meaning: If you keep putting in the hard work, you may wind up with something beautiful and useful
In between these two beautiful proverbs, Dr. Nguyen introduced us to Victoria Sweet's book, Slow Medicine (if you haven't read it, both he and I highly recommend it!) and highlighted some of the core tenets she promotes in her book:
1) Gevuld (Dutch for "stuffed"), in the contest of medicine the idea that wounds can literally fill themselves in, that the body knows how to repair itself, that illness is not always an enemy to defeat. In this model, physicians are stewards of processes, not commanders of outcomes.
2) Slow ≠ passive: medicine doesn't always require an intervention, time itself may heal. Sometimes the best intervention isn't doing more-- it's doing less. Not ignoring or neglecting but allowing the body's processes to work.
3) Observation: observation is itself an active clinical skill, paying attention matters, and watching the body heal itself may be our only duty. Tolerating uncertainty is another part of our job.
I particularly appreciated this slide from Dr. Nguyen, summarizing Sweet's argument and contrasting "fast medicine" (how we do things) to slow medicine (how he wants us to consider doing them):
In this section, he talked about the contrast of metrics vs. meaning, of productivity vs. presence and shared some of the data regarding burnout in the primary care workforce as well as patient perceptions of being held/cared for based on time spent with them.
And for those of us who have been through residency and/or are witness to our residents going through residents in this era, we can related to these tensions, the feeling of not having enough time to sit with patients BUT wanting nothing more than to have the time to do so. The feeling of data overwhelm without a true understanding of the patient's lived experience.
Dr. Nguyen shared with us two meaningful patient experiences he has had during his residency training-- one that ended with a peaceful death, the other that left a patient without a diagnosis but getting better (who knows why? perhaps it was the time he spent with her?).
And, finally, some wisdom for his juniors and colleagues:
Metabolic Dysfunction Associated Steatohepatitis (MASLD) (Holt, 2/25/2026)
A recording of this presentation is available HERE.
Deep gratitude to Dr. Will Holt, CPMC Hepatologist, who drove to SSRRH from Piedmont at the literal crack of dawn to teach us about Metabolic Dysfunction Associated Steatohepatitis (MASLD) and Alcohol-Associated Liver Disease (AASLD) and then changed hats to spend the morning with our residency leadership as a faculty leader for graduate medical education within Sutter.
His talk was fantastic! I recommend you watch it.
For those of you who prefer to read, the highlights:
First, MASLD
- We all known that the prevalence of obesity and diabetes have both skyrocketed over the last several decades-- nearing 50% in some regions of our country.
- Along with these metabolic issues, comes MASLD-- world prevalence is estimated to be 29.8% lowest rates for those of African descent (thought to be both genetic and food access/lifestyle related)
- Risk factors for MASLD include age >50, high BMI and DM2
- MASLD is a risk factor for death
- Assume that people are high risk (>50, high elevated BMI, DM2) have MASLD>> screen them for MASH with via fibroscan
- For everyone else with any component of metabolic syndrome (e.g. overweight, a1c>6%, hypertension, HDL<40 (F) and <50 (M), triglycerides>150)>> use FIB-4 to screen first
- if the FIB4>1.3>> Fibroscan,
- unless they are >65yo, then use FIB-4>2.0
- Fibroscan uses a weighted hammer/pulse to measure liver stiffness-- this is available through Sutter Airway)
- Fibroscan <8 is normal (=reassuring, low risk), >14 demonstrates cirrhosis
- for those with a normal fibroscan, focus on lifestyle modification for metabolic disorders
- for those with an abnormal fibroscan, refer to hepatology
- Fibrosis predicts liver-related mortality (see graph below from J. Hepatology 2017)
- stage 0/1 fibrosis: no increased mortality
- stages 2, 3, 4>> increased liver mortality
As per the 2024 AASLD Guidelines for clinical suspicion of steatotic liver disease
- Pharmacologic:
- Vitamin E: 96 week RCT: reduced fibrosis 41% vs. 31% (placebo)
- Pioglitazone: meta-analysis, reduced fibrosis vs. placebo OR 1.77
- There are two FDA approved medications:
- Resmetirom (2024): TRH-beta agonist, 52 week RCT vs. placebo, reduced fibrosis 24% vs. 14%
- Semaglutide (2025): GLP1 agonist, 72 week RCT vs. placebo, reduced fibrosis 37% vs. 22%
- Non-Pharmacologic: diet/exercise/weight loss
- weight loss improves liver histology! Even 5%!!!
Now, a little bit on ALD
- Defining Alcohol use disorder (AUD)
- Biomarkers for ETOH
- Urine tests (EtG, EtS) have a very short detection window (<48 hours)
- PEth is current "truth serum", gives us information about the last 30 days, though there are some false positives in the lower ranges (20-40). Very high results (>400-1000 are very reliable)
- Diagnosing Alcoholic Hepatitis can be tricky!
- elevated MCV (100), elevated WBC, jaundice
- Treatment of alcohol-associated hepatitis with prednisolone (rather than prednisone due to first pass metabolism, when not available, prednisone is acceptable) FOR:
- Patients WITH Maddrey Discriminant Function >32>>
- AND WITHOUT
- evidence of biliary obstruction on ultrasound
- uncontrolled infection (especially bacteremia)
- AKI with SCr>2.5
- UGI bleeding
- Severe shock/hemodynamically unstable
- Expect 3 month recovery (bili will remain high)
- You can wait a couple of days before starting prednisolone (e.g. if any of the above active), pts can still benefit with delayed start
- Use the Lille score to predict (7 days) who will respond
- N-Acetylcysteine= mixed bag, there does appear to be a mortality benefit at 30 days but not at 3 months/6 months (NEJM 2011, see image)
- What about liver transplant (LT) in ALD?
- 2011 RCT from France (NEJM 2011) was practice changing, randomized patients with AH without sobriety and first decompensating event to LT vs. no LT (only <10% deemed candidates)>> found that 1 and 3 year survival was the same for patients with ALD as any other liver disease
- This led to a change in practice in which transplant can/may be considered for alcoholic hepatitis in select patients, not specified as a specific duration of sobriety>> at CPMC, this is called the "limited sobriety pathway to LT"
- Careful patient selection for LT (with ALD) is key.
- Family support
- Absence of untreated psychiatric disorder
- Agreement by patient with support to LIFELONG abstinence (this can be harder to get to that you might imagine)
- This assessment is done by LT SW at CPMC (often via video visit prior to Transfer)
- We know that patients with AUD will relapse
Ethical Deviations and Inequities in the Delivery of Health Care (Matthews, 2/11/26)
A recording of this presentation is available HERE.
***
Special thanks to Dr. Adora Matthews, Sutter's CME of Inclusion and Belonging. She gave an important presentation on Inequity in the Delivery of Health Care-- as a celebration/reminder of Black History Month and a reminder of our commitment to delivering equitable and excellent care to every patient we serve.
Dr. Matthews reminded us of four important historical occurrences that still contribute to fractured trust in the medical system for black Americans:
1) Dr J. Marion Sims, often referred to as "the father of modern gynecology", a white man, who operated on black slaves without anesthesia, perfected his hysterectomies and vesico-vaginal fistula repair on black slaves without consent, and contributed to a long-held notion in medicine that "black people don't feel pain the same as white people". After all surgical assistants resigned due to discomfort with his work, he ultimately forced three black slave women (named Anarcha, Betsy, and Lucy) to assist him in these experimental surgeries.
A statue to honor these three women, the "Mothers of Gynecology" stands today in Montgomery, Alabama.
2) The Tuskegee Syphilis experiment, which took place from 1932-1972, in which 400 black male sharecroppers were knowingly observed to study the natural history of syphilis, even after cure/treatment for syphilis was widely available (in the form of penicillin!). Spouses were infected, babies were born with congenital syphilis, extreme pathology was documented. This is widely considered the greatest failure of medical ethics in our country. This experiment didn't end until it was leaked to the press in 1972. A formal apology rendered by President Bill Clinton in 1997, calling the experiment "shameful and racist".
These historical truths (and many others) contribute now to systemic inequity and mistrust. We must be aware of these histories, warned Dr. Adora Matthews, when we are caring for black American patients. We must be aware of them when we see current inequities. And while being aware isn't enough, it's a start.
Four current inequities for Black patients:
1) Healthcare access: black and brown patients have higher rates of being uninsured, are less likely to have preventive care, and less likely to have a regular PCP.
2) Chronic disease management: black American women have some of the highest rates (40%) of metabolic syndrome, which doubles CV risk, increases all cause mortality, and is associated with DM, CKD and stroke.
3) Maternal and fetal health outcomes: black women have highest rates of maternal mortality and fetal mortality, even when controlling for SES (see graphs below)
4) Pain management: Biased beliefs about black patients and pain tolerance dating back centuries with no evidence-- still exist today. There is literature from emergency rooms, hospitals and clinics that black patients are less likely to receive pain medication for the same painful condition.
Dr. Matthews reminded us that knowing the history (and the current inequities) is where we begin-- from here we begin to look at systems and address systemic racism in the daily work we do. We turn our grief, sadness, anger and despair into hope for our patients. We confront our own biases by attending lectures like these and participating in unconscious/implicit bias assessment ( Harvard's can be found HERE).
"Hotter than Ever" Menopause and Non-Hormonal Therapies (Kareer, 2/4/2026)
A recording of this presentation is available HERE.
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Great thanks to Dr. Jose Maldonado, a Stanford psychiatrist and neuropsychiatrist, who literally wrote the benzodiazepine-sparing alcohol wi... -
A recording of this presentation is available HERE . Many thanks to Dr. Andrew Brown, who gave an excellent Grand Rounds presentation this w...
