Confronting Complacency in the Face of Calamity: Mobilizing for the Home Front War Against Diabetes

by Dean Schillinger, MD


Please see the recent thoughtpiece in the Journal of Endocrinology and Diabetes.

Their Values and Ours

By Alicia Fernandez, MD

A really important Perspective piece was published recently in the NEJM, and I am proud to say that one of our colleagues, Margot Kushel, was senior author. 

Cautionary tale of health disparities in the age of precision medicine

by Kirsten Bibbins-Domingo, PhD, MD, MAS

 

Many of us do not routinely read the genetic literature, but for those of us interested in health disparities, a study in this week’s NEJM and its implications are critically important. 

Science and Public Health on Trial

by Dean Schillinger, MD

Our purpose in writing this piece was to alert the scientific, clinical, and public health communities about the outcome of the landmark decision regarding warning notices on advertisements for sugar sweetened beverages (SSBs) and explain its legal underpinnings. We also wanted to show this as an exemplar of how industry-misappropriated scientific language and scientific methods to hijack science and public health and obfuscate scientific truth and introduce controversy regarding associations between their products (in this case SSBs) and health harms (in this case obesity, diabetes, and tooth decay). Finally, we wanted to highlight the importance of such policy efforts for improving the health of at-risk populations, including children, ethnic minorities, and individuals with limited health literacy.

Click below to read the full JAMA viewpoint:

http://jama.jamanetwork.com/article.aspx?articleID=2542158

Citizen Engagement in Precision Public Health

By Courtney Lyles, PhD and Kirsten Bibbins-Domingo, MD, PhD

At the Precision Public Health Summit held this week at UCSF (sponsored by the Bill and Melinda Gates Foundation and the White House Office of Science, Technology, and Policy: see), we were inspired by many great discussions and ideas.  While the field is still figuring out how to define and conceptualize the core elements of “precision public health,” a broad interpretation that is relatively simple and straightforward includes:  a discipline for using the best methodologies and datasets to tailor interventions (from medical screenings and treatments, to community wellness and prevention programs, to science-informed advocacy and policy) that better meet the needs and priorities of local communities and individuals. 

Dean Schillinger Receives 2016 James Irvine Foundation Award

Congratulations to our Chief of the Division of General Internal Medicine on receiving the prestigious James Irvine Foundation Award!

Below is his acceptance speech and a link to the UCSF article about the award:

Digital literacy and what it means for healthcare

by Courtney Lyles, PhD

Should healthcare organizations be taking a major role in increasing the overall digital literacy of their patients? 

In my last post I talked about how most patients in our health system, the SFHN, want to use the internet to manage their health care and health, but don’t have the proficiency they need to be able to do so. I wanted to take that idea one step further. If our patients often can look something up on Google but don’t know how to use an email account (which is often required for signing up to access your electronic health record online) – should we be providing them with basic technology classes?  The answer I keep coming back to is “yes,” and here are a few reasons why:

Partnerships to Prevent Violence: ARISE

By Leigh Kimberg, MD

Each day, an overwhelming majority of our patients arrive in clinic wishing that their healthcare providers would ask them questions about how their personal relationships affect their health and, more specifically, whether an intimate partner, family member or other person has hurt or threatened them.  And, despite the requirement by the Affordable Care Act that all women and girls be offered interpersonal violence (IPV) (intimate partner violence and sexual assault) screening, brief counseling and referral, healthcare providers and healthcare systems have not institutionalized this practice.  “Aspire to Realize Improved Safety and Empowerment” (ARISE), a partnership program newly funded by the Office of Women’s Health in the US Department of Health and Human Services, will fully institutionalize these life-saving practices in the San Francisco Health Network primary care system.

“Where Can This Person Go?”: A Plea for the Expansion of Medical Respite Services

 

by Soraya Azari, MD

While recently working in the hospital I was often asked by my interns and medical students: “so where can this person go?”  An example: a 53 year old homeless man, wheelchair-bound from prior injuries, who had his wheelchair stolen during an assault, which led to pneumonia and hospitalization.  He quickly improved with intravenous antibiotics, was medically stable, and no longer met criteria for inpatient hospitalization.  So then the question is where should he go? 

Moral Compass

By Dean Schillinger, MD

Dear Colleagues,

Today we are releasing a new film, "Biker with a Moral Compass: Dr. Dick Fine and the Evolving Culture of SFGH", a documentary portraying and paying tribute to the life, times and contributions of UCSF and SFGH physician Dick Fine MD, Founder and Former Director of the General Medicine Clinic, among many things.

Please feel free to share this film with colleagues, friends, and family, and consider using it as part of your health professions trainings.    

Finally, I would like to take this opportunity to ask you to consider making a donation on behalf of Dick, and in support of the many causes he has steadfastly stood for. The San Francisco General Hospital Foundation has created the Richard H. Fine Fund, whose purpose is to support education, clinical innovation, and discovery in The Richard H Fine People's Clinic. You can donate here:

• Go to https://sfghf.org/support-us/donate/
• Under the “Please use my Gift” section select “For the following Program or Department” and write in “In Honor of Richard H Fine DGIM Fund”

 Now....ENJOY THE SHOW !

 

Connecting the dots: Health information technology expansion and health disparities

By Courtney Lyles, PhD, Dean Schillinger, MD and Urmimala Sarkar, MD, MPH

Check out our newest essay in PLOS Medicine outlining how health technology could be better designed and implemented to meet the needs of diverse patient populations:

http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001852

Making Older Homelessness a Never Event

by Margot Kushel, MD

On April 2, Bevan Dufty, (@BevanDufty) the director of the HOPE program (Housing Opportunity, Partnerships and Engagement) for San Francisco (aka the official responsible for addressing homeless services and outcomes), posted the following message to his 4500 followers on twitter: “86-year old staying @ECS_SF Next Door Polk/Geary shelter needs help walking/feeding small dog. Without dog, client likely returns to street.”

The future is already here, it just not very evenly distributed.

By Courtney Lyles, PhD

The title of this blog post is a quote by science fiction author William Gibson (who coined the phrase many years ago, by the way).  And I think it is spot on in a number of ways.  It is clear that so many seemingly futuristic technologies have already been developed: from using your smartphone to passively track your activity and mood, to the development of a sensor to test blood glucose through the skin without drawing blood.  But the reality that is so clear to us working in the safety net is that most of these tools are not distributed to those who need it most, and sometimes even only make their way to our settings after they become somewhat obsolete in the tech space.

Primary Care residency alumnae in UCSF Frontiers of Medicine for work in Navajo Nation

Two of our recent graduates from the SFPC residency program, Drs. Mia Lozada and Jennie Wei, were featured in an article, "You Will Become Well", in the UCSF Frontiers of Medicine spring issue.  The article highlighted their dedicated work caring for patients in Navajo Nation in New Mexico at the Gallup Indian Medical Center.

Click here to read more about their work improving health for underserved patients without running water or electricity, in rural and inaccessible communities, and with hugely different cultural expectations and references.

We are so proud of the work they are doing, including starting the first transgender clinic in Navajo Nation and diving into the quality improvement work at their health center! 

From e-patients to all patients

by Urmimala Sarkar, MD MPH

As a primary care provider practicing in the safety net, I work with incredibly diverse patients with chronic illness. My patients have a wide range of beliefs and preferences about how to best manage their health. I believe their varied perspectives, if more widely shared, could meaningfully improve health care.

Introducing the Next Generation of Primary Care Leaders for the Under-served!

For those of your that may not know, Friday, March 20 was Match Day - the  much-anticipated day in which medical students find out where they will do their residency training.  For those that may not be in medicine, the path to an MD (medical doctor) degree includes (typically) - 4 years of college, then 4 years of medical school, and then 3-7 years of residency training, depending on what field you decide to pursue.

I am fortunate to be the Associate Program Director for a residency track called the San Francisco General Primary Care program, or SFPC, which is a track within the University of California, San Francisco Internal Medicine residency program.  Every year we recruit eight outstanding individuals that exhibit a true commitment to primary care for under-served populations.  

Given the leadership roles that our graduates go on to play in caring for vulnerable populations, it gives me great privilege to introduce the newest 8!  

Chloe Ciccariello 

Chloe is finishing medical school at Mt. Sinai's Icahn School of Medicine.  She worked previously as a peer educator, and elaborated on those skills while at Mt. Sinai taking on several leadership positions within the East Harlem Health Outreach Partnership (EHHOP) Clinic.  She has also been involved in Primary Care Progress, working towards the goal of having more trainees pursue careers in primary care. 

Matt Hickey

Matt is completing medical school at the University of California, San Francisco.  He has a strong, long-standing interest in global health and HIV care, most recently working on a project about engaging social networks to aid in HIV treatment.  He has also worked on decreasing conflict of interest among academic educators, and education programs for youth. 

Ashley McMullen 

Ashley will be coming from the University of Texas, Houston School of Medicine.  She has significant experience in basic science research on tuberculosis, but has developed increasing interest in HIV primary care, working with homeless adults, and advocacy. She has also developed educational opportunities for peers on the topics of street medicine and HIV care.

Alicia Morehead-Gee

Alicia is currently enrolled at the University of California, Los Angeles (UCLA) Drew School of Medicine.  Alicia has researched several underserved populations, including HIV-positive adults in South Los Angeles suffering from mental illness and rural Ghanaians.  She also has served in leadership roles with the Student National Medical Association (SNMA) and has consistently worked on mentorship and pipeline programs for youth.    

Kenny Pettersen

Kenny is finishing medical school at the University of California, San Francisco.  Kenny has been a leader in UCSF's student-run Homeless Clinic and has established several programs and performed research in Haiti.  He is particularly interested in the role of informational technology in aiding chronic disease management abroad. 

Arjun Suri

Arjun will be graduating medical school from Harvard.  He has extensive experience working abroad - most recently in Cuba to understand primary care and social medicine training, but also in Peru related to community-driven approaches to quality improvement, and India studying neonatal and maternal health.  He is also very interested in systems improvements within urban, public hospitals. 

Emily Thomas

Emily is completing medical school at Yale University.  She has been particularly interested in studying incarcerated populations and characterizing the health disparities that exist among these individuals.  She has also been involved in the student-run free clinic (HAVEN) and supporting fellow students to participate in service activities while at Yale. 

Jessica Wang

Jessica is finishing medical school at Yale University, as well.  She is interested in improving patient safety by decreasing medication errors.  She has also been an active leader in several student-run free clinics at Yale (HAVEN, Neighborhood Health Project).  She aims to be a provider and educator in the service of vulnerable patients. 

We feel incredibly fortunate to have this group joining our community - Congratulations and Welcome!!  

State of the research on online patient portals

By Courtney Lyles, PhD

My main area of research over the past few years has focused on getting diverse patient groups to engage in accessing their medical record information online, through websites called online patient portals that are linked to electronic health record systems in hospitals/clinics. Portals typically involve allowing patients access to viewing their test results, visit summaries, and sometimes emailing with providers. Because most healthcare systems (with the exception of places like Kaiser) have only just recently created these portal websites as a part of the Meaningful Use certification process, there is a huge need for research studying their use and effectiveness. 

This post includes my thoughts about what we know and don’t know from the research to date, especially in light of two recent systematic reviews on 1) the effect of portals on outcomes  and 2) how patients with chronic disease and their providers view using an online portal.  (Apologies in advance that it is a very research-specific post!)

Achieving Health Equity is Risky Business: Secondhand Smoke and Vulnerable Populations

By Dean Schillinger, MD

The constructs of “vulnerable populations” and “vulnerability” have increasingly gained a foothold in the fields of Clinical Medicine, Genetics, Epidemiology and Public Health.  Vulnerability, outside of the health context, is broadly defined as susceptibility to attack or to physical or emotional damage. In Public Health, vulnerable populations are typically conceptualized as culturally, economically, geographically or socially defined groups who experience health disparities in relation to a pre-defined dominant (e.g. less vulnerable or invulnerable) group. In Epidemiology, however, vulnerable populations are characterized as groups who experience “greater risk of risks.”  This framing of vulnerability acknowledges that (a) health or illness is often a result of social risks that give rise to environmental exposures (or risks), and (b) these social and environmental risks compound one another to generate a higher and higher risk of being exposed to a causative agent, either at one point in time, or over the life course.

A Trip to Rikers Island: The Community Aging Health Project and Aging Criminal Justice Populations

Geriatrics may seem tame, but so far it has taken me to SF County Jail and, recently, to Rikers Island. 

I and several other geriatricians were hosted by the medical services and the Deputy Medical Director, Dr. Zachary Rosner, our guide through multiple checkpoint and buildings. With this crew of geriatricians, we spent a day and a half doing trainings for about 30 health services staff and 30 correctional officers as part of Dr. Brie Williams' Community Aging Health Project (CAHP).  We did hands-on exercises on geriatric syndromes such as hearing and vision loss, dementia, incontinence, medication issues, mobility impairment and assistive devices, and we even taught exercises for inmates to do in their cells to prevent falls. We helped them think about critical issues, such as when “behavior” could be a sign of dementia, or failure to follow an order may be a sign of hearing loss.

There is no corner of U.S. society that is not affected by growing numbers of older adults in our population.  This includes jail and prison populations. While the US population saw a doubling of adults over 55 years old from 1990 to 2009, in prisons the number more than tripled.  

This presents problems for many who serve criminal justice-involved populations.  Older criminal justice populations have more chronic health conditions and different social service needs. Functional impairments can impact their ability to care for themselves independently, inside and outside of correctional environments. On all fronts-- "inside" and "outside"-- the need is growing for geriatrics training and sensitivity.

Dr. Willams has made this need her mission. CAHP, supported by Tideswell at UCSF and the Langeloth Foundation, developed geriatrics training for a spectrum of professional networks that face the reality of an aging criminal justice population-- social workers, correctional offers, police, and jail and prison health service providers. They have already delivered many trainings across California to jail and prison health services staff, correctional officers, and SF police. 

Rikers Island was the first dissemination site.  “The Island” is New York City's main jail though it is actually a huge complex of buildings, accessed by only one bridge.  It has many buildings; one is a woman's facility ("Rosie's") and the rest of the 10 jails are for men.  Rikers also has an extra prison on a barge that is floating just off the Bronx.  All in all, they house over 11,000 people a day.

On top of our trainings, we were able to see the Geriatrics housing unit with a capacity for 30 men over 50 years old.  At the time we visited they were all lying in bed.  The communal room was not open and dinner was not yet served (at about 4:30pm to mirror the 4:30am breakfast).  One older gentleman who appeared about 80 listened quietly to something on his headphones and several others greeted us and briefly asked us for medical advice.  One of the biggest problems: the low toilet seats and wet floors in the communal, one-room bathroom.  It was hard to get on and off of them and even scarier to contemplate a serious fall.  They can have canes, but not walkers or wheelchairs in most units (one medical unit allows these if needed).  The policy varies across jails and units, but even a raised toilet seat, a common remedy in the community, could be a weapon here. For mobility and frailty issues, no solutions are simple or obvious in a correctional setting.

We also saw the women's jail and attached clinics (medicine, specialty, dentistry) and infirmary where sicker inmates are housed.  Among the women there was one, just over 50, who described myriad medical problems, including a wound that was so difficult to heal she had been in the infirmary for weeks.  Another approached us to ask about what could be done for her- she fell on a wet floor after a property search left debris and food on the ground on her unit, and she said she still did not know what was wrong with her back. 

After our visit, we all agreed that the staff and officers were one of the most engaged group of people we had ever trained.  While Rikers is a huge place, and the aging of the population will continue to put huge pressure on their system, I feel hopeful that this training made an impact and may help this particularly vulnerable and incarcerated population.

Photos: 
1) Tim Gruber (http://www.motherjones.com/politics/2012/09/massachusetts-elderly-prisoners-cost-compassionate-release)
2) Rikers Island, wikipedia: http://commons.wikimedia.org/wiki/File:USGS_Rikers_Island.png#mediaviewer/File:USGS_Rikers_Island.png

by Anna Chodos, MD

Nutrition and the Tax Code

By Hilary Seligman, MD & Marydale Debor, JD

On December 31, 2014, the Internal Revenue Service issued the long-awaited final ruling implementing Section 501 (r) of the Patient Protection and Affordable Care Act of 2010 (ACA). This section of the Internal Revenue Code deals with the conditions hospitals must meet in order to retain their nonprofit health status.  In an exciting development, this new code directs attention to the elimination of “root causes of disease,” especially among medically underserved, minority, and vulnerable populations.