Pandemic Pearls and Pivots: A Public Health Perspective (Drs. Mase & Shende, 5/25/2022)

Many thanks to our SoCo Public Health Officer, Dr. Sundari Mase and our SoCo Vaccine Chief, Dr. Urmila Shende for an excellent Grand Rounds this week on Pandemic Pearls and Pivots: A Public Health Perspective.

A recording of their presentation is available HERE. 

As we all know, COVID-19 has taken a great toll on our world, our nation, and our county. As of this week,  there have been 6.28 million deaths worldwide (probably an underestimate), >1 million US deaths (more have died from COVID-19 than HIV/AIDS, the 1918 influenza pandemic), 90,000 deaths in California, and 491 deaths in Sonoma County. This has led to the largest drop in life expectancy since WWII. And we know that there have been disproportionate numbers of cases, hospitalizations, and death among people of color.

Key SoCo public health interventions during the COVID-19 Pandemic

• Building Public Health testing capacity
• SoCo regional lab has done 206,000 (of 1.6 million PCRs total) to date in SoCo
• State of California and FQHC partnerships
• Focus on equity
• bilingual messaging
• pop up testing sites (using local data to determine neighborhoods for sites)
• bilingual/bicultural testing/contact tracing
• With increase in Ag testing (no longer have a denominator), we are beginning to pivot toward wastewater surveillance

Public Health Mitigation Measures

• Communication campaigns, outreach, press conferences
• re. masking, hygiene, social distancing, gathering size limitations
• reaching so many different sectors, subgroups was VERY challenging (e.g. reaching the elderly: age, transportation, low tech)
• local radio, social media: FB, instagram, etc, flyers
• work with community based organizations, promotoras essential
• Shelter in place (averted huge surge/disaster early on)
• Alternate care site/non-congregate site (for people with unstable housing, served thousands of people, SSU>>hotels)
• State, local and Bay Area health orders to protect vulnerable populations 
• Vaccines

Disproportionate impacts of COVID

• Magnification of underlying/pre-existing disparities
• Latinx  residents: largely essential workers, hardest hit
• 27% of our population is Latinx, accounted 45% of all cases
• at one point, case rate was 9X higher for Latinx
• In 2020, life expectancy decreased by 2.1 years in Latinx population (compared to 0.7 years in White SoCo population)
• Addressing these inequities, THE PUBLIC HEALTH CHALLENGE of this pandemic
• Health Equity Working Group helped get services to vulnerable population
• trusted messengers (community health workers, promotoras)
• vaccines, masks/PPE, rental assistance
• CURA: important partner to reach community, ensuring financial assistance provided to people who needed it ($8 million)
• FQHC network for collaboration--> 13 different vaccine sites to prioritized populations
• Special shoutout to Dr. Jenny Fish and Dr. Panna Lossy for uplifting the voices of vulnerable communities

COVID-19 Deaths

• 75% of SoCo deaths were in people >65
• residents of skilled nursing facilities were particularly vulnerable prior to the introduction of vaccines

Vaccine Rollout

• SoCo PH chose to prioritize the most vulnerable residents for vaccine roll out
• older adults (65+, 75+)
• SNF and residential care facility patients (RCF)
• Essential workers and marginalized communities (health workers, farm workers, food service workers, homeless)
• We have very high degree of vaccination in our elders: 93% of those >65 are fully vaccinated
• Vaccination of vulnerable elders reduced deaths at SNFs and RCFsVaccines work!  The reduce infection, hospitalization, and deaths.



from https://socoemergency.org/

SoCo has the 9th highest vaccination rate (of 58 counties in CA), which is amazing! 78.7% of the total population fully vaccinated (this includes under 5 year olds); 82% of eligible population are fully vaccinated. We have a lower than expected unvaccinated rate (11% compared to 15% in all of CA). Boosters are catching up (66% of those eligible). Vaccination rates for our BIPOC population are high, particularly for our Black population (lots of education, outreach, webinars, presentations, etc). Latinx population while lagging is close. BUT, disparities still exist (see image below) and SoCo Public Health continues to work on this to encourage everyone to get boosted

  

In summary, Drs. Mase and Shende highlighted this list of pearls in public health management of this pandemic: data-driven decision making, constant pivoting, expanded communication, collaboration with all the health care entities in SoCo, importance of community outreach and trusted messengers, and ultimately active listening.

Be Curious (Jordan, 5/18/2022)

If you are interested in this week's Grand Presentations Be Curious: Cultivating Curiosity in Learners, Teachers, and Practitioners of Family Medicine, a recording is available HERE.

I will be brief with my notes:

I presented Dr. Todd Kashdan's model for the 5 Dimensions of Curiosity:

• Joyful exploration: pleasurable, knowing for the simple sake of knowing
• Deprivation sensitivity: the itch you must scratch, can be uncomfortable, even painful
• Social curiosity: interest in knowing what makes people tick
• Stress tolerance: discomfort with novelty, mystery, unknown
• Risk tolerance/thrill seeking: desire for thrill, adventure

We discussed how these different dimensions come into play in different people at different times. How curiosity is dynamic, often pleasurable (but definitely not always); how our tolerance for novel, mysterious and uncertainty play a role.

What does this have to do with Medicine?

I introduce you to the work by Dr. Faith Fitzgerald, a long time teacher and internist at UC Davis, who wrote extensively about curiosity. My favorite of her writings is a 1999 reflection from the Annals of Internal Medicine on curiosity in medical education. If you haven't read it, please do. Just click on the caption to the image below, and you will be taken straight to it. It's a beautiful piece, definitely worth your time!

Dr. Fitzgerald writes that in order to be curious, you must have 1) competence (otherwise answers fill up the space instead of questions) and 2) time. She also writes that medical education and medical practice suppress curiosity. 

To quote her further:

“Curiosity is fundamental to our physicianship, and serves both the art and the science of medicine. (How do you do? What’s your name? Where do you come from? How do you feel? Tell me more about this pain you’re having…). Curiosity is how we explore the world, this primal “wonderment” that stimulates exploration, engages both the human imagination and human intelligence. Both are integral to the humanities and science, as well as the synthesis of the two, which is clinical medicine.”

https://www.bumc.bu.edu/facdev-medicine/files/2010/09/Fitzgerald_AnnInternMed_1999_130_70_Curiosity.pdf

I also shared with you a model created by an Israeli hematologist, Dr. Shattner, in his essay from 2015 on Curiosity in medicine. His model (which I don't love aesthetically but adore in its core tenets) espouses that curiosity is good cognitively and emotionally, and it's good for patients and physicians.

You can see his model below and an updated rendition below (by yours truly)

Shattner, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4484215/

And below my own rendition of his work:

As a medical educator, I am also interested in the way that -- as Faith Fitzgerald writes-- medical training can negatively impact one's curiosity. This can happen in countless ways.

Things we know suppress curiosity: haste, efficiency, fatigue, ignoring/suppressing feelings, overconfidence, rigid structures, depression/anxiety.

Ways in which teachers could enhance curiosity in the learning environment: promoting responsibility for one's own learning, welcoming diverse opinions, offering space for reflection, modelling effective management of emotions, confronting both uncertainty and overconfidence, using inquiry based learning, helping students see familiar situations as novel, maximizing small group discussions.

Are you, medical educators, using these techniques? How could you infuse the work you do with curiosity?

A final word on burnout, defined as a condition of physical and mental exhaustion pertaining to caregiving activities and arises from chronic exposure to interpersonal stressors at work. Very common in residency training, very common in primary care practice. Characterized by 3 traits: emotional exhaustion, depersonalization, and lack of personal accomplishment.

I pose this final question to you: How might we use curiosity as a mindfulness exercise to prophylax against burnout AND an advocacy tool to work toward systems changes?

Some examples:

• What happens if you are truly curious about a patient’s chronic pain?
• Or their itchy scalp?
• Or their dietary habits?
• What happens if you are curious about a surgeon’s outburst?
• Or an administrator’s edict?
• What happens if you are curious about your own wrist pain?
• Or why it is that physicians don’t take lunches?

More to come on curiosity and a proposal I have for Curiosity Rounds.

In the meantime, I encourage you all to tend to your curiosity-- it's good for patients, learners, AND for you.

Cardiology Potpourri (Tsai, 5/11/2022)

Thanks to our speaker this week, cardiologist Dr. Joanne Tsai, for an excellent review of cardiology topics for outpatient care of cardiology patients, particularly regarding Atrial Fibrillation and Atrial Flutter.  

A recording of her presentation is available HERE. 

My notes:

• When in doubt, get a 12 lead EKG
• That being said, accuracy of EKG interpretation is shockingly poor:
• 42% for med students, 55% residents, 69% primary care, 75% cardiologists
• It is super important to provide clinical framework for the EKG reader; clinical information definitely increases accuracy
• The most common errors with computerized EKG interpretation occur with sinus arrhythmia (computer only accurate 55% of the time) and AV nodal conduction disturbances (2nd, 3rd degree AV block)

pseudo atrial flutter

CHA2DS2-VASc scores

CHA2DS2 stands for (Congestive heart failure, Hypertension, Age ( > 65 = 1 point, > 75 = 2 points), Diabetes, previous Stroke/transient ischemic attack (2 points). VASc stands for vascular disease (peripheral arterial disease, previous myocardial infarction, aortic atheroma), and sex category (female gender) is also included in this scoring system.

Reliability of CHA2DS2-VASc scores

• "C"=in the CHA2DS2 stands for CHF; however, guidelines are quite vague in the case of  HFpEF and whether CHF should be considered if pt history vs. symptomatic
• Of note, people with OSA have higher risk of stroke (compared to people without OSA), so assessment for OSA is of utmost importance

CHA2DS2-VASc scores predict MACE=Major Adverse Cardiac Events (whether or not you have Atrial fibrillation). In fact, CHA2DS2-VASc score >4 puts you at particularly high risk for cardioembolic stroke, even in the absence of AFib.

Atrial Fibrillation 

• Lifetime prevalence of developing AFib for a 40 year old in the US is 1 in 4 (compared to breast cancer 1 in 8)
• overlap between Afib and OSA is 80-90%
• it's really important to get patients with HFpEF into sinus rhythm (and out of AFib)
• even though the AFFIRM trial found that rate control> rhythm control, Dr. Tsai argued that most of these trials excluded people with HFpEF
• that for patients with AF and  HFpEF, we really need to put them into sinus rhythm, including anti-arrhythmics
• weight loss is associated with decreased CV mortality in A Fib

Evaluation for AFib/AFlutter

• TTE (looking for ejection fraction, evidence of genetic disorder e.g. hypertrophic cardiomyopathy), EKG (looking for prior infarct, LVH, evidence of genetic disorder), sleep study (looking for OSA), ischemia evaluation 
• Don't forget exogenous toxins (e.g. alcohol-- direct cardiogenic effect at the level of the atria)

Who should get oral anticoagulation regardless of their CHA2DS2-VASc score?

• hypertrophic cardiomyopathy
• hyperthyroid (especially when actively thyrotoxic; once no longer some will stop anti-coagulation; others continue because still hypercoagulable)
• moderate-severe mitral stenosis
• mechanical heart valves

Syncope: history building (vs. history taking) 

• getting a good history regarding the loss of consciousness can determine cause 90% of the time without any testing
• face to face conversation, ask open ended questions
• "How many times have you passed out/lost consciousness?"
• Calculators for syncope evaluation:
• San Francisco Syncope Rule
• Dr. Tsai prefers the  EGSYS (Evaluation of Guidelines for Syncope Study)

Let's Talk about Sex (MacArthur 5/4/2022)

 Big thanks to Dr. Sophie MacArthur for her excellent presentation on a topic that we could  ALL use a little education on-- Sex. And specifically how we talk about it with patients.

The recorded presentation is available HERE. 

Link to her slides is HERE. 

My notes:

• The Sex Ed most of us had in school wasn't any good 
• a meta-analysis of 48 different studies in 10 countries (including US) in BMJ found high school students believed their sex ed to be impractical, out of touch, sexist, heteronormative, and embarrassing
• And. .. let's face it. Physicians aren't very good at talking about sex with patients. 
• While 88% of primary care physicians say they take a sexual history, only 25% of charts have said history recorded
• A study from the 1990s-- height of the AIDS epidemic-- found providers didn't take sexual history because they didn't feel it was relevant, didn't feel well-trained, and felt embarassed
• We are inadequately trained
• We tend to discuss sex only when patients ask
• But. . .patients want to talk about sex! 
• In one large study from Europe, 91% of patients want their physicians to ask about their sexual history and sexual health
• Even of the 15% who would feel embarrassed talking about sex, 75% still wanted their doctor to ask

As part of sexual history and STI screening, many of us were trained to ask the following question: "Do you have sex with me, women or both?"

Dr. MacArthur asked us to consider a better question: "When you have sex, what parts of your body come in contact with what parts of someone else? And how?"

Two reasons this question is a better question than the men, women or both question:

• it is not heteronormative
• it allows us to screen people for STIs at appropriate sites (e.g. for rectal,  oral GC/CT)

There are several different ways we can approach the topic of discussing sex with our patients. All of them promote using open ended questions. 

3 options:

1) CDC "6Ps"

• Permission ("May ask you a few questions about your sexual health and sexual practices?")
• Partners ("Do you have any new partners in the last 12 months? How many? Do your partners have any risk factors?"
• Practices ("When you have sex, what parts of your body come in contact with what parts of someone else? And how?")
• Protection from STIs ("Do you and your partners discuss protection from STIs? "What methods do you use? How often do you use them?")
• Past history STIs ("Have you ever been tested for STIs? Have you ever had an STI?")
• Pregnancy intention ("Do you think you would like to have (more) children some day?")

2) AAFP "Proactive Sexual Health History" (2020)

3) Fenway Institute/Harvard: 6Ps + Guidance: Taking an Affirming Sexual History

• Ask routinely, confidentially and free of assumptions
• Do it often (you will get better at it)
• Explain why it's important to know what you are asking
• Ask about function and satisfaction (not just about STI risk)
• Use open ended questions (e.g. "what types of sex do you have?"), at least initially
• Normalize less desired responses (e.g. many people don't consistently use condoms; how often do you find yourself not using a condom?")
• Mirror patient's language if possible 
• Make the interaction as natural as possible (not robotic) 
• Give patients the option to answer questions indirectly (e.g. I recommend screening for GC/CT in all the sites that may have been exposed; for example, the throat, the anus, the penis, the vagina. Which of these sites should you have tested today?)
• Tone and rapport matter, at least as much as the questions 

Risk reduction is an important part of sexual history, but risk extends beyond our traditional view of STIs and unwanted pregnancy. 

Risk=anything that is not sexual health and/or sexual well-being

This can include non-consensual sex, painful sex, bad sex, legal repercussions of sexual behavior (e.g. consent is not sufficient to protect someone), nerve damage (S&M practices)

Risk reduction Resources

STIs: Not just condoms - frequent testing, PrEP or PEP, etc.

Contraceptives: RHAP Birth Control Options Fact Sheet; bedsider.org

Consent: Yes, No, Maybe Inventories

Painful sex: Mayo Clinic resources

BDSM/Kink safety: San Francisco Aids Foundation S&M and Kinky Sex Resources; NCSF Kink Aware Professionals Directory

Legal: National Coalition for Sexual Freedom Incident Report; safewordtax.com

Strategies to Build Resilience and Happiness: The Art and Science of Gratitude (Lo, 4/27/2022)

I am personally feeling very grateful to Dr. Onna Lo for a really lovely presentation this week on Gratitude, Happiness and Resilience. I have already integrated some of her techniques. . .priming my day and granting myself a "celebration" list (what I have accomplished in the last 24 hours) rather than a "todo list" (all the things I feel bad about not accomplishing).

If you are interested in watching her presentation-- and you should be --  it is available HERE .

Here are my notes. sorry they are brief:

Dr. Lo encouraged us to start every day and  every encounter with the ABCs:

A: Awareness (ground yourself)

B: Body/breath (be in your body, find your breath)

C: Connection (with your surroundings, yourself, your patients)

People are struggling

• 36% of Americans are cognitively tired
• 44% of Americans are physically tired
• Depression rates have increased over the last decade from 8% to 22% to 32% in 2022

Something to strive for -- Dr. Lo recommends in our own lives and for patients. To be: Empowered, Engaged, Excited, and Embodied

Some definitions:

• Reactive gratitude: appreciation for a gift received
• Active gratitude: seeking out gifts occurring in life that are appreciated
• Happiness: enjoyment of the present good
• Hope: desire for valued future
• Resilience: the ability to prepare for, recover from, adapt in the face of adversity, stress or challenge

Lesson #1: A positive mindset sets you up for better learning

A positive mindset leads to better learning, improved performance, better problem solving

In  The Happiness Advantage, author and researcher Shawn Achor, proposes that personal happiness leads to professional success (not vice versa). Happiness is a choice. Happiness spreads. Happiness is an advantage. Read more about his work here. 

The happier you are, the more successful you will be (Horn & Arbuckle). 

Gratitude predicts hope and happiness more than forgiveness and patience.

How can YOU build happiness? 21 days in a row x 2 minutes >> 3 gratitudes, positive journaling

Lesson #2: Our brains tend to get stuck in negativity

Half glass full or half empty?

Dr. Lo showed us a series of sociological experiment in which people consistently chose the negative response consistently after being primed with a negative response, even when the outcome was quite positive. If primed with the positive response, people were more likely to choose positive. 

We can unstick ourselves by "priming"-- that is, retraining the mind first thing in the morning with gratitude. That is, starting the day positive allows for the day to be more positive.

Exercise: Draw a triangle, write down 3 gratitudes (these must be heartfelt!)

1) what I am grateful for in myself

2) what I am grateful for in others

3) what I am grateful for in my current situation

Exercise: Draw a triangle, write down 3 wonderful things that you accomplished in the last 24 hours (this is your celebration list)

Exercise: Draw a triangle: write down 3 things that will make today great

Lesson #3: There is science supporting positivity and gratitude

Coherence=optimal coordination between the heart and the mind ==> heartrate variability is a really beautiful sinus curve in someone who is completely in a coherent state. Being in this mindset is better for your whole body.

Much more information about coherence and Heart Math at the Heart Math Institute Website found here. 

Exercise:

1) Heart focused breathing: 5 breaths in/5 breaths out (requires nothing more than the breath)

2) Inner coherence: use positive emotions or feelings of gratitude to establish a coherent beat (using heart math monitor)

And finally, keep a gratitude journal. Even in these hard times, there are big and small things to be grateful for.