sutures newsletter

PRODUCED BY AND FOR MEMBERS OF THE DEPARTMENT OF SURGERY December 2017 | Archived Issues

President's Perspective

Presidents-Perspective-logo-callout

By Thomas M. Priselac, President and CEO

Accessibility to our services for patients and consumers is one of the three imperatives for Cedars-Sinai that I outlined in June’s President’s Perspective: retain our absolute commitment to quality; make our services more geographically and virtually accessible to patients and consumers; fulfill our obligation to make healthcare affordable through operational and clinical efficiency work. No matter how outstanding, efficient and appropriate Cedars-Sinai’s patient care is, if it is not accessible, we are not fulfilling our mission to the public.

» Read more

Providing Care for Transgender People

Cedars-Sinai recognizes the need for transgender care, especially amid the large and diverse community of Los Angeles. The most recent census-based population studies estimate that 1.4 million of adults and 1.6 million adolescents in the United States identify as transgender.

» Read more

Two Minutes With …

This question-and-answer feature will help you get to know some of the faculty in the Cedars-Sinai Department of Surgery. This month's installment features Maurice Garcia, MD.


» Read more

New Name in Orthopedics

Cedars-Sinai announced the formation of the Cedars-Sinai Kerlan-Jobe Institute this week, which includes multiple care locations throughout Los Angeles and Orange counties. Cedars-Sinai, Kerlan-Jobe and Santa Monica Orthopaedic & Sports Medicine Group are founding partners of the institute.

» Read more

HR Launches Multiyear Strategy to Support Staff

Human Resources has embarked on a transformational, multiyear strategy to cultivate Cedars-Sinai’s skillful workforce and to meet the changing demands of the healthcare environment through greater efficiency, better service and enhanced talent management.

» Read more

POLST Project Prompts Important Conversations

"As an institution, Cedars-Sinai wants to ensure that the care we're providing aligns with our patients' goals, values and preferences, particularly in relation to end-of-life care. Physicians want to know that they're respecting their patients' wishes," said Edward Seferian, MD, chief patient safety officer and medical director, Medical Affairs.

» Read more

FDA Issues Alert About Risks of Febuxostat

The U.S. Food and Drug Administration is alerting the public that preliminary results from a safety clinical trial show an increased risk of heart-related death with febuxostat (Uloric) compared to another gout medicine called allopurinol.

» Read more

Surgeons Lead Class at ACS Clinical Congress

Two surgeons and a research scientist from Cedars-Sinai recently helped lead a course at the American College of Surgeons Clinical Congress in San Diego. Harry Sax, MD, Rodrigo Alban, MD, and Tara Cohen, PhD, were part of a team featured in a track on performance improvement for surgeons. The course was entitled: "Measure Twice, Cut Once: Optimizing Surgical Systems of Care."

» Read more

Study to Explore Role of Hormones in Breast Cancer

Researchers at the Saul and Joyce Brandman Breast Center — A Project of Women's Guild, are conducting a study to explore the role hormones play in the development of breast cancer. The purpose of the study is to find differences in hormone levels between patients who have a new diagnosis of breast cancer and those who do not.

» Read more

CS-Link Tip: Pulling Imaging Results

When using CS-Link™, you may want to pull an imaging result into your note. Instead of using copy and paste, you can type dot, "img," and then the anatomical area. For example, typing ".lastimgchest" will pull results for any CT, ultrasound or X-ray of the chest.

» Read more

President's Perspective

By Thomas M. Priselac
President and CEO

Accessibility to our services for patients and consumers is one of the three imperatives for Cedars-Sinai that I outlined in June’s President’s Perspective:

  • Retain our absolute commitment to quality;
  • Make our services more geographically and virtually accessible to patients and consumers; and
  • Fulfill our obligation to make healthcare affordable through operational and clinical efficiency work.

No matter how outstanding, efficient and appropriate Cedars-Sinai’s patient care is, if it is not accessible, we are not fulfilling our mission to the public.

For decades in America, most healthcare providers operated under the principle that patients would come to them on the provider’s terms. The provider would be in a single location (as a hospital or a physician’s office), would determine when and how they would be available to see patients, and it was the patient’s responsibility to make any adjustments needed to fit the provider’s setup.

Today, both patients and healthcare providers benefit from ever-expanding ways to make care more accessible. At Cedars-Sinai, this has been a key component of our strategy and takes many different forms, including geographically distributed primary and specialty care locations, digital access to our services and expansion of urgent care.

Geographic expansion

A decade ago, Cedars-Sinai consisted of our flagship medical center and several nearby buildings for outpatient visits and procedures (the 310 Building, Mark Goodson Building, Medical Network offices and licensed space in the Medical Office Towers). Then, as now, people were willing to drive (and fly) great distances for our renowned tertiary and quaternary services. But for all other medical needs, most people prefer to get that care closer to where they live or work.

To help meet the growing community demand for Cedars-Sinai care closer to home or work, several years ago, we began expanding our locations; and we're doing this in a variety of ways:

Medical Network offices: Starting a few years back with the opening of a primary/urgent care facility in Culver City, Cedars-Sinai Medical Network has since opened facilities in Playa Vista and Tarzana, providing both primary and urgent care as well as a variety of specialty services. The largest one, in the new Runway Playa Vista retail/residential center, just opened and has quickly become a healthcare destination for local residents.

Affiliate offices: Many prominent medical practices throughout Southern California continue to join the Cedars-Sinai Medical Network, which further expands our geographic footprint and makes Cedars-Sinai care more accessible. These groups include primary care practices in the San Fernando Valley; oncology practices in Santa Monica, West Los Angeles, Tarzana and Beverly Hills; and two of the nation’s most prominent sports medicine/orthopedics groups, now known as the Cedars-Sinai Kerlan-Jobe Institute, with offices throughout Los Angeles and Orange counties.

Joint ventures: Among our more visible joint ventures is the 138-bed California Rehabilitation Institute in Century City, a joint venture between Cedars-Sinai, UCLA Health and Select Medical. Other joint ventures include several freestanding outpatient surgery centers and freestanding imaging centers.

Cedars-Sinai Marina Del Rey Hospital: With the growing outpatient presence of Medical Network offices throughout the Silicon Beach area (Culver City, Playa Vista, Marina del Rey, Westchester), the availability of a nearby community hospital that is part of the same system provides an important piece of healthcare for the local community.

Our proposed affiliation with Torrance Memorial has the potential to facilitate many different collaborations between the two institutions, extending the geographic reach of both. Based on the success of our collaboration with Torrance Memorial's telestroke program, we anticipate many other opportunities to expand access to clinical trials and other specialized care.

Digital access

The launch of My CS-Link™ enabled our patients to access their health information online, ask their physicians questions any time and get test results. But that was just the beginning. Today, we are piloting a number of new ways to enable our patients to digitally access our care and expertise from wherever they are. The entry points for consumers to all of these services are the Cedars-Sinai website and flagship mobile app, both of which are undergoing major enhancements/overhauls to provide a simpler, easy-to-use interface and tools for consumers.

Expanded urgent care

Urgent care centers — providing immediate access to non-emergency but time-sensitive care — have become increasingly popular with consumers around the country. The demand for Cedars-Sinai urgent care has been significant, with all three of the Medical Network’s urgent care centers (Beverly Hills, Culver City and Playa Vista) keeping very busy. For some consumers, a visit to a Cedars-Sinai urgent care center is their first experience with us and becomes the start of a long-term relationship.

There are literally hundreds of other ways we facilitate access to healthcare for the public, including many of our community benefit programs — providing health education as well as screenings and immunizations to underserved residents in their communities.

In the months and years to come, we will continue to enhance access, in many different ways, to meet the growing regional demand. It is clear that the community wants the outstanding care that Cedars-Sinai provides, and it is our job to help them access it.

Closely related to access is our third imperative — affordability. If people (and other payers) cannot afford our care, then they won’t be able to access it, no matter how close it is. In my next Perspective, I’ll share some thoughts on how we can fulfill our obligation to make healthcare affordable through operational and clinical efficiency work.

Providing Care for Transgender People

Maurice Garcia, MD, Director of the Cedars-Sinai Transgender Surgery and Health Program

The most recent census-based population studies estimate that 1.4 million adults and 1.6 million adolescents in the United States identify as transgender. There has been a slow but steady movement toward greater social acceptance of diversity within our society. This has led to people of diverse sexual orientations — and more recently, diverse gender identities — being visible and better represented in the media, census studies and health policy. Changes over the past five years in California healthcare legislation and federal Medicaid and Medicare policies have eliminated the use of exclusionary insurance policy clauses in both commercial and public health-insurance plans, which previously denied transgender-related care and gender-affirming surgery (GAS).

In addition to California, an increasing number of states prohibit such exclusionary clauses. Owing to decades of commercial and federal health insurance plans not providing coverage, genital GAS performed in the United States has been limited to the private-practice sector. Today, very few surgeons are trained to competently perform genital GAS. As a consequence, there is a relatively sudden and significant need for transgender care. While other domains of transgender care such as mental health (psychiatry), hormone management (endocrine) and gynecological care have clear parallels in traditional cisgender medicine, genital GAS techniques are unique relative to traditional genito-urinary surgery and, hence, expertise in genital GAS is most in need today.

Cedars-Sinai recognizes the need for transgender care, especially amid the large and diverse community of Los Angeles. In January 2014, Maurice Garcia, MD, was recruited to found and direct the Cedars-Sinai Transgender Surgery and Health Program. The interdisciplinary clinical and research program leverages the breadth of expertise already present within Cedars-Sinai to ensure that the program can provide comprehensive care across the spectrum of disciplines relevant to the care of the transgender patient.

Garcia is a reconstructive urologist who came to Cedars-Sinai from the University of California, San Francisco (UCSF). He completed his residency training in urology at UCSF, and after fellowship training (andrology, sexual medicine and neurourology) and completion of a two-year master's degree in clinical research, also at UCSF, he joined the UCSF faculty in the Department of Urology. In 2013, he spent several months in London to complete fellowship training in genital GAS. In January 2014, he founded and led the genital GAS program at UCSF, which at the time was the only academic center program to offer genital GAS in the Western United States and only one of three in the nation.

The rollout of a transgender care program is not without challenges. For our institution to be welcoming to patients, it is essential that our physicians, nurses and staff are familiar with this patient population and educated about basic terminology and patient needs. One of the biggest pitfalls for us, as an institution seeking to be welcoming to transgender patients, is misgendering patients — addressing transgender patients using pronouns (she, her; he, him) that would apply to their birth-sex but not to the gender with which they identify after starting their gender transition.

A cisgender person is someone whose birth-sex/body and gender identity are in alignment, whereas a transgender person's birth-sex/body does not reflect the gender they identify with. Misgendering happens because we use secondary sex characteristics as cues to determine the gender of the person before us. For transgender people, changing the "sex" of their voice or their physical features is challenging. Being referred to with the wrong pronouns is very wounding to most transgender patients and perceived as a rejection of who they are. Misgendering can also happen when we address a transgender person by their birth name (i.e., pretransition).

While any patient may change their legal gender and name, many have not completed that sometimes lengthy process before they present at our center for care. Misgendering can be perpetuated by incorrect pronouns in other clinician's notes. Misgendering in all of these ways is inadvertently facilitated by our electronic medical record, which always lists the legal gender and name (typically what is listed on the health insurance records).

Garcia and colleagues from the transgender services task force have organized interactive educational lectures by leaders from local transgender community centers for our campus faculty, students and staff to learn more about how to interact with transgender patients in a culturally sensitive manner. The task force is also working on strategies to prevent misgendering of our transgender patients. The electronic medical record banner, the most prominent place listing a patient's gender and name, should reflect the patient's gender identity and preferred name.

The expertise that the Transgender Health and Surgery Program brings together from the Cedars-Sinai community creates unique opportunities to expand patient care. For example, cisgender women who have lost most or all vaginal depth due to a history of surgical and/or radiotherapy treatment for some gynecological cancers can be offered intestinal vaginoplasty — a well-proven technique offered to transgender women wherein an intestinal segment is harvested to line the obliterated vaginal cavity (cisgender) or newly created vaginal cavity (transgender).

Other transgender surgery expertise that can be translated for use among nontransgender patients includes vaginal reconstruction for women suffering from aftereffects of female circumcision (or female genital mutilation). Garcia has already established contacts within local communities that are home to such victims. Men whose genitalia have been affected by major physical trauma (including battle-related injuries among veterans) also benefit from transgender surgery expertise that focuses on urinary tract and sexual functions. The Transgender Health and Surgery Program also offers unique opportunities for research collaboration at Cedars-Sinai, particularly via the sharing of tissues, clinical data and research expertise.

The expectation is that the Transgender Surgery and Health Program will grow and contribute widely to the medical center's educational mission. Cedars-Sinai offers transgender surgery and health-related education to medical students, residents and fellows. As the program expands, it will increasingly contribute to both our campus and to healthcare on a regional, national and international level, through education, peer-reviewed publications and contributions to professional organizations. Garcia, for example, is author of the American Urologic Association's inaugural core curriculum dedicated to transgender care; he is a founding member of the multidisciplinary American Society for Gender Surgery; and he provides surgical training courses across the country. He was recently invited by the Ministry of Health of the State of Jalisco, Mexico, to contribute content, lectures and educational materials for the development of what will be Mexico's first transgender surgery academic program.

Two Minutes With …

This question-and-answer feature will help you get to know some of the faculty in the Cedars-Sinai Department of Surgery.

Maurice Garcia, MD

Maurice Garcia, MD, director, Transgender Surgery and Health Program

Where did you grow up?

Hollywood, Calif.

Why did you decide to specialize in urologic surgery?

I enjoy the combination of continuity of care, complexity of reconstructive surgery and heavy use of technological “gadgetry” in our field.

If you were not a physician, what career would you choose?

Veterinarian.

What is the funniest thing a patient has ever said to you?

Probably too risqué to print!

If you could spend the day doing one thing, what would it be?

Fishing!

Is there something or someplace you have never seen that you would like to see in the near future?

I would very much like to travel to and explore India.

New Name in Orthopedics

Cedars-Sinai announced the formation of the Cedars-Sinai Kerlan-Jobe Institute this week, which includes multiple care locations throughout Los Angeles and Orange counties.

The new name reflects Cedars-Sinai’s, Kerlan-Jobe’s and Santa Monica Orthopaedic & Sports Medicine Group (SMOG)’s positions as founding partners of the institute. The naming also highlights the expanding footprint of Cedars-Sinai’s Department of Orthopaedics, which was created in 2016.

"This transition has been years in the making and best represents our joint commitment to be a world leader in the diagnosis, treatment and prevention of sports-related injuries and illnesses, and other orthopedic conditions," said Mark Vrahas, MD, founding chair of the Department of Orthopaedics.

Kerlan-Jobe Orthopaedic Clinic and Santa Monica Orthopaedic & Sports Medicine Group first joined forces with Cedars-Sinai in 2013. SMOG, located at 2020 Santa Monica Blvd., Suite 400, will now also be known as the Cedars-Sinai Kerlan-Jobe Institute.

"For us, this is more than a name change. It is an opportunity to synergize and integrate our world-class institute with other preeminent physician leaders, researchers and staff members throughout our orthopedic network and the Cedars-Sinai Health System," said Bert R. Mandelbaum, MD, DHL (hon), co-chair of Medical Affairs for Cedars-Sinai Kerlan-Jobe Institute.

The Cedars-Sinai Kerlan-Jobe Institute is internationally recognized for research and education in sports medicine. Institute physicians have pioneered advanced surgical methods and procedures to enhance treatment, rehabilitation and recovery.

"We’re excited about the opportunity to take this powerful partnership to new heights," said Neal S. ElAttrache, MD, a member of the Kerlan-Jobe Orthopaedic Clinic Board of Directors and co-chair of Medical Affairs for Cedars-Sinai Kerlan-Jobe Institute. "This step further solidifies the collaborative work of these long-standing names in orthopedic medicine to provide exceptional care to the Los Angeles community and beyond."

As the sports division of the Cedars-Sinai Department of Orthopaedics, Cedars-Sinai Kerlan-Jobe Institute physicians also are the team healthcare providers for the Los Angeles Dodgers, Los Angeles Rams, Los Angeles Angels, Anaheim Ducks, Los Angeles Galaxy, U.S. Men’s and Women’s Soccer and the Special Olympics.

HR Launches Multiyear Strategy to Support Staff

Human Resources has embarked on a transformational, multiyear strategy to cultivate Cedars-Sinai’s skillful workforce and to meet the changing demands of the healthcare environment through greater efficiency, better service and enhanced talent management.

The strategy, to be implemented over the next few years, is rooted in four pillars:

  • Enhancing operational efficiency and service
  • Energizing the work climate
  • Facilitating change
  • Recruiting, developing and retaining top talent (talent management)

This approach will help maintain Cedars-Sinai as a leading healthcare employer through a new service delivery model, advanced technologies and other efforts to attract, serve and develop top-performing staff.

"A superlative health system needs to engage top talent to achieve its mission of providing world-class healthcare," said Andy Ortiz, senior vice president of Human Resources and Organization Development. "That requires a world-class Human Resources function, and that’s what we’ve set out to deliver. The foundation for this work is building a platform for operational efficiency and enhanced service."

In the next year, employees will see several changes in Human Resources, including more active recruitment efforts, streamlined performance management tools, development of an employee culture change plan and enhanced communications with staff.

Human Resources will soon roll out HR Connect — a new cloud-based technology that will streamline access to Human Resources services. This new technology, coupled with implementation of an HR Shared Services Center, will make it easy for employees to get answers to Human Resources questions, and for leaders to get complete and accurate HR data to support better decisions.

"The healthcare industry has its challenges, but this strong foundation will enable Cedars-Sinai to meet them with a talented workforce that is inspired by those challenges, engaged in their work and deft in their ability to adapt to the ever-changing healthcare environment," said Ortiz, who marked his one-year anniversary with the organization in July.

Watch The Sutures in the months ahead for follow-up stories about Human Resources’ strategic pillars.

POLST Project Prompts Important Conversations


A three-year improvement project resulted in increased completion rates of POLST forms.

"As an institution, Cedars-Sinai wants to ensure that the care we're providing aligns with our patients' goals, values and preferences, particularly in relation to end-of-life care. Physicians want to know that they're respecting their patients' wishes," said Edward Seferian, MD, chief patient safety officer and medical director, Medical Affairs.

To help achieve these objectives, the Cedars-Sinai Quality Council launched an initiative in 2014 aimed at improving end-of-life care.

"We knew we needed to do a better job of eliciting from patients what they wanted in relation to end-of-life care, and we knew we needed to be more effective in making those preferences available in the medical record for use by all providers," said Michael Langberg, MD, chief medical officer and the initiative's executive sponsor. "One way to do this is with the POLST form, so we launched an effort specifically focused on this form as a means of prompting these dialogues and documenting patients' wishes."

POLST is an acronym for Physician Orders for Life-Sustaining Treatment, a form designed to increase patients' control over end-of-life care and across care settings. Recognized in California since 2009, the POLST form is administered by the Coalition for Compassionate Care of California and enables patients to have frank discussions with their healthcare providers and specify their preferences in relation to CPR, artificially administered nutrition and the scope of medical interventions desired.

Printed on hot-pink paper, the form reflects the provider's clinical judgment and is signed by the patient (or a legally recognized decisionmaker in case of incapacity) and provider — which can be a physician, nurse practitioner or physician assistant. POLST forms transform patients' preferences into physician orders that are to be followed across healthcare settings.

"One of the POLST form's goals is to protect patients and preserve their preferences outside of a hospital environment," said Jaime Goldberg, clinical social worker with Supportive Care Medicine. "Increasing completion rates of POLST forms has been a focus for several years, but over the last three years we've refined and intensified that focus."

For example, two populations were targeted: patients being discharged who have a Do Not Attempt Resuscitation (DNAR) order in their hospital medical record; and patients with dementia being discharged to a skilled nursing facility.

"These aren't the only patients we've been working with. We're also focusing on patients with advanced conditions, such as cancer and other complex, life-limiting illnesses," said Seferian, associate professor of Pediatrics.

Seferian is a team leader of the improving end-of-life care initiative along with: Beth Karlan, MD, director of the Women's Cancer Program in the Samuel Oschin Comprehensive Cancer Institute and professor of Obstetrics and Gynecology; and Bradley Rosen, MD, vice president of Physician Alignment and Care Transitions and assistant professor of Medicine.

Several strategies were employed to boost completion rates of POLST forms.

"One of the most effective strategies was integrating POLST into the workflow, particularly into progression of care rounds where patients appropriate for a POLST conversation could be identified," explained Seferian. "This was a multidisciplinary effort, including social work, case management, supportive care medicine, internal medicine, nursing, surgery, transplant, the enhanced care program, bioethics, the emergency department and physician advocates."

Seferian pointed to other impactful strategies.

"Since 2014, we've been providing physician-specific POLST form completion rates annually. We also showed how they compared with their peers' POLST completion rates," said Seferian. "In many cases, physicians wanted to know which patients would have been appropriate for POLST conversations."

A CS-Link™ best-practice alert similarly helped move the POLST-form-completion needle. When a physician places a DNAR order, a Best Practice Advisory displays indicating that a POLST form should be completed for that patient.

"The first phase of the POLST effort was increasing completion rates, which has been accomplished," Seferian said. "The completion rate for patients with a DNAR order went from about 41 percent to more than 73 percent. For patients with dementia, which is a much more complex population, the completion rate was at around 45 percent and is now nearing 60 percent."

Goldberg credits rising completion rates to the combined impact of multiple strategies.

"Some strategies were very concrete, such as making sure POLST forms were available on the units. Others were more philosophical, focusing on the importance and benefits of having these conversations," Goldberg explained.

"The POLST initiative is now in sustainment mode. The next step is making sure that the care we're delivering aligns with patients' preferences," Seferian said.

For additional information, POLST forms and a FAQ sheet in multiple languages, visit the Cedars-Sinai POLST web page.

Questions about the POLST form can be directed to Supportive Care Medicine (Inpatient: 310-423-9520; Outpatient: 310-423-7500) or the Center for Healthcare Ethics at 310-423-9636.

FDA Issues Alert About Risks of Febuxostat

The U.S. Food and Drug Administration is alerting the public that preliminary results from a safety clinical trial show an increased risk of heart-related death with febuxostat (Uloric) compared to another gout medicine called allopurinol. Healthcare professionals should consider this safety information when deciding whether to prescribe or continue patients on febuxostat.

The FDA website has more information.

Surgeons Lead Class at ACS Clinical Congress

Two surgeons and a research scientist from Cedars-Sinai recently helped lead a course at the American College of Surgeons Clinical Congress in San Diego.

Harry Sax, MD, Rodrigo Alban, MD, and Tara Cohen, PhD, were part of a team featured in a track on performance improvement for surgeons. The course was entitled: "Measure Twice, Cut Once: Optimizing Surgical Systems of Care."

The course focused on the application of basic performance improvement tools necessary for surgeons to succeed in a new era of value based care. Lean and Six Sigma concepts applied to healthcare initiatives and human-factors engineering principles were taught. Students interacted with case studies of root cause analysis, failure mode and effects analysis, and other examples of Lean methodologies applied onto systems to improve efficiency and outcomes.

The course was sponsored by the Colleges' Committee on Emerging Surgical Technology and Education.

Study to Explore Role of Hormones in Breast Cancer

Researchers at the Saul and Joyce Brandman Breast Center — A Project of Women's Guild, are conducting a study to explore the role hormones play in the development of breast cancer. The purpose of the study is to find differences in hormone levels between patients who have a new diagnosis of breast cancer and those who do not.

The aim is to develop a blood test to identify patients with early breast cancer or to identify those at higher risk of developing breast cancer.

To be eligible to participate, you must be:

  • A female patient aged 18–50
  • Currently having regular menstrual periods (not pregnant)
  • Not taking birth control pills or other hormones

You do not have to have breast cancer to participate. If you have breast cancer, you must participate in the study before you receive treatment (major surgery, radiation or chemotherapy).

Subjects will have blood drawn between two and four times, and must answer a short questionnaire during study visits. Participation is voluntary.

For more information, contact Edward Phillips, MD, or Laura Sarmiento, research coordinator, at 310-423-4295.

The Role of Hormones in Breast Cancer (PDF)

CS-Link Tip: Pulling Imaging Results

When using CS-Link™, you may want to pull an imaging result into your note. Instead of using copy and paste, you can type dot, "img," and then the anatomical area.

For example, typing ".lastimgchest" will pull results for any CT, ultrasound or X-ray of the chest. Make sure you still review the results under the imaging tabs as this link pulls in the summary and you need to read the entire report.

Also, HealthStream offers physician efficiency training modules for continuing medical education credit. There are 22 modules that last 15 minutes each. They include topics such as "In Basket Quick Actions," "Smart Blocks in Progress Notes" and "SmartList Editor."

To take advantage, log into HealthStream and search the catalog using keywords: PET CME. Select the module you want to view, then click "Enroll."

If you have questions, contact groupeisphysicians@cshs.org.