Functional Disorders, Somatic Symptoms and Chronic Pain (Jones, 8/5/2026)

 A recording of this presentation is available HERE

Thanks to Dr. Kendall Jones for a fantastic opener for R3/Senior Grand Rounds presentation this week. She borrowed from a lecture she attended last spring at the Family Medicine Colloquium by Kaiser Family Medicine teachers. . .but really brought it home to our patient population. 

If you are a primary care clinician caring for patients with functional disorders (think IBS, migraine, fibromyalgia. . .and all those unn-nameable conditions), you should watch this!

Functional Disorders

Medical school trains us well to investigate mechanical/structural abnormalities (e.g. SBO, carotid stenosis, hip fracture), assess for biochemical abnormalities (e.g. low hb, elevated a1c, hyperthyroidism), but does not prepare us for functional disorders-- which, by definition, have no specific tests. Functional disorders are diagnosed with symptom assessments, validated tools, in combination with negativing imaging/labs or other work-up. 

And yet, in primary care, we see a LARGE number of patients with functional disorders. Here are a few:

These patients are challenging. They bring up a lot in clinicians, and they don't always get the care they need. Sometimes they are left to steer their own ship (which doesn't reliably make them better), they get HUGE work ups (all of which turn out negative or equivocal), and they get labels that do not really apply, labels that are hard to remove. 

Dr. Jones reminded us that we use clinical judgement all the time to make diagnoses-- think a viral URI or a migraine. For these patients, we use illness scripts and confidence in our experience. This same notion applies to patients with functional disorders.

Central Sensitization

Central sensitization is a state of persistent CNS hyper excitability in which the brain and spinal cord amplify incoming signals beyond their objective magnitude. The "volume of the nervous system" is literally turned up. This is not psychological. It is driven by neuroinflammation, HPA axis dysregulation, synaptic plasticity in the dorsal horn, reduced descending inhibition, and more. This phenomenon is propagated via ACEs, chronic stress, trauma, perception, expectation, and neuroplasticity. 

I LOVE this fire alarm analogy!

Reminder: our job is NOT to keep searching for a fire.

We need to be able to recognize patterns of central sensitization:

• multi-system symptoms with no unifying biomedical lesion (though don't forget connective tissue and EDS)
• severity out of proportion to objective findings-- the gap is the signal amplification
• symptoms fluctuate with stress, sleep
• prior extensive negative work up but patient remains symptomatic
• presence of ACEs or chronic stress (which patient may not have insight into)
• hypervigilance: symptom tracking, googling, frequent visits, lots of messages
• sensory hypersensitivity: light, sound, temperature, touch, odors (more than just pain)

Language matters

When tests come back negative, avoid "everything is fine", "your tests are normal", "nothing is wrong", "maybe you're stressed". These statements do not explain what IS happening for the patient and leave them searching for another explanation. 

Communication is key!

Remember patients can have central sensitization AND something else!!!

Validated Tools for assessing for Central Sensitization include:

• Somatic Symptom Scale - 8. Gierk B et al. JAMA Intern Med. 2014.

• Eight items rated 0-4 over the past 7 days (GI, back pain, limb/joint pain, HA, CP/SOB, dizziness, fatigue, sleep)

• 8-11 = medium, 12-15 = high, 16-32 = very high.

• Each category increase is associated with 53% more healthcare visits

• CSI: Central Sensitization Inventory. Mayer TG et al. Pain Pract. 2012; Neblett R et al. J Pain. 2013

• Part A: 25 items, scored 0-100 

• Part B: Prior CSS diagnoses (unscored, clinical context)

• Cutoff ≥ 40: 81% sensitivity, 75% specificity for CS syndromes

• <30 = subclinical, 30-39 = mild, 40-49 = moderate, 50-59 = severe

Treatment of Central sensitization:

Education: normalize, reframe: "Your symptoms make sense to me. Let's try to understand what is going on." Discuss the context/ask the question: "What do you think is making your nervous system so sensitive?" Help change their relationship with their symptoms-- to decrease their fear. Remember, having somatic symptoms is part of living inside a body.

Nervous system retraining: mindfulness based pain reduction, breathing exercises, cold exposure (resets the mamalian dive reflex), singing, humming, yoga, meditation, massage (feet and neck)

Central sensitization and Chronic pain

• nociplastic pain happens over months to year; it can be at least partially reversed with desensitization of the oversensitized alarm
• patients have to be patient (months to years) to notice improvement
• patients and physicians benefit from moving away from "symptoms" into acceptance, understanding an rehabilitation>> goal is improving quality of life and increasing function
• movement is key: motion is lotion

Primary care needs united partnership with specialists.

We don't need to get it all done in one visit, even 2 minutes can help shift mindsets

We are not just asking patients to relax, we are helping them re-calibrate their nervous system.

Central sensitization does not invalidate the patient's experience, it only offers an explanation with evidence-based interventions.

Clinicians must NOT miss red flags

References:

Mohabbat AB & Wilkinson J (2023). Central sensitization: when it is not all in your head. Am Fam Physician. 101 (1):92-96

G. Lorimer Moseley & D Butler (2017). Explain pain supercharged: the clinician’s manual. 

tamethebeast.org (refer patients with chronic pain to this website)

Van Oosterwick J et al. (2013). Pain physiology education improves health status in fibromyalgia. Clin J Pain. 29(10):873-82.

Difficult (aka Dysregulated) Patient Encounters (Pimental, 7/29/26)

 A recording of this presentation is available HERE

***

Thanks to Dr. Britni Pimental, who gave us a fantastic presentation on Difficult Patient Encounters. She started by changing our word choice from "difficult" to "dysregulated".  When we label patients as difficult (angry, demanding, emotionally intense), we should be really calling them dysregulated-- shifting this label can help us shift in how we see patients. 

There were SO many pearls in this presentation, I definitely recommend listening to it yourself. But for the notes version:

It's not surprising that patients being seen in the clinic or hospital are dysregulated-- their nervous system is literally being stressed-- they are scared, in pain, feeling a loss of control, triggering old trauma and sensing systemic pressures.

When people get overwhelmed, their executive function goes down. They cannot listen. They cannot process high level medical information.

Clinician response to dysregulation can lead to to an unfortunate feedback loop:

Trigger>>>> Arousal>>>> Behavior>>>>Clinician Response>>>Trigger 

We are not neutral. We are human beings too.

Countertransference is the phenomenon in which our own emotional reaction to the patient is shaped by our own previous experiences. This can lead to helplessness, frustration, avoidance, over compensation, and assertion of control. 

We must strike a balance between empathy and limits/boundaries. Empathy does not require agreement. Most people do better with limits and effective boundary setting helps people who are dysregulated. Rather than being exclusive, empathy and boundaries are complementary.

3 steps to empathic boundary setting:

1. Validate the emotion
2. Set clear limits (without excessive justification-- see above, people's ability to tolerate info is low)
3. Offer alternatives (a small # of choices) to give control back

Restore regulation

Our tone, posture, body language and pacing will impact our patients' behaviors.  Clinician regulation is the most powerful de-escalation tool. Patients are highly attuned to non-verbal cues from clinicians (pacing, tone, body language)

The goal of de-escalation is NOT to win the argument or to convince the patient of a particular viewpoint. The goal is to maintain a functional relationship, create a safe and collaborative environment. 

Self-regulation for clinicians

-lower tone

-slow speech

-adapt a non-threatening posture

-sit down (if safe)

NURSE

Name

Understand

Respect

Support

Explore (options)

Offer choices as much as possible. Patients want to feel they have some say in their care.

Allow for pauses>> to avoid rushed decision-making. People need wiggle room. 

Ask open ended questions

Practice reflective listening

Avoid escalation

-avoid interrupting

-avoid power struggles

-avoid defensive responses

-avoid arguing the facts

A simple self-check re. countertransference:

What am I feeling right now?

What is this patient activating in me?

How is this helping/hurting their car?

Re-engage with your own executive function

-pause

-slow breathing

-relax your shoulders

-consciously slow your speech

-decrease your own physical arousal

RESPOND INTENTIONALLY RATHER THAN REACTIVELY 

The clinician-patient alliance builds trust, creates psychological safety and decreases emotional arousal. Regulation+ relationship + respect= safer encounter

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!

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:

Non-Beneficial Treatment (Garson Leder 1/7/2026)

 A recording of this presentation can be found HERE (will be added as soon as it is available).

***

Thanks to our Sutter bioethicist, Dr. Garson Leder, for a thoughtful presentation on Non-Beneficial Treatment. This is a heavy (and heady) topic, and I recommend you listen to the presentation if you want to get into the weeds on bioethical conundrums. 

If you just want the brief notes, keep reading!

Any good ethics lecture begins with terms and definitions:

• Medical Futility: a treatment is highly unlikely to benefit a patient or achieve a meaningful goal 
• quantitative futility: the chance of expected benefit is judged to be so low as to not justify treatment (sometimes but not always defined loosely as <1% chance of success, though numbers as high as a surgery that only has 30% chance of success may also fall into this category)
• qualitative futility: the quality of the expected benefit is judged to not justify treatment (quality as defined by who?)
  
• physiological futility: the treatment cannot achieve its intended purpose
• Moral authority: the right to make a decision for another person. 
• What gives physicians the power to be the decision-maker/moral authority?
• medical knowledge and experience (medical professionals are often right about likely outcome/course)
• don't patients still have right to make other/different decisions for themselves (i.e. do we have moral standing to unilaterally refuse treatment?)

(Resource allocation-- the question of should one be using limited resources to accomplish a specific goal-- is a different question)

A few pearls
-Continuing treatment is, no matter what, a decision

-Consider using the term "potentially inappropriate" rather than medically futile or even non-beneficial

-CA law supports the right of physicians to decline to continue care if it is deemed medically ineffective and/or is considered with "standard of care"

-Most conflicts about non-beneficial treatment can be resolved with clear communication AND time. 

Family Communication in Palliative Care (Wagner, 12/3/2025)

 A recording of this presentation is available HERE.

***

Thanks to Dr. Andrew Wagner, who gave a really thoughtful and important Grand Rounds this week entitled, Palliative Care Pearls. He spent the bulk of the time showering us with pearls about how to connect and communicate with patients, particularly at the end of life. He touched on spirituality in medicine and lifted up the notion that good communication is good medicine. The sound quality on the recording isn't excellent, but still is worth watching so that you can experience directly his wisdom and experience.

I highlighted the key pearly questions in bold below. 

He highlighted listening and relationship, generous listening, and presence/compassion/empathy. He talked about how death is a part of the life cycle (not a failure) and that healing is coming to peace with mind, body, and soul relationships with spirits on a higher power. If we reframe death as a life cycle event, we can help patients find peace.

One question: "What needs to happen so you can lay your head on your pillow, and say 'I am good'?"

Dr. Wagner talked extensively about centering the patient's identity, values and meaning, which lends itself toward shared decision making: align decisions with values and what matters most, explore "what are you hoping for and what are you most worried about"?, present options in terms of burdens and benefits, and ensure patient and family understand prognosis realistically.

We have the opportunity to offer "a sense of calm", which can be achieved by making eye contact, touch (if/when appropriate), reading the room, modulating voice, sitting down (and ensuring everyone has a chair), arranging the room. 

Another possible question: "How are you doing? How is this going for you?"

Imagine if we regarded death as a final stage of growth. Could we then turn toward death as a master teacher and ask "How then shall I live?"

A third question: "What do you know about what the doctors have been telling you?"

Normalize things for patients, "most people in your situations are anxious/fearful-- how are you doing?", OR "Many people are afraid of dying, is that you?"

Palliative care is understanding people's values and goals and creating care plans that are consistent with those values and goals. Everyone gets tired and frustrated with serious illness, but if someone is feeling that way consistently, "it's important for you to tell us that because there are care plans for people who are tired of doing those things". 

When dealing with surrogate decision makers, it is extremely important to help the surrogate bring the patient into the room: Tell us about [Joe]. Who was he? What did he love? What made him happy? What was important to him?

A fourth question: "Imagine [Joe] had a crystal ball and could hear all the things we have been talking about; what would [Joe] say?". And then a follow-up once you have elicited Joe's ideals, "I recommend, given what we know about what [Joe] cares about, I recommend . . ." (is this consistent/not consistent with Joe's values.

Dr. Wagner reminded us that physicians can and should be more directive when it comes to Code/CPR decisions.

And when it comes to families that do not want information disclosed to patients, try this fifth question: "I understand you don't want me to tell grandma, but is it okay if I ask grandma if she wants to know more about what is going on?"

Lean into the mystery. Nobody knows.

He also reminded us about self care-- I am enough (see below) and I am not alone (we have teammates, colleagues, chaplains, pastoral consultation), and we should be sharing stories as a means of self-healing.

For those of you interested in the resources he references, here are some:

• Rachel Naomi Remen, MD (Kitchen Table Wisdom and My Grandfather's Blessings) "Healing and the Inner Life: The role of clinician is witnessing>> connection>>healing
• "I am enough" (this he lifted up as important to physicians to remember and recite before stepping into challenging situations. We meet patients AS THEY ARE; our presence is enough"
• "All healing is mutual" (physicians are also healed by the encounter)
• Generous listening-- listening to understanding, NOT fixing, the quality of listening 
• Blessing each other-- seeing wholeness beneath illness
• Ira Byock, MD "The Four Things:
• Please forgive me
• I forgive you
• Thank you
• I love you
• Balfour Mount, MD "Human Question": What would you want me to know that will allow me to give you excellent care?
• Harvey Chochinov, MD, "Dignity Therapy"
• continuity of self: "What do you most want remembered about you?"
• role preservation
• generativity
• hopefulness

Finally, some clinician take-aways: 1) holding safe space 2) healing at the end of life 3) honoring intuation and wisdom ("trust your gut, your intuition, your wisdom"). A final useful statement: "We are helping [Joe] to die".

Trauma Informed Care (Lund, 3/26/2025)

  A recording of this presentation is available HERE. 

Thanks so much to Dr. Erin Lund for a very impactful presentation this week on Trauma Informed Care. I have to confess that I have seen this presentation (or a previous version) before, but I DO need to hear and rehear and rehear this topic. 

If you remember nothing else, take pearl in: In our daily work should use "universal trauma principles" with ALL patients and then add "extra carefuly trauma informed care" with those whom we KNOW have had extra trauma. 

This includes things like asking for consent, empowering patients over their own bodies and histories, and resisting retraumatization.

I love/hate this image she shared, reminding us of the context of trauma that extends far beyond a person's individual experience. The medical trauma many of our patients have experienced primes them to respond in particular ways to our care provision, and we need to be prepared, but the collective and structural trauma is also ever present.

© Lewis-O’Connor, A. 2015 © Rittenberg, E 2015 © Grossman, S. 2015 UPDATED, April 2020, Feb 2022

Trauma abounds. 

Many of us are well-versed in the original Adverse Childhood Events (ACES) study, which found that 61.7% of CA adults had experienced at least one ACE, and 1 in 6 (16%) had experienced 4+ ACES. You can see the most common ACEs in the image below.

But trauma doesn't end in childhood. Adult traumatic experiences are also common; these include: intimate partner violence, gun violence, sexual assault, incarceration, birth trauma, accidents, racism, sudden loss of a loved one, and more. 

The actual "traumatic experience or incident" matters much less than how we respond to the trauma. What are our resources? Do we have resilience? What are our protective patterns? Do we have time to recover?

The image below is a schematic of a stress trigger, the natural response, and then what follows. Note the time of calming down, depletion and recentering. If we have the tools to pass through these stages, we can recover from the trigger. If not, we may not be able to. Traumatic experiences can lead to developing toxic stress physiology. And repeated stress can impact our neurodevelopment, interfering with executive function

www.dovetaillearning.org

Toxic Stress and Caring Adults - KABOOM!

 
A local non-profit does trainings/workshops to promote resilience. In their workshops, they teach us that our protective patterns, which we develop over time, can be helpful and keep us safe. But when overused or used in incorrect situations, they can be harmful, self-destructive, and inhibit connection with others. Those patterns are seen in the slide below:

SAMSHA (2021) says that to be trauma-informed we must 1) Realize the widespread impact of trauma and understand potential for recovery 2) Recognize the signs/symptoms of trauma 3) Respond by integrating this knowledge about trauma into policies and procedures and practices and 4) Seek to active Resist retraumatization. 

We can create a safe context, restore power, value individuals. We can use universal trauma precautions and stay patient-centered. Being trauma-informed in the medical setting involves empowering patients, giving choice when we can, collaborating, offering safety and trustworthiness. In addition, get curious, learn the back story, listen to patients' fears. Ask yourself and the patient, "How can we help you get through this?"

Resilience is protective. I very much recommend you listen to Dr. Lund's presentation, where she goes on to really talk about heartfelt listening, growing empathy to connect, not defining people by their trauma, and making a real difference through trauma-informed care. 

She ended her presentation with a seminal paper on Trauma informed care in the ED from Ashworth et al (2023). A link to that paper and very helpful tables is available HERE. 

The Pelvic Exam through a Trauma Informed Lens (Goldberg-Boltz, 1/22/25)

A recording of the presentation is available HERE. 

Many thanks to Dr. Nicole Boltz for an excellent presentation this week on The Pelvic Exam through a Trauma-Informed Lens. This was both a practical and meaningful presentation -- one which will stick wit you as you move quickly through your clinic day.

Here are my notes:

• If you do intimate/pelvic exams, consider reading this letter: Dear Doctor: A letter from a survivor or sexual trauma to all medical professionals, by Carol Chandler

• We should all be doing universal sexual assault screening for ALL patients (do not leg bias guide you). There are many ways to do this screening that are patient-centered, but there is no one right way. Remember it may take many visits (or many years) for a patient to feel comfortable enough to disclose. Meet the patient where they are.

• The four Rs of a trauma-informed approach (SAMHSA)
• Realize: Understand the impact of trauma on people and communities
• Recognize: Identify the signs and symptoms of trauma
• Respond: Integrate knowledge about trauma into policies, procedures, and practices
• Resist re-traumatization: Take action to prevent re-traumatizing individuals

• Find humor even in the hard things we do: https://www.instagram.com/reel/C7kbKUpsuAD/?igsh=NTc4MTIwNjQ2YQ%3D%3 (this is super funny!!!!!!)

Okay, onto the Pelvic Exam:

• Prepare a safe and non-judgmental space
• ideally meet the patient prior to the exam or procedure (when dressed!)
• set the ground for empowerment: they are in charge, we go at their pace, they can stop whenever
• explain the procedure and purpose
• ask if they want to see/touch/listen to the instruments
• ask of they want a support person in the room
• ask if they want you to know anything before the exam
• ask what can be done to make the exam more comfortable
• ask for any questions
• Language, language, language
• the goal is to use non-triggering language
• empower the patient with your language (they are in charge)
• framing matters: "when/if you are able" and "you MIGHT feel" and "would you like me to proceed or shall I pause?" and "tell me when you're ready"
• consider these substitutions: exam table (instead of bed), drape (rather than sheet), foot rests (rather than stirrups), instruments (rather than device names)
• Body positions matter: for some, certain positions can be triggering. Ask which position is most comfortable for them
• in/out footrests, frog legged, on exam table
• never force legs open
• ask permission to move/touch body, considering tapping knee to get legs to drop
  
  
  
  
• During exam
• Consider distractions: toe wiggling, tapping on knees in a pattern, tapping on chest, deep breathing
• Getting dressed: After the exam, allow patient to get dressed before you discuss findings/assessment/plans. Then explain what you did, what you saw, what are the next steps.

Healing through Strengths, Movement, and Culture (Fleg, 1/10/2024)

 A recording of this presentation is available HERE.

***

Deep gratitude for today's Grand Rounds, an impactful presentation by Dr. Anthony Fleg from  University of New Mexico in Albuquerque, about changing the way we assess and treat patients by assessing for their strengths, rather than their deficits. 

I would say this is a presentation better watched and absorbed than summarized, but here are my notes for those of you who prefer them.

Dr. Fleg encouraged us from the beginning of his presentation to consider how we are trained in medicine to assess and manage patients by understanding their "problems" or "deficits" rather than to understand their strengths. 

To begin, he asked us to consider one of the patients we may have struggled to serve effectively in recent weeks and to list out their problems. After about a minute, he then asked us to list out this same patient's strengths. Once we were done with the exercise, he made us do a self-assessment.

• What was our ratio of problems to strengths for our patient? (on average, he said, physicians are able to list 6 problems to 1 strength)
• Did we have trouble thinking of strengths? It wouldn't be surprising, we aren't trained to look for them.
• How might we care for our patients differently if we ask "what is right with you?" instead of always "what is wrong with you"?          
• How can we possibly ask patients to use those strengths if we do not know what they are? 
• How can we change even very complex medical situations into achievable goals for patients -- particularly for historically marginalized patients, e.g. BIPOC patients, but really for everyone?    

Dr. Fleg spoke about how social workers are trained to do something called "asset mapping" with their clients, which is exactly what it sounds like -- looking for people's strengths, even under challenging conditions. The idea is that, by understanding assets, we  empower people in communities to build on what they do well in order to improve their health. 

Take, for example, Dr. Fleg's wife's 95 year old Navajo grandfather, a traditional medicine man, who died of COVID early in the pandemic. This person, Grandad Bahe Manybeads, looked at from a traditional medical model -- a deficit perspective -- had many things stacked against him: low English proficiency, low educational attainment, minimal eye contact, hard to communicate with, doesn't share, geriatric. But what happens if we flip his deficits into strengths: he is Navajo speaking, culturally competent and highly educated in Navajo culture, a recognized community healer, humble and modest, stoic and strong, wise elder, a physical strong healer who still performs all night healing ceremonies well-into his nineties. How does that lens change how we treat his medical illness?

By not focusing on strengths, Dr. Fleg argues, we perpetuate racism, lose key chances to empower patients to heal from within, dehumanize patients and ourselves, and feed into our own burnout. Deep breath. Take that for consideration. Consider how focusing on patient strengths may actually feed you and sustain your practice.

***

Dr. Fleg ended his thought-provoking presentation on leading with strength on a reminder of  the decimation of the Indigenous people in California (from the state of CA court's website):

• From 1840-1870, the California indigenous population decreased from 200,000 people>> 12,000 due to disease, removal and death. This was not accidental.
• Even still, CA has the largest Native American population in the country (12% of all Native Americans in the US live in California)
• Over 1/2 of California's indigenous people are descendants of those displaced due to mass relocation to urban centers (SF and LA)
• Systematic oppression, codified by law:
• Any Indian declared vagrant could be thrown in jail 
• Indian children were allowed to be sold as slaves
• Laws explicitly prohibited Indians from testifying in court against a white person
• While there are currently >100 tribes recognized in CA, there are also tribes that were erased by federal policy. Be careful with each individual's identity and passing value judgements without understanding

In summary, while we may be medically proficient, we may also be culturally and historically deficient in understanding people's contexts. Be sure to consider be peoples contexts and make an effort each day to care for people, rather than treat patients.

I'll end on a state from Dr. Fleg that was particularly poignant for me: "We decolonize ourselves when we are strength-based and that is good for ourselves and for every single person we care for."

Serious Illness Communication (Sanders, 6/2/2021)

Many thanks to Dr. Justin Sanders for a really important Grand Rounds presentation this week on Serious Illness Communication. Dr. Sanders is a family physician, a palliative care specialist and a researcher in Dr. Atul Gawande's think tank, Ariadne Labs. He has a particular interest in disparities and inequities in end of life care.

A recording of his Grand Rounds can be found HERE.

What is serious illness communication, you ask? 

Serious Illness Communication is a framework for how health care providers can engage with patients with advanced illness to elicit their goals and values, share their prognosis, and explore key topics for their end of life care-- all essential components of advanced care planning as well as the physician-patient relationship. 

Dr. Sanders (and the serious illness care model) ask us to proactively identify patients with severe illness so that we can prioritize and systematize important conversations. The goal?  Improved communication with our patients and "goal-concordant care"-- that is, to be sure that the care a patient receives at the end of their life is concordant with the life they want to live.

Take a moment to consider your patient panel, or if that feels overwhelming, take a look at your patient schedule for today and ask yourself this question: which of my patients would I not be surprised if they died in the next year? 

This is called "the surprise question" and has been validated in palliative care studies. Maybe you are thinking about a patient with chronic heart disease, lung disease, cancer, or  maybe one who has been hospitalized several times in the last year; perhaps it's someone with decreasing mobility, or even one that you hear a lot from their caretaker. It may be helpful to extend that time to 1-2 years so you capture as many patients is possible.

Now, the next question: is there a way your system can help plan the time, space, and opportunity to have these important conversations? Maybe an EHR prompt? An extended visit? A dedicated visit?

Once the space is set, the serious illness communication can begin-- guided by the serious illness communication guide (SICG) cut and paste below. 

The work is big: Have you asked them who their surrogate decision-maker should be in their stead? Do they have an Advanced Care Plan? Do they have a POLST? But perhaps more importantly:

 Here are the key SICG questions:

• What are YOUR goals?
• What are YOUR fears and worries if your health deteriorates or your illness progresses?
• What are your strengths?
• What abilities are important for you in your life?
• What might you be willing to go through for the sake of more time?

These are such a powerful set of questions-- of course, the very questions I would want someone to ask me if my time was short-- and turns out the very questions patients want to be asked. 

He also spent some time talking about framing prognosis and encouraged us to use a framework for how we present this information. An original viewpoint co-authored in JAMA by Dr. Sanders and colleagues is linked here for your own reading.

The short take is this: prognosis communication is super challenging, many of us struggle with how to provide this type of information in a useful way that doesn't allow for hope. The article argues that prognosis may be communicated in three different approaches: time-based, function-based, and reasonable-uncertainty based. Exploring with a patient for his/her preferences to guide the discussion will help providers give the patient the most useful information.

Time: how much time do you think I Have

Function: what will my function look like

Reasonable uncertainty: remember our goal is not to be right; it's to help patients have the information they need to reach their goals.

And then, finally Dr. Sanders said, you (the provider) should take the information gleaned from this rich conversation with your patient, apply the prognosis information you have, and make a recommendation (patients want a recommendation from you!), using language like this: "I have heard you say_________________and based on what you said, I am going to recommend ________________________."

Voila. Hard stuff. Thanks for the work you do.

Augmented Intelligence in Primary Care (Mendoza 1/6/2021)

Many thanks to Dr. Emmanuel Mendoza for his Grand Rounds tour of the current state of technology in primary care and the emerging role of artificial intelligence (or as he reframed as "augmented intelligence") in primary care.

Dr. Mendoza reminded us that the transition in medicine to electronic medical records (EMR) has happened intensively and quickly over the last decade, leading to a great change in how we deliver healthcare and affecting our experience as clinicians caring for patients. Dr. Mendoza recommends three books on this transition for your pleasure reading: Deep Medicine, The Patient Will See You Now, and The Digital Doctor (see image below).

While the transition to the  EMR was touted as something that would be helpful and advantageous to physicians and healthcare delivery, many providers have felt professionally burdened and by the EMR. 

• 70% of clinicians report that the EMR increases their work hours
• 70% of clinicians believe that the EMR is contributing to burn out
• 70% of clinicians say that the EMR takes time away from patients

Are machines going to replace doctors?

Dr. Mendoza thinks not. He thinks, in fact, that computers and AI and machines should be thought of as tools that are designed to enable us to practice better medicine. Physicians are still needed because medicine is not just a set of algorithms. This includes a wide range of evolving AI technologies:

• Image processing

e.g. benign vs. malignant lesions

e.g. radiology (cxr reading)

e.g. diabetic retinopathy

• Patient engagement

via APPS

via Health trackers

via E-health programs

Dr. Mendoza covered a long list of different technologies and AI programs, and he reminded us that many of these technologies are works in progress; some will be raging successes and are more effective and more applicable than others. In fact, many will ultimately fail. Be aware of where the product is in its natural evolution (see image below).

Dr. Mendoza encouraged us to engage with the technology and explore them as they are being developed. Here are a few programs/apps/ideas for you to try in your spare time:

Technology you should play round with!

1. Patient symptom checker:  Symptomate: https://symptomate.com/

2. Preventive health via Facebook Preventive health: https://preventivehealth.facebook.com/

3. Chronic disease management via Omada: https://www.omadahealth.com/

4. Clinical Decision support: https://www.ibm.com/products/micromedex-with-watson

5. Medical education: FOAM: https://litfl.com/foam-free-open-access-medical-education/

6. Diagnosis: Human Diagnosis project: https://www.humandx.org/

7. EMR Voice Assistant: https://www.epic.com/epic/post/hey-epic-tell-voice-assistant-clinicians

8. Digital assistant for physicians: https://www.suki.ai/

Finally, Dr. Mendoza encouraged us to check out the AAFP innovation lab, where you can sign up to trial many of these technologies and give direct feedback.

https://www.aafp.org/family-physician/practice-and-career/managing-your-practice/health-it/innovation-lab.html

What Language do you Prefer: Care of Patients with Limited English Proficiency (Jordan, 11/2020)

Limited English Proficiency (LEP) refers to anyone above the age of 5 who reported speaking English less than “very well,” as classified by the U.S. Census Bureau. Though most LEP individuals are immigrants, nearly 19 percent (4.7 million) were born in the United States, most to immigrant parents

            The US Department of HHS  defines LEP as “individuals who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English.”

• Overall, the LEP population represents about 8% of the total US population ages 5 and older.

• Between 1990 and 2013, the LEP population grew 80% from 14 million to 25.1 million.

• California has a high proportion of people with LEP, almost 20%

• Sonoma County is higher than the national average, at 10.5-11.5%. The overwhelming majority of people with LEP in SoCo speak Spanish.

Medical interpreters are trained to interpret the spoken word, whereas translators work with written words. Although the two professions are often confused, they require different skill sets, with interpreters working in live situations.

Professional Medical Interpreter: An individual who has been assessed for professional skills, demonstrates a high level of proficiency in at least two languages and has the appropriate training and experience to interpret with skill and accuracy (certification varies).

A bilingual individual is a person who has some degree of proficiency in two languages. A high level of bilingualism is the most basic of the qualifications of a competent interpreter, but by itself does not ensure the ability to interpret. A bilingual employee may provide direct services in both languages but, without additional training, is not qualified to serve as an interpreter.

LEP impacts health.

• Lower likelihood of having a regular source of care
• Lower rates of preventive services (mammogram, colonoscopy, paps)
• Less likely to receive standard care for chronic medical illnesses
• Increased rates of medication complications
• Higher acuity of illness at presentation to the hospital
• Longer length of hospital stay

Medical Interpretation impacts health. 

• Access to medical interpretation improves patient experience
• Patients who need but do not get interpreters have a poor self-reported understanding of their diagnosis and treatment plan and frequently wish their provider had explained things better
• Ad hoc interpreters
•     misinterpret or omit up to half of all physicians’ questions
•     are more likely to commit errors with potential clinical consequences
•     have a higher risk of not mentioning medication side effects
•     ignore embarrassing issues (esp when children are interpreting)

Who are our patients at SSRRH?

• 13.8% of ALL patients prefer a language other than English
• 12.6% of ALL patients prefer Spanish
• In addition to Spanish, languages include Vietnamese, Khmer (Cambodian), Tigrinya, Laotian and Mandarin

How are we doing on interpreter use?

• In 2020, 88% of minutes used were Spanish
• 5.7% American Sign Language (ASL), 2% Cambodian, 2% Lao
• Some departments in the hospital use interpreters more than others. Specifically L&D has increased their use of interpreters over the last year due to intensive interdepartmental work and the placement of an interpreter device in every room.
• ED and Women's Services also have high number of minutes
• 

That being said, our documented of use of interpreters is pretty depressing.

See graphic below which shows which percentage of patients with LEP have documented use of interpreter at least ONE time on their chart.

Some questions to ponder with regards to interpreters:

• Identification of language preference: How should we ask? How do we document that we asked? How do we not miss this? 

• Ad hoc Interpreter: When is it appropriate to use a family member as interpreter? Who decides? How can we best use family?

• Medical error and/or adverse outcome: Who is responsible for communicating medical error or bad outcomes? How should that be done for LEP patients?

• Family Meetings, Family with mixed language status: How should complex conversations with interdisciplinary teams  and multiple family members be conducted? When should bilingual staff be used vs. VRI vs. both?

We need to cultivate the expectation that we use the interpreter just like we use hand sanitizer. Every. Single. Time.

An Epidemic of Loneliness (Naderi, 4/29/2020)

Such an important topic this week from Dr. Tahereh Naderi: An Epidemic of Loneliness. While she focused her talk on loneliness in elders, her presentation certainly has me pondering a loneliness in my own life-- especially in pandemic times.

What is loneliness? It's subjective: it's your own perception of the lack of interaction
What is social isolation? An objective lack of meaningful and sustaining communication and/or interaction.

Risk factors for loneliness include: older age (esp >80), poor subjective health and self-reported functioning, large number of chronic illnesses, impaired hearing, functional disability, lack of mobility or motor decline, hopelessness, depressed mood, psychiatric morbidity (e.g. depression), quality and quantity of social interactions, living arrangements, low SES, and race.

2 in 5 Americans report they sometimes or always feel their social relationships are not meaningful.
1 in 5 Americans feel lonely or socially isolated
In the past decade, average household size has decreased leading to 10% increase in people living alone, 28% of older adults live alone
Over the past 2-3 decades, the average size of our social networks has declined

The impact of loneliness is real:

• greater risk of cognitive decline and dementia
• lower self esteem and limited use of coping mechanisms
• increase in personality disorders, schizophrenia
• increase in risk for depression
• predictive of suicidal ideation and behavior
• increased substance use (especially alcoholism)

And what about quarantining?

Data following the SARS health crisis in China in 2003, found that quarantining had particular impact on healthcare workers even after restrictions were lifting including:

• low social contact
• avoiding enclosed public spaces
• not returning to work
• long term behavioral changes such as excessive hand washing

Isolation can exacerbate feelings of anxiety, anger, and pre-existing symptoms, can increase one's risk of developing PTSD, and interrupt treatment for substance use disorders. 

Dr. Naderi reminded us (we need to keep hearing this) that social distancing DOES NOT equal social isolation.

Also, guess what? There is an antidote to loneliness: social connection. Social connection actually makes people healthier!

• A meta-analysis including >300K people concluded that greater social connection is associated with a 50% reduced risk of early death
• In studies of the "blue zones" (regions in the world with the greatest concentration of centenarians), social connection is a component of 4 of the 9 of the power principles. The power principles are the 9 lifestyle habits that seem to be associated with longer, healthier, happier lives. 

Believe it our note, we can work on increasing or firming up our social connections in several different ways-- through mindfulness and acceptance, increased use of technology (yep, it's true, even for seniors) and intentionally reaching out to others to form community.

• A randomized controlled trial using mindfulness-based techniques was able to reduce loneliness by 22% and increased social interactions in daily life by 2 more interactions per day and one additional person per day!
• The use of technology-- even in seniors-- can effectively decrease loneliness (multiple modalities including email, video conferencing and computer training). 
• Shared activities were effective: gardening, physical activity, visual arts discssion, even animal therapy!!

Dr. Naderi introduced us to the concept of  Moais (模合, Mo-ai):social support groups that form in order to provide varying support from social, financial, health, or spiritual interests. Moai means "meeting for a common purpose" in Japanese and originated from the social support groups in Okinawa, Japan. These have been studies as part of the blue zone studies.

While Okinawan Moais are inherently built in to society, we may have to be more proactive about reaching out and creating ours. If you don't have one, consider taking steps toward forming a Moias. Or identify and strengthen the one you have. 

Dr. Naderi concluded with an quote by Vivek Murthy, internal medicine physician, 19th Surgeon General of the US, who took a particular interest in loneliness as surgeon general:

"The irony is that the antidote to loneliness, human connection, is also a universal condition. In fact, we are hardwired for connection-- as we demonstrate every time we come together around a common purpose or crisis- and even now as we face the global COVID-19 pandemic and resort to physical distancing to reduce the spread of the virus, we are recognizing that we cannot make it through fear, dager, and uncertainty of the current moment without supporting one another. "

Go ahead, close this browser, call that person you've been meaning to call. You won't regret it.