September Seems Steady & Strong

How do we continue,
When there is more gun violence, kids still in cages, health inequities?
We find within you
 And us, connections, drive, advocacy, preparedness and other remedies. 

President's Column
Raelene Walker, MD, FAAP
As the new school year starts and many of us are inundated with all the activities that go along with that for our patients and our own families, our chapter has also been planning our annual Board Retreat as well as several activities for this fall and engaging in a lot of advocacy for children and pediatricians locally, statewide and nationally. You’ll read about many of these activities in this newsletter and we hope you have and will engage with us now and in the future.

Indeed, we all engage with so many people and projects and ideas every day. And it’s hard. As a colleague said the other day, “Some days I want to save lives and change the world. Some days I just want to go home.” Same. So how do we maintain these intense levels of engagement with each patient, each new teacher, and each other day after day? And how do we continue to do so when every day there is more gun violence, more/still kids in cages in our country, more health inequities? And we’re tired. I was struggling with these questions as I watched my children start school again this year and realized that perhaps children already know the answer, as they often do. We do it together, with other people, collaboratively. We engage, we work, we problem solve, we persist, we resist. We also need to play, sleep, eat, enjoy nature, and seek fun. And by remembering to include all these things together, we will be able to keep engaging.
Photo Caption: Chapter Leaders at Board Retreat on September 7, 2019.
Vice President's Column
Nelson Branco, MD, FAAP

It seems like every conversation about medicine and practice today eventually leads to the topic of physician wellness and burnout. Statistics abound – 44% of physicians report at least one symptom of burnout, only 43% are satisfied with their work-life integration, physicians have higher levels of burnout than similarly educated professionals, burnout begins in the second year of medical school and peaks 10-19 years into practice, burned out physicians garner more patient complaints, feel less effective, and so on.

My favorite burnout statistic is the ranking of burnout by specialty – in this particular 2011 survey, pediatricians had the third-lowest levels of burnout. Only dermatology and physical medicine/rehab beat us out! Is it the cute babies? The funny and interesting (and challenging) teens? The satisfaction of helping a mom learn how to breastfeed, treating a child in respiratory distress, figuring out a complicated and confusing presentation of a disease or helping a family deal with learning and behavioral issues? Do pediatricians pay more attention to work-life balance or self-care? Maybe all of the above, plus.

I recently attended a talk by Tait Shanafelt, MD , the Chief Wellness Officer for Stanford Medicine. After presenting the statistics and discussing the scope of the problem, he talked about some interventions that specifically addressed burnout and satisfaction by fostering community and support from colleagues. The results were impressive, if unsurprising. Physicians who had a structured, regular way to connect with colleagues had lower levels of burnout and found more meaning in their work. His summary: “The medicine was colleagues connecting with each other. Everything else was the syringe.”  

That message resonated with me. I know that the connections I have with all of you, with the other physicians in my community and those I connect with virtually through listservs and social media help keep me from feeling burnt out. I know that I have built a community of colleagues and friends who I can turn to for support, and who I support in the same way. Add to that my family and as many miles on the bike as I can manage, and I hope to practice burnout-free for many years. That’s the medicine, and the side effects are very tolerable.
Santa Clara Member-At-Large Report
Gun Violence - So Close Was Home
Meera Sankar, MD, FAAP

The recent gun violence attacks over the past two months in the Wal-Mart store in El Paso, Texas to the shooting in the nightclub district in Dayton, Ohio and hitting us close to home in Gilroy during the annual Gilroy Garlic Festival are a stark reminder of the dangerous and unpredictable world that we currently live in and raise our children and youth. These attacks are thought to be carried out by mentally unstable individuals harboring violent ideologies.

The United States loses more people to gun violence than almost any other country in the world. Every day, 100 Americans are killed with guns and hundreds more and shot and injured. The 40,000 fatalities with at least 100,000 injuries last year show an alarming increase compared to previous years. Nearly two-thirds of gun deaths are suicides and a third are homicides. Access to a gun increases the risk of death by homicide by two-fold. African Americans represent the majority of gun homicide victims. Firearms are the leading cause of death for American children and teens and first leading cause of death for African American children. Nearly 3700 children and teens succumb to gun violence every year. For children under the age of 13, these gun homicides most frequently occur in the home and are often connected to domestic or family violence. The effects of gun violence extend beyond the casualties -- they shape the lives of millions of Americans, especially youth and children, who witness it, know someone who was shot, or live in fear of the next shooting. 

Our parent organization, AAP and other health care groups are calling for swift action to reduce firearm injuries and deaths as the country is still recovering from these mass shootings. The health groups laid out several policy recommendations.
They recommend:
  • implementing comprehensive criminal background checks for all firearm purchases;
  • finding robust, nonpartisan research on firearm-related injuries and deaths;
  • expanding firearm prohibitions on those found guilty of domestic violence;
  • making it illegal to negligently store firearms where minors can access them;
  • improving access to mental health care while not prohibiting all people with a mental health condition or substance abuse disorder from purchasing firearms;
  • allowing families and law enforcement to petition a judge to temporarily;
  • remove firearms from individuals who may harm themselves or others while providing due process;
  • allowing all physicians to counsel patients on firearm safety; and
  • regulating high-capacity weapons and other firearm features that allow a rapid rate of fire. 

The AAP wrote, “The medical profession has an obligation to advocate for changes to reduce the burden of firearm-related injuries and death on our patients, their families, our communities, our colleagues and our society.”

In addition to this CME conference, there is information and resources for physicians and their patients and families on the following websites.
  • has a special resource article on talking to children about these attacks. This guide offers advice on how to talk to children about shootings and terrorist attacks, that they are likely to hear about at school and /or on the news. It is always a good idea to bring this topic up with children, when a major crisis of this nature occurs. Teenagers and older children may react differently than young children and may not want to discuss it when you bring it up. In those instances, it’s important to keep the door open for them to come back and discuss it later and not force them to talk to you.
  • also is a great resource for safety and prevention regarding gun related injuries. AAP advises that the safest home for a child is one without guns. They recommend all guns at home should be locked and unloaded, with ammunition stored separately. As primary care providers, address firearm safety as part of routine anticipatory guidance with children of all ages
  • Pediatricians should screen for mental health concerns and substance abuse during routine well child visits and provide families with mental health materials and access support services as needed
  • Self-care for physicians is very important during these tough times as compassion fatigue may set in as clinicians are listening and helping families and patients dealing with gun violence events. 
Advocacy Committee: Gun Violence and Immigration
Lisa Patel MD FAAP, Heyman Oo MD FAAP, Raul Gutierrez MD FAAP

Sadly, the nation suffered mass shootings and murders in Gilroy, CA, in Dayton, OH, and in El Paso, TX that have resulted in renewed calls for the Senate to take up debate on H.R. 8, a measure passed by the House of Representatives for universal background checks but which has stalled in the Senate. The murderer in El Paso is possibly facing charges for a hate crime, as anti-immigrant and racist documents were posted on his online accounts. 
The medical community also continues to strategize and advocate for immigrant children and families. Several stories have circulated detailing the inhumane conditions that place children’s health at risk when in the custody of Customs and Border Patrol, which has resulted in the deaths of children from influenza related illness at a higher rate than the general population for example. The Department of Homeland Security released its rule on the Flores Settlement Agreement with the plan to hold children indefinitely with their parents in detention centers. Additionally, the final rule on public charge was published in August with well documented “chilling effect” that is resulting in families disenrolling from public assistance programs even in cases where they still qualify. Most recently, stories have also circulated that the U.S. Citizenship and Immigration Services has stopped granting deferred action for medical reasons. This has resulted in children in immigrant families receiving letters stating they must leave the country even if receiving life-saving treatment. 
The AAP has responded swiftly. Many of you reached out to your members of Congress supporting the bill, H.R. 3239, which passed to ensure proper medical care for those in CBP custody. A Senate bill is now under consideration. The AAP is also engaged with law firms to submit amicus briefs related to the Flores Settlement Agreement and public charge litigation that speaks to the health and developmental harms to children. You can get more information from the AAP at Protecting Immigrant Children . The policy statement, “Providing Care for Children in Immigrant Families,” will be published in the September issue of Pediatrics . And finally, the AAP has also formed the Council on Immigrant Child and Family Health (COICFH) to replace the Immigrant Health Special Interest Group. We will provide more information on how to join COICFH soon. 
These events can feel overwhelming while we continue to fight for what is best for our patients, families, and communities. There are many opportunities to make a difference, and if you don't know where to start, or want to connect with other pediatricians to amplify your voice and work, please join us at the Advocating for Children Together conference being spearheaded by AAP-CA1. The conference has been a grassroots, volunteer-led effort by pediatricians in the Bay Area passionate about change. Please join us for inspiring talks, hands on workshops to learn important advocacy skills, and plenty of networking opportunities to meet other Bay Area pediatricians passionate about advocacy.
Disaster Preparedness, Part 2
John I. Takyama, MD, MPH, FAAP
Immediate Past President

Disaster Preparedness Part 1 article can be found HERE .

September is National Preparedness Month and this year’s theme is “Prepared, Not Scared!” This was an apt reminder that disasters, even preparing for them, can be a scary experience. As I surfed the varied websites on disaster preparedness, I started to feel increasingly anxious. I was also repulsed by some of the emphasis on “personal needs” and “planning financially.” What saved me was “ Guidelines for Child-Friendly Disaster Management and Response ,” a 2005 brochure prepared by the government of Jamaica, with assistance from UNICEF; it takes a broad perspective, describes the needs and rights of children, and highlights the roles of systems and governments.  

How can we plan for disasters yet avoid scaring children and their families? Know your contacts, make a plan and pack a bag. Know your contacts really means communicating regularly with the important people in your family and community, and including your children. When old enough, children can learn how to call or text and even to walk over to a trusted neighbor. In moments of chaos, a familiar face and place can be reassuring for children. Making a plan can start with common scenarios, how to clean up a kitchen mess or what to do if a parent is late to pick a child. Appropriate coloring books for younger children, and more expansive ideas from youth organizations, such as the Girl Scouts, may be helpful. Finally, pack a bag with contact information, child-friendly map (i.e., hand written) and directions, snacks, water, clothing and a flashlight. Don’t forget to include photos, transition objects (i.e., second favorite teddy bear) and an age appropriate activity kit (to keep children occupied). Have them take the bag with them to an overnight stay, perhaps with grandparents.

Planning takes time and that is ok. It can be an integral part of daily activities. Attending to small and common disasters in a logical yet sensitive way can help build resilience. The more children participate, the more empowered they can be. Once children are old enough, and to the extent that such activities do not provoke anxiety, discussing scenarios and participating in drills may also be helpful. The more I think about this, there may be a cost to over-preparing, including triggering anxiety and costing money (emergency supply kits). On the other hand, since large disasters affect communities, perhaps we need to shift our focus and help systems and governments better include children and families in disaster plans.

Please take our chapter survey to gauge how disaster ready you are: AAPCA1 2019 Disaster Preparedness Survey

Potentially useful references:
What's New with Influenza Vaccine this Year?
Dean A. Blumberg, MD, FAAP
Chapter Immunization Champion

The AAP and CDC update influenza vaccine recommendations every season. Here are the main changes from last season:
  • Two of the strains included in the vaccine have been changed, the influenza A H1N1 and influenza A H3N2 components. These have been updated to better match the expected circulating strains. The influenza B strains remain the same as last season.
  • The AAP is now recommending either the inactivated influenza vaccine injection (the “flu shot”) or the live attenuated influenza vaccine (the “nasal spray vaccine”). This is a bit different from the last season when the AAP preferentially recommended the injected vaccine due to concerns about the live vaccine effectiveness against influenza A H1N1. The formulation of the nasal spray vaccine has been changed and the latest data support this change.
  • One of the inactivated vaccines, Afluria Quadrivalent, is now licensed for persons aged >6 months (dose volume 0.25 mL per dose 6-35 months and 0.5 mL per dose >36 months of age).
  • The dose volume for another inactivated vaccine, Fluzone Quadrivalent, has been changed for children 6-35 months of age to 0.25 mL or 0.5 mL (it was previously 0.25 mL); the dose volume for those >36 months of age remains 0.5 mL.

In recent seasons, influenza immunization rates have been less than 60% for children, so there is clear room for improvement. And remember that influenza is not just a few days of fever, chills and respiratory symptoms—influenza may be fatal: there are generally more than 100 pediatric deaths every year from influenza in the US (129 for the 2018-19 season).

Don’t forget to encourage your obstetric colleagues to provide influenza vaccine (and Tdap) during pregnancy, which protects the mother and newborns against influenza. In fact, influenza vaccine during pregnancy significantly reduces hospitalization due to influenza in the first 6 months of life.
National AAP Reminders
  1. National AAP Elections are OPEN. We encourage you to vote. To view the full candidate listing and learn more, visit The District IX Office Position includes National Nominating Committee Representative.
  2. Reminder to write your ALF Resolutions! Marsha Spitzer, MD, FAAP, District IX Chapter Forum Management CommitteeRepresentative, provides a breakdown on how to do so HERE.
The SGA Side
Your Key to State Government Affairs

AAPCA sponsored bill SB 276 (Pan) Immunizations: Medical Exemptions passed both houses and was signed by Governor Newson. SB 276 increases state oversight of medical exemptions (ME) for school entry vaccinations. If a doctor writes five or more MEs in a year or if a school has <95% overall immunization rate, those MEs are reviewed for appropriateness by state public health. Other MEs are not reviewed, but are entered into a database.
Upcoming CME Conferences

Around the corner is the Advocating for Children Together (ACT) CME conference. See the special guest announcement below!

Registration is OPEN for Pediatric Mental Health Day CME Conference on November 9, 2019.

Pediatric Puzzles 2019 registration is to be released in early October. Speakers are already confirmed! Check out more conference information HERE.
Opportunities for Your Benefit
Pediatric Musculoskeletal Boot Camp for Primary Care Providers
The National AAP Section on Orthopaedics presents Pediatric Musculoskeletal Boot Camp for Primary Care Providers . The Boot Camp course combines case-based lectures, interactive physical exam and casting/splint workshops, and question and answer sessions to address frequently seen problems of the MSK system in children and key aspects of physical examination of the musculoskeletal system. Through coverage of key MSK topics, the course focuses on improving the musculoskeletal care of children. 
The Boot Camp course takes place on September 21, 2019 in two locations - one right in San Francisco!  Please join the pediatric orthopaedic faculty from UCSF for this high yield MSK course. Dr. Coleen Sabatini is the local course Director and faculty include Drs. Nirav Pandya, Mohammad Diab, Sanjeev Sabharwal, Jason Jagodzinski, Kristin Livingston, bone health expert Dr. Ellen Fung, Rheumatologist Dr. Nicole Ling and new MSK Pediatrician Celina de Borja. AAP Chapter 1 Past President Dr. John Takayama will give the lunchtime address and current President Dr. Raelene Walker will welcome everyone that morning!  It will be a wonderful day of learning and demystifying pediatric MSK conditions and physical exam. Please join us!
For more details on the course and for links to register visit

UC Irvine/UC Davis Train New Trainers (TNT) Primary Care Psychiatry (PCP) Fellowship 2020
A year-long clinical education program for primary care-oriented providers and trainees providing over 50 hours of advanced training in primary care psychiatry. Thanks to California Office of Statewide Health Planning and Development (OSHPD), there are full-tuition scholarships available! 

The fellowship includes a two-weekend, mandatory in-person, teaching sessions (January 2020 & August 2020) with 24-28 CME hours, One hour a month mentorship with mentors experienced in primary care psychiatry, Two lectures a month: Interactive online case-based learning (20+ CME hours), a copy of the new Primary Care Psychiatry Textbook 2nd Edition, and the Essentials in Primary Care Psychiatry Conference taking place January 24-25, 2020 in Newport Beach. Topics include AMPS primary care psychiatric assessment, mood/anxiety disorders, personality, psychosis, substance misuse, pain management and more.

For more information, visit:

Children’s Mental Health Program: Uplift Family Services Survey
The influx of emerging behavioral health problems into pediatric primary care practices is a growing problem because of a lack of resources needed to adequately address them. Uplift Family Services, a children’s mental health program, is developing a demonstration project that will integrate it’s behavioral health services into a pediatric practice. This survey was developed to better understand the scope of the problem and the services that would be beneficial. Please take a moment to complete this survey as addressing mental health is a priority for our chapter.

October 5, 2019:  Advocating for Children Together Conference, Oakland - Register Now

October 25-29, 2019:   AAP National Conference & Exhibition , New Orleans

November 9, 2019:  Pediatric Mental Health Day, Madera (Valley Children's Hospital) - Register Now

November 21-24, 2019: AAP California 41st Annual Las Vegas Seminars - Pediatric Update

December 7, 2019:   4th Annual Pediatric Puzzles Interactive CME Conference , San Francisco

Our mission is to promote the optimal health and development of children and
adolescents of Northern California in partnership with their families and communities, and to support the pediatricians who care for them.

President: Raelene Walker • Vice President: Nelson Branco
Secretary: Janice Kim • Treasurer : Nivedita More • Past President: John Takayama
Executive Director: Isra Uz-Zaman