We must reaffirm one another

“We are only as strong as we are united; as weak as we are divided.” - Albus Dumbledore, Harry Potter and the Goblet of Fire

One year ago today, when humans were free to roam the planet, TPMG hosted its annual Shareholders’ Day at the Oakland Marriott to celebrate 70 years of our group practice and the role we have played in advancing medical care in America and beyond. It was a day to step back and reflect on our achievements and renew our commitment to leverage prepayment, integration, and evidence-based care to improve the health and wellness of our patients and the communities we serve. It was a day to honor decades of physicians who have stepped up during difficult times to meet the challenges of their day. And it was a day to acknowledge that this work we do, described by former Associate Executive Director Sharon Levine as “no less than God’s work,” can take a toll on the health and wellness of ourselves and the families who support us. Guest speaker Dr. Vivek Murthy, the 19th Surgeon General of the United States, reminded us that while we are mighty, we are also human and vulnerable. “We are all going to have moments of doubt. I have them. I’m sure you have them - where we wonder if we’re actually enough, if we’re the right person to do the job and get it done. And it’s in those moments that we need to reaffirm each other.” Reaffirm is a transitive verb. According to Grammarly.com, “Transitive verbs are not just verbs that can take an object; they demand objects. Without an object to affect, the sentence that a transitive verb inhabits will not seem complete.” Today is March 31st, 2020 and we are in the midst of a pandemic, preparing for a surge. Now more than ever, we physicians must reaffirm one another and other members of our care delivery teams. #inthistogether

The Royal Family Doctor

You have heard it said that “laughter is the best medicine.” Indeed, most of us have experienced the pure joy associated with a good belly laugh. Laughter is often just what we need to snap us out of a foul mood or distract us from worry. It is also one of the best weapons we have to fight disease. In his bestselling book Anatomy of an Illness as Perceived by the Patient, Norman Cousins described his own recovery from a life-threatening condition, which he credited in large parts to laughter induced by watching Candid Camera and funny movies. Cardiologist Michael Miller from the University of Maryland has demonstrated that “mirthful laughter” works likes exercise and statins to postpone heart disease by a variety of mechanisms that reduce endovascular inflammation.

So please take this opportunity to watch a video that will make you laugh. Menu options include:
The Royal Family Doctor, a 2012 Saturday Night Live classic starring Martin Short as Rupert Smythe-Pennington, Bill Hader as the Royal Family Doctor, and Fred Armisen as Queen Elizabeth II.
Candid Camera: Lousy License Plates Would you accept a plate that read 2STUPID?
Ellen Degeneres 1st Appearance on Johnny Carson’s Tonight Show, 1986 “Dear God, why fleas?”
I Love Lucy:  The Chocolate Factory

Donuts, and other simple pleasures

I know that donuts are not the healthiest food. But I love them, and they make me happy, so I allow myself to eat about one every other month. If that shortens my life by a few months, so be it. I’m a human being trying to live a full life, not a lab rat in someone’s longevity experiment. This morning I wanted to treat my family to something special, so I drove to Pinks Donuts on East Covell Boulevard in Davis and bought a small bag of our favorite donuts plus a half dozen glazed donut holes. While checking out, I thanked the proprietor for staying open during the pandemic and shared with her that in my mind, she and her family provide an “essential service” for my family and our community. She smiled, paused, and replied, “I don’t think that we provide an essential service, but I believe that what we do helps people with their mental health.” I wanted to leap over the counter and give her a big hug for helping to boost HOW I FEEL in a time of need (but left her a big tip instead). What are the donuts in your life that give a boost to your mental health? What simple pleasures that comfort you emotionally can you liberally sprinkle onto your weekly routine during a time of fear, uncertainty, and physical distancing? What about listening to music, going for a run, curling up with a good book, or binge watching a Netflix series? If you need more suggestions, either text me at 530-919-9705 or check out Healthy Pleasures by David Sobel (TPMG’s former director of health education) and Robert Ornstein.

Addendum:  within a few hours of this post, my gastroenterology colleague Dr. Salwa Hussain sent me this beautiful poem to get us ready for tomorrow.

Look for the helpers

Fred Rogers often told this story about when he was a boy and would see scary things on the news: “My mother would say to me, ‘Look for the helpers. You will always find people who are helping.’ To this day, especially in times of disaster, I remember my mother’s words, and I am always comforted by realizing that there are still so many helpers — so many caring people in this world.”

In this recent email communication about the benefits of meditation, my AFM colleague Erwin Boco describes the inherent cognitive bias that makes us focus on the stressful and negative aspects of a situation. He invites us to balance out this predisposition by training our brain to also look for the positive. I echo his recommendation. No matter where you sit on the spectrum that spans from cynic to optimist, I am certain that you will be more settled and function better if you cultivate the habit of looking for the positive and focus on the helpers. Today I am inspired by my colleagues who continue to bring positive energy and big smiles to their work and Team Shield, a volunteer group of students (that includes the kids of Vinh Le and Sarah Heringer and nephew of Mel Vallero) making face shields for frontline health care workers.

(L) Mr. Rogers; (M) ER helpers Chris Canfield, John Wiesenfarth, Margaret Smith, and Ken Collins; (R) Team Shield

What the world needs now is love

Quarantined students from the Berklee College of Music in Boston produced this beautiful virtual performance of Burt Bacharach and Hal David’s 1965 classic, “What the World Needs Now is Love.” Add to that love healthy servings of courage and grit and we’ve got something we can be proud of, a collaborative effort that brings hope and healing to ourselves and those we serve. Thanks to two people for bringing this performance to my attention: former colleague, Heather Martin, PharmD., UC Davis Medical Center; and David Granovetter, Regional Chair of the Physician Well Being Chiefs Group.

Physically distanced, socially connected

“SOCIAL distancing” was the term introduced to describe our efforts to flatten the curve of coronavirus infection by decreasing community transmission. But as our colleague Andy Walter, urogynecology, points out, words matter and we need to replace that misnomer with PHYSICAL distancing. A more accurate description of the current situation is that while maintaining a radius of safety to protect our permeable mucous membranes from the spray of coughs and sneezes, our strong drive to be social and in community with others is irrepressible and has found new ways to express itself. Andy reports that in his neighborhood, he has never seen so many people out walking and biking together (while maintaining a safe distance) and his dog is now getting walked 4x/day (more than ever before). Meanwhile, last Saturday in the hamlet of Davis, my family rode our bikes on the arboretum loop for the first time in 24 years of living there. Then on Sunday, after observing worship services online, we biked to church to deposit our offering in the dropbox. Motivated by your craving for connection, many of you are similarly shaking things up by participating in online fitness classes and staying in touch with friends and family members via phone calls, group texts (filled with rich emojis), and AV apps such as Zoom, Facetime, Google Hangouts, and GoToMeeting. The bottom line is this: physical separation sucks but we are a resilient species. At some point in the future, the restrictions will ease up and we can re-embrace with newfound appreciation the proms, graduations, weddings, funerals, sporting events, and dinner gatherings that bring us together as families, friends, and a society. Until then, keep on breathing, adapting, and investing in creative and innovative ways to stay connected.

   

Breathe

Mike Totaro, AFM Roseville, sent the following message to his colleagues to help them perform at their best day to day and into the future: “Back when I ran distance (track, cross country), I found that I could go farther and even faster if I focused on my present moment, my breath or my cadence. Once I started to think about the finish line, how far away it was, how many hills were still ahead of me, and how tired I was feeling, I would inevitably slow down and feel even more depleted. Distance running is a mental exercise as much as it is about physical effort. Breathe. And, think, “breath, breath, breath…..”

Mike Totaro (R), glory days, Roseville High School

Creating moments of calm

Today’s message comes in the form of a video from two of our wellness leaders in the GSAA, Amanda Nummi, anesthesia, and Sabine Hill, AFM. They pose the question, “What’s the mindful response to the novel coronavirus? Amidst the turmoil is it possible to find a silver lining?” The answer is that the stresses of today give us an opportunity to create moments of calm within our workday. Click here to find out how.

The power of knowledge and perspective

During times of rapid change and new challenges, nothing fills the void more effectively than knowledge, innovation, and perspective. Examples of knowledge and innovation allowing us to advance the frontiers of medicine include anesthesia for surgery (William T. G. Morton, 1846); germ theory (Louis Pasteur, 1861); penicillin (Alexander Fleming, 1928) which revolutionized the war against deadly bacteria; organ transplantation (Drs. Joseph Murray and David Hume, 1954) using techniques of vascular anastomoses, organ placement, and immunosuppression; vaccinations which have eradicated or restricted diseases such as smallpox, polio, measles, and influenza; and anti-viral drugs which have used to treat HIV, herpes, hepatitis, and the flu.

In times like this, TPMG’s integration with Health Plan and Hospitals, commitment to evidence based medicine, and strong physician leadership allow us to leverage knowledge, innovation, and communication to all be on the same page about how to best respond to the COVID-19 pandemic. Our leaders have come out early and strong with a statements about what we know about the novel coronavirus and a strategy for how to meet this challenge head on, including this JAMA online article titled “From Containment to Mitigation of COVID-19 in the US” co-authored by Stephen Parodi and Vincent Liu.



In addition, among your colleagues are some physicians who have lived through war time conditions, when things were not fully under their control, and survived to tell about it. These people can lend us a perspective that most of us are unfamiliar with, a perspective that will help you know that you are not the only one who feels unprepared and inadequate for the task at hand, and that your best effort put forth in collaboration with your outstanding colleagues is part of a noble cause. One such person is Richmond neurologist Carson Lawall who served in Afghanistan in 2010-2011 in mass casualty situations. Click here for his comments about modified expectations in the era of COVID-19.

Facing your fears

Originally sent 3/20/20

Pandemics generate fear: Fear about getting infected and really sick; fear about our hospitals being overwhelmed and us being unable to handle the load with our usual level of expertise; fear about the future of society as we know it.

Here are some suggestions about how to face your fears (adapted from Sherry Amatenstein, LCSW)

Allow yourself to sit with your fear for 2-3 minutes at a time. Breathe with it and say, “It’s okay. It feels horrible but emotions are like the ocean—the waves ebb and flow.” Have something nurturing planned immediately after your 2-3 minute sitting period is completed: Call the good friend waiting to hear from you; immerse yourself in an activity you know is enjoyable and engrossing.

Use humor to deflate your worst fears. There’s plenty of COVID-19 humor to be found on social media.

Appreciate your courage. Every time you don’t allow fear to keep you from doing something that scares you, you are making yourself stronger and less likely to let the next fear attack stop you.

Perhaps the most important coping tool is to be kind to yourself. You have never faced this. None of us has. We will make mistakes. There will be times when will fall short. But it won’t be because we didn’t give it our best effort. Of that I am certain.

Parent resources guide

Originally sent 3/19/20

Today’s nugget of wellness comes courtesy of Shannon Udovic-Constant, a pediatrician at our San Francisco medical center and member of the TPMG Board of Directors for which she chairs the Quality of Professional Life Committee. She is also the Vice-Chair of the California Medical Association (CMA) Board of Trustees. Shannon has collated some material/resources to help parents and adults involved in kids/teens lives on how to navigate the current covid-19 situation. Click here for her parents resources guide.

Basic survival skills

Originally sent 3/17/20
These are tough times professionally and personally, so just a few thoughts about how to hang in there today and return refreshed for another day tomorrow:
· Modify your expectations for how you feel. We’re facing many dynamic stressors at a rapid pace, and information and protocols are changing by the hour, so it’s hard to be your normal “settled self.” Know that everyone is in the same boat. There is some consolation in a community of shared suffering so share your worries with colleagues, family, and friends. I have found much needed reassurance from wonderful conversations and Teams chats with colleagues, groups texts with family and friends, and inspirational social media posts from Permanente colleagues throughout Northern California. If you would like to speak to a professional counselor, you can reach out to our Employee Assistance Program (contact information found on our Sac Valley home page) or use our supplemental Cigna mental health plan to get discounted counseling in the community. I’m also available for anyone who wants to chat with a grey haired family doctor. Text me at 530-919-9705 to set up a time.
· Now more than ever, calming and centering practices such as mindfulness, prayer, and yoga can bring you some inner peace. Being present in this moment (without regrets about what’s already happened and excess anxiety about what tomorrow brings) empowers you to make more adaptive choices about your own feelings and behavior and also positions you to be at your best for patient encounters. Just this morning, Nichole Tyson informed me that Headspace is making its mindfulness app free to healthcare providers through 2020. Click here to register.
· Be worried enough to be vigilant about best practices to protect yourself and others, but not so worried that you become anxious and less functional. Click here for some suggestions for interrupting your worry with some healthy pleasures.
· Remember that much of our patients’ fear about COVID-19 is related to an information deficit. While we do not know nearly everything we need to know, we have the advantage of medical training, clinical experience, and daily updates from our infectious disease leaders and world experts. I have found that the vast majority of patients are reassured by brief but reassuring conversations.
· Know that our patients and communities are extremely grateful for our commitment to keeping them safe. I received this email from a patient yesterday: “I just wanted to give a shout-out to you and your co-workers at Kaiser for all you are doing to help patients during this coronavirus pandemic. I'm sure it must be difficult being a healthcare worker now, with the potential exposure to this particular virus. Perhaps you and your team members at Kaiser don't hear it often enough, but the community appreciates your efforts! Best wishes.”
· Do your best to eat healthy foods, get good rest, and go outside for some physical activity, even if it’s just a ten minute walk.
· Good news for fans of evidence based wellness: the best university-based wellness programming can be found just down Highway 80 at UC Berkeley’s Greater Good Science Center. The GGSC’s director, Dacher Keltner, has been a frequent speaker at TPMG wellness events. I signed up for their emails several years ago and enjoy receiving their uplifting messages on a regular basis.
· And finally, there is always a little room for humor in tough times, so here you go . . .