INSIDE: Excerpts from the 2024 SFMMS Addiction Seminar
Medical Student Perspectives
Physician Wellness… and much more
Howard Kornfeld,
William Andereck,
by Eric Shanabrook, in Lake Placid, NY, April 8, 2024
CMADocs.org – June 5
The California Medical Association (CMA)-led initiative to expand access to and improve health care for all Californians took another significant step forward this week as the “Protect Access to Care” initiative officially became eligible for the November 2024 ballot after counties throughout the state finished counting the signatures submitted by the campaign coalition. The initiative will bring billions of dollars in federal funding to California to improve care for patients across the state, particularly the more than 15 million Californians, including half of the state’s children, who depend on Medi-Cal for health insurance.
The initiative builds on the historic investment that the Governor and Legislature made earlier this year to dedicate additional funding to the Medi–Cal program. The Protect Access to Healthcare Initiative is critical to ensuring the accessibility and affordability of health care services for all Californians, as well as recognizing the critical role that physicians play in achieving this vision.
Without raising taxes on individuals, the measure will bring more federal funds back to California and improve access to critical health care services. This initiative includes targeted rate increases for primary care and specialty care to make it easier for Medi–Cal patients to find a physician. In addition, the measure includes funding for graduate medical education to create more residency slots and new residency programs and loan repayment for those who agree to treat Medi–Cal patients. Specifically, the initiative will:
Expand access to preventive health care for Medi–Cal patients, leading to fewer costly emergency room visits and shorter wait times for all Californians
Increase funding for mental health, including for those who need in–patient care
Help California to manufacture its own insulin and other prescription drugs for much lower prices than exist currently
Expand California’s education and training to create a pipeline of physicians and other health care providers to help alleviate shortages in underserved areas of the state
The support and engagement of you — and the other physicians of California — is crucial to driving this initiative forward. In the coming weeks and months, we will reach out to you with opportunities to assist in outreach and education efforts and keep you updated on the progress of this initiative. Please visit AccesstoHealthcareCA.com for more information.
Governor’s Health Care Funding Cuts Highlight Urgency of Protect Access to Healthcare Ballot Initiative CMADocs.org
Governor Gavin Newsom released his proposed May Revision to the 2024-25 state budget, revealing disappointing news about the state's financial outlook. Despite efforts to reduce the projected shortfall earlier this year, the current deficit for the 2024-25 budget year is $27.6 billion, with a projected deficit of $28.4 billion for 2025-26. The proposed revisions to the budget underscore the importance of passing our ballot measure in November, the Protect Access to Healthcare Act, to ensure continued investment in Medi-Cal and the health care workforce.
CMA Statement on Supreme Court Ruling on Abortion Medications
Sacramento, CA — Tanya W. Spirtos, M.D., president of the California Medical Association (CMA), issued the following statement in response to the U.S. Supreme Court’s decision in FDA v. Alliance for Hippocratic Medicine, which preserves the U.S. Food and Drug Administration’s (FDA) approval of the abortion medication mifepristone:
“The U.S. Supreme Court’s unanimous decision today is welcome news, as it will preserve access to the medication mifepristone, which has been used in nearly two-thirds of all abortions in the U.S. last year, and safeguard patients’ rights to evidence-based reproductive health services.
Mifepristone is a safe and effective drug that has been used by millions of Americans since the FDA approved its use more than 20 years ago. Limiting the availability of mifepristone would have had devastating health impacts and further intruded on the private health choices of patients. CMA is pleased the Supreme Court has rejected this attempt to interfere with the FDA approval process.
As physicians, we at CMA believe it is essential that patients have access to vital, often life-saving, reproductive health care. CMA stands committed to protecting the fundamental right to access reproductive health services. We will continue to work to ensure that personal medical decisions are made by patients in consultation with their health care providers.”
Physician and medical student leaders at the Annual Meeting of the American Medical Association House of Delegates have approved policies aimed at fighting for greater insurer accountability and transparency regarding prior authorization requirements—issues which the AMA said are denying necessary care for patients and adding administrative burdens for physicians. The policies adopted by the House of Delegates address what it sees as the need for greater oversight of health insurers' use of prior authorization controls on patient access to care.
SFMMS Past President, Dr. Monique Schaulis, Discusses the Many Misconceptions of Palliative Care
Dr. Monique Schaulis, SFMMS Past President, was featured on a recent episode of Fixing Healthcare. This episode dives into the essential yet often misunderstood world of palliative and hospice care—part of this ninth season’s continued focus on end-of-life issues.
Alongside cohosts Dr. Robert Pearl and Jeremy Corr, Dr. Schaulis tackles common myths and misunderstandings surrounding palliative care. She explains why palliative care is not just for end-of-life situations, and how it can be integrated with curative treatments at any stage of a serious illness. She emphasizes that palliative care is a holistic medical specialty focused on improving the quality of life for patients of all ages by addressing physical, psychosocial, spiritual, and existential distress.
To listen to the episode: https://www.fixinghealthcarepodcast.com/2024/05/14/ fhc-133-palliative-care/
San Francisco’s Only Independent Hospital Will Receive $5 Million From the State
Termed-out Assemblymember Phil Ting secured the budget allocation, which will pay for construction of a subacute-care unit in Chinese Hospital. The City currently has no such beds in its public health system, and the closest such facility is in Daly City. “It’s a terrible situation for San Francisco to be in,” Ting said. “Demand for these beds is escalating, and we have nothing to offer.”
SFMMS Leaders, Drs. Roger Eng, Joseph Woo, Sarita Satpathy, Dennis Song and SFMMS Executive Director Conrad Amenta attend Chinese Hospital's 125th Anniversary Celebration.
SFMMS Community Service Foundation is Seeking Organization Nominees
The SFMMS Community Service Foundation (CSF), a charitable 501c3 organization, was founded decades ago to collaborate with and support community health organizations in San Francisco and Marin.
One of the CSF roles is to provide small but significant unrestricted cash grants to worthy local health-oriented nonprofits, from a long-standing CSF fund. Previous grantees include: NovatoSpirit, GirlVentures, SF Marin Food Bank, Homeward Bound, American Clinicians Academy on Medical Aid in Dying, Glide Church, Planned Parenthood of Northern California, Brady Center to Prevent Gun Violence, SFGH Foundation for reproductive health services at San Francisco General Hospital/ UCSF, the San Francisco Free Clinic, Operation Access, the Marin Canal Alliance, and the Palestinian Children’s Relief Fund.
To discuss nomination of an organization, contact Steve Heilig: Heilig@sfmms.org
April/May/June 2024
Volume 97, Number 2
Editor Michael Schrader, MD, PhD
Managing Editor Steve Heilig, MPH
Production Maureen Erwin
SFMMS OFFICERS
President Dennis Song , MD, DDS
President-Elect Jason Nau, MD
Secretary Ian McLachlan, MD
Treasurer Sarita Satpathy, MD
Immediate Past President Heyman Oo, MD, MPH
SFMMS STAFF
Executive Director
Conrad Amenta
Associate Executive Director, Public Health and Education
Steve Heilig, MPH
Director of Operations and Governance
Ian Knox
Director of Engagement
Molly Baldridge, MPH
Senior Director, Advocacy and Policy
Adam Francis, CAE
2024 SFMMS BOARD OF DIRECTORS
Edward Alfrey, MD
Melinda Aquino, MD
Julie Bokser, MD
Kristina Casadei, MD
Clifford Chew, MD
Esme Cullen, MD
Manal Elkarra, MD
Mihal Emberton, MD
Cindy Greenberg, MD
Ian McLachlan, MD, Secretary
Jason Nau, MD, President-Elect
Heyman Oo, MD, Immediate Past-President
David Pating, MD
Sarita Satpathy, MD, Treasurer
Michael Schrader, MD, Editor
Yalda Shahram, MD
Neeru Singh, MD
Dennis Song, MD, DDS, President
Kristen Swann, MD
Ranna Tabrizi, MD
Kenneth Tai, MD
Melanie Thompson, DO
Kristin Wong, MD
Andrea Yeung, MD
Helen Yu, MD
For questions regarding journal, including possible submissions, contact Steve Heilig: Heilig@sfmms.org
Dennis Song, MD, DDS
In healthcare, the amount of data is voluminous, doubling every three years. Even if one were to try , it would take several lifetimes to read every journal article while critically evaluating the flaws, errors, or omissions of each study. How does a physician sort through this? Furthermore, not all research and data is with the best of intentions. The funding has to come from somewhere and the research produced is expected to be scientific and without bias. Unfortunately, this isn’t always the case and as scientists, we seek trustworthy authorities to help us navigate through this sea of data. Healthcare providers rely on trusted entities to sort through this information to provide best practices and recommendations. The public and legislators also rely on us to be experts in these areas.
In the 1960’s, the National Institute of Dental Research conducted research to eradicate dental caries. With what is obvious now, the role of sucrose was undeniable in dental caries. Based on one company’s internal documents, the sugar industry instead directed public attention and research to find enzymes to break up dental plaque and vaccines to target bacteria found in tooth decay rather than decrease sugar consumption. Central to this strategy was developing relationships within the NIDR leadership and expert consultants, which led to the formation of the National Caries Program in the 1970’s—deflecting negative attention from the sugar industry by redirecting research priorities. Dental caries was reduced by this program, but most children still developed disease.
At the same time, in the 1950’s, the sugar industry realized that if a lower fat diet was promoted for the sake of health, America's sugar consumption would go up by one third. The sugar industry could downplay the risks of sugar and highlight the hazards of fat. Funded by the sugar industry, the Sugar Research Foundation sponsored research to refute sugar’s role in heart disease published by highly regarded academic institutions in national medical journals. This would change the public perception and influence medical education for decades. At the same time, hiding sugar under different names (sucrose, dextrose, barley malt, agave nectar, etc.) easily deflected the public perception of a food product, never mind there is little transparency in meals purchased at restaurants. The diabetes and obesity found in the population today can be correlated with increased sugar consumption.
A similar approach was taken by the tobacco industry in the 1950’s. The National Cancer Institute pursued a Smoking and Health Program with the idea to develop a safer cigarette and invited tobacco manufacturers to participate with the idea that they had product expertise. Instead, their involvement resulted in opposition of funding to smoking cessation programs while withholding the knowledge of the detrimental biological effects
of cigarette smoke and nicotine addiction. This blocked effective control strategies for decades.
These historical examples illustrate how industry could control research and affect policy today. Given all our specialties and the global responsibility of primary care, how and by what means does the physician navigate? With which data do we advise patients and advise politicians for proper advocacy to enact legislation to protect patients and physicians? One of my attendings in medical school was a chain smoker. While counseling patients on tobacco cessation, she would then take a break by smoking a cigarette between patients. As a medical student, I found this to be a clashing contradiction. An example today is the literature regarding alcohol. The World Health Organization’s cancer research arm concluded that alcohol was a group one carcinogen in 1988. What has the alcohol industry done since then? How have recent studies influenced the public and the behavior of the healthcare provider?
Are we practicing the best medicine by treating the sequelae of disease resulting from flawed research or biased policy rather than the underlying process? Rather than prevention and root cause analysis, we are treating iatrogenic disease by bandaging chronic disease with medications, excising cancer, or treating a myocardial infarction. At one time, menopausal hormone replacement therapy was universally recommended, but after the Heart and Estrogen/Progestin Replacement Study and Women’s Health Initiative trials reported excess cardiovascular risk, no medical society recommended hormone replacement for prevention of cardiovascular disease. Later, the risk was better understood and now is recommended for appropriate patients.
With the advent of the internet, access to data is easier, but so is the amount of misinformation. Couple this with security breaches, artificial intelligence, political motivation, and profiteering. Then throw in politics and religion. How can a physician navigate and decide? We forget as well that physicians are patients too. Academic institutions and healthcare organizations should be free of influence from politics and industry influence. Trust and validity are important. With its volunteer leaders, the San Francisco Marin Medical Society does its best in providing the right direction for healthcare policy and good medicine.
Dennis Song, MD, DDS is an oral and maxillofacial surgeon in private practice and Chief of the Dental Division at Sutter California Pacific Medical Center. He also serves as an Associate Adjunct Professor at the University of the Pacific School of Dentistry. A graduate of the UCSF School of Dentistry, UC Davis School of Medicine, and UCSF Residency programs, he has been active in organized healthcare since his days as a student.
Conrad Amenta, SFMMS Executive Director
In today’s highly politicized climate, physicians often find themselves in the challenging position of having to navigate difficult discussions with patients, colleagues, and the public. These conversations can range from public health measures to humanitarian issues, and they often carry strong political undertones. As I reflect on my experiences over the past several weeks, here are some strategies to consider as you navigate difficult conversations.
1. Maintain Professionalism
First and foremost, it is crucial for physicians and their advocates to maintain their professionalism, focusing on the medical facts at hand and deliberating in a collegial manner. More often than not, it's the tone and tenor of our deliberations that creates the conditions for compromise.
2. We're All in This Together: Empathize and Learn
Empathy is a powerful tool in any difficult conversation. Try to understand the other person’s perspective and validate their feelings. This doesn’t mean automatic consensus, but acknowledging an opposing viewpoint can go a long way in building trust and rapport. Importantly, physicians should aspire to maintain solidarity as a profession, knowing that the fight for patients and health outcomes must continue beyond the debate of the day.
3. Stick to the Facts
In a world of misinformation, physicians and their advocates have a responsibility to adhere first to evidence-based information. Stick to the facts and avoid getting drawn into speculative or opinion-based arguments. This is especially important during dynamic and shifting events about which we may not have access to reliable information.
4. Set Boundaries
While it’s important to be open and empathetic, it’s also necessary to set boundaries. If a conversation becomes too heated or unproductive, it’s okay to step away by suggesting continuing the conversation at another time.
5. Practice Self-Care
Lastly, don’t forget about self-care. These conversations can be emotionally draining, and it’s important for physicians to take care of their own mental health. This might mean taking a few moments to decompress after a difficult conversation, seeking support from colleagues, availing yourself of the health and wellness resources provided by SFMMS and the California Medical Association, or using mindfulness techniques to stay grounded.
SFMMS' physician leadership has recently engaged in some difficult discussions. Our leadership, which is comprised of diverse medical specialties, modes of practice, age, and demographics, and is broadly representative of the profession in San Francisco and Marin, come together to deliberate because the Medical Society is a place where members can advance what matters to them most. It's at the Medical Society that physicians discuss with their colleagues the best path forward for their patients and for the profession.
I would like to acknowledge our leaders who have brought to the Society important and complex questions, who have prioritized an atmosphere or respect and collegiality, and who have worked to heal fissures when they occur. In this moment, maintaining the strong bonds in the medical community is paramount.
Since the overturning of Roe v. Wade last year, reproductive health and rights have been constantly in the news— and constantly under threats. This is of course not truly new, but the threats are now more serious, varied, and widespread than ever in modern history.
We have seen the Dobbs decision overturn what we and many of our patients thought was a basic right to healthcare. We have seen a judicial challenge to medical abortion and the power of the FDA to regulate drugs brought to the Supreme Court. We have seen the resurrection of the archaic 1800s Comstock Act with the intention of limiting access to medical abortion. Many states have banned abortion and others have changed the gestational limit to less than 20 weeks and even to six weeks. This challenges the benchmark concept of fetal viability at 24 weeks of gestation.
Now we are seeing legislative efforts to outlaw IVF and even political campaigns to restrict access to contraception. The most extreme anti-abortionists want abortion to be deemed murder with severe penalties for physicians and pregnant women, with even “bounty hunter” financial payments offered to anyone who turns a patient or clinician in to authorities.
All of these efforts abridge women’s rights to healthcare and the autonomy of the physician and patient relationship to make individual complex medical decisions based on our best judgment. This impacts the management of non pregnancy related medical conditions. Medical education is being compromised by legislation that restricts best medical practices, and trainees are lamenting the lack of full specialist education and even shunning states where bans are in effect, further compromising future access in those areas.
The Supreme Court is hearing a case, Moyle vs United States, that challenges EMTALA directives to render treatment to all who seek it. This stems from an Idaho law that terms fetuses “unborn children” and could result in the Supreme Court establishing personhood for fetuses. Tragic outcomes of such restrictions are already being reported.
California has already done much to assure continued access to the full spectrum of reproductive health services, but all is not assured. Reproductive rights are state and national issues. Federal laws could supersede our state laws. Our physicians could be prosecuted in other states. Distribution and availability of mifepristone could be disrupted or banned.
The SFMMS has a long history of promoting reproductive health and rights. Years ago our policy resolutions to CMA and AMA resulted in those organizations supporting “pro-choice” positions rather than being neutral or silent on abortion. We advocated for expanded abortion training in medical education and sent mailings on this to every American medical student. We developed policy on universal access to contraception. We
Michael Schrader, MD, PhD and Steve Heilig, MPH
conducted the first survey about abortion medication of American OB-GYNs, showing strong support for availability here. After RU486 had been used safely and effectively by hundreds of thousands of European patients and called “The Moral Property of Women” by France’s Minister of Health, our early policy resolution got the CMA and AMA to support fair evaluation of abortion medications and approval if indicated. And we have supported reproductive health organizations such as Planned Parenthood for decades.
In 1992, after outgoing President George HW Bush vowed that abortion medications would never become available in the United States, a group of SFMMS members and staff conducted a “staged” import of then-illegal RU-486 (now mifepristone) from France to garner support for FDA approval. The intentional detainment of the pregnant woman bringing the pills into the US landed the issue on the front page of the New York Times and the nightly news. Her case was ultimately heard by the US Supreme Court which upheld the Bush import ban. However, newly-elected President Bill Clinton, citing this event and the AMA support SFMMS initiated via our delegation, pledged to have the FDA fairly review the medication for eventual approval. It then took eight years, but this early publicity and advocacy eventually helped culminate in the FDA approval of mifepristone in 2000.
Organized Medicine is still responding in many ways. Our SFMMS District VIII Delegation proposed a Major Issue topic— which focuses CMA activities for a year—to the CMA House of Delegates supporting reproductive rights. At the Council of Delegation Chairs in May this was combined with other proposals into a Major Issue combining reproductive rights, maternal/fetal health, and obstetric “deserts.”
With our upcoming CMA Major Issue including reproductive health and rights to be presented to the CMA House of Delegates in October, we hope to help create consolidated and comprehensive CMA policy on reproductive health, rights, and access. And from policy we can mobilize opinion and advocate for legislation and other important tools for access, training, and more. Despite all the politicization and divisiveness, the strong majority of Americans do still strongly support reproductive rights, and still listen to physicians and our organizations on this topic. We will make our informed and compassionate voices heard, and hopefully heeded, wherever we can.
Dr. Schrader, an internist at Dignity Health, is Chair of the SFMMS delegation to the CMA and a past-president of the SFMMS.
Steve Heilig is on the SFMMS staff and managing editor of this journal, co-editor of the Cambridge Quarterly of Healthcare Ethics, and a former director at Planned Parenthood and other healthcare organizations..
Michael Schrader, MD, PhD
Once again we have participated in the prelude to the CMA House of Delegates (HoD). The foci of the meetings is decided by a meeting of the Council of Delegate Chairs (CDC) where two to three Major Issues are selected to be the basis of discussion and policy formation. The object is to propose issues that are of interest to the delegates and then propose a coherent body of policy that can be advocated for at the state and national level.
As many of you may remember, last year’s meeting at LA Live was canceled due to a labor dispute over health insurance coverage. CMA did what was necessary and cancelled the meeting. The HoD meeting was then divided into two meetings with a required business meeting in 2023 to elect new officers and take care of corporate business.
Our own Dr. Shannon Udovic-Constant was elected PresidentElect and our own Dr. George Fouras was elected Vice-Speaker. Major Issues were addressed in a second teleconference meeting where important policy was adopted on climate change and artificial intelligence. The third Major Issue was educational about the new state Office of Health Care Affordability.
This year our CMA HoD will meet in Sacramento and will be presided over by Speaker Dr. Jack Chou and Vice Speaker, our own, Dr. George Fouras. Our directive this year was to limit to two Major Issues as the allotted HoD time will be limited; we will have a three-way contested election for CMA President-Elect and a presentation by the Governance TAC.
The first round was introducing each delegation’s Major Issue proposals. There are 26 delegations in total representing both regions and physician groups. Our SFMMS Delegation VIII submitted three resolutions: reproductive rights, treatment of addiction and overdose deaths, and migrant health.
Because of the current political climate we elected to focus on reproductive rights. Dr. Schrader reached out to the other delegation Chairs individually via email prior to the CDC meeting to generate support.
Each delegation presented two Major Issue proposals. These were then voted on in a sequence of eliminations. The CDC meeting Wednesday evening went for 3.5 hours. All delegations were represented. We went through four rounds of voting, eliminating and consolidating Major Issue topics. The first Major Issue topic to be selected was Rural Health Equity.
Our Major Issue of reproductive rights had a decent amount of support. Related issues were obstetrics deserts and maternal/ fetal health care. More than 20 Major Issues were proposed in all, including drug pricing/availability, physician burnout, scope of practice, cybersecurity, and physician workforce.
Through an iterative voting process, the Major Issues with the least support were winnowed out or rolled into other Major Issues, e.g., workforce became part of rural health. Reproductive rights was combined with obstetric deserts and maternal/fetal health.
The voting and negotiating were tense and strategic. Right up to the final vote it was uncertain. Reproductive health/rights went head to head with drug pricing and availability. CMA staff weighed in that the CMA policy would have only minimal impact on either drug pricing and availability. Votes were changed at the last minute until we ultimately prevailed. It was like winning in double overtime.
This topic will give CMA a good opportunity to work with the Governor, who is very committed to protecting reproductive rights. The whole process was complex, sometimes confusing technically, and impressively managed by Speaker Chou and Vice Speaker George Fouras.
As a final note, the AMA recently adopted the CMA’s resolution on medical responses to climate change challenges, with an SFMMS action item on developing good clinical tools for addressing such concerns with patients added to the new policy.
Dr. Schrader, an internist at Dignity Health, is Chair of the SFMMS delegation to the CMA and a past-president of the SFMMS.
SFMMS Leader Linda Hawes Clever honored for Lifetime Contributions to Physician Wellness
Adam Francis, CAE
Each year in May, hundreds of bills face the gauntlet of the Senate and Assembly Appropriations Committees’ Suspense File. The bills on this File are ones that would cost the state money, and the Committee has a special hearing to determine their fate. In a mix of high stakes political and fiscal decisions, many bills are held back, essentially eliminating their prospects of becoming law. SFMMS’s priority legislation came out relatively unscathed, with only three supported bills no longer moving forward in the legislative process:
• AB 2303 (Carrillo, Juan) would have required the Department of Health Care Services (DHCS) to apply for a waiver from the federal government to increase Federally Qualified Health Centers (FQHC's) and Community Health Clinics (CHC's) prospective payment system rate before April 1, 2025, so that they could afford the raised minimum wage for health care workers.
• AB 2142 (Haney) would have established a pilot program that allows for two prisons to expand mental health therapies to inmates the Department of Corrections and Rehabilitation (DCR) has deemed "not eligible" to receive mental health services.
• AB 3073 (Haney) would have required wastewater testing to pinpoint drug hotspots and identify new drugs in the population.
Some of the SFMMS-supported bills that continue to move toward the Governor’s Desk include:
• AB 1778 (Connolly)
This bill puts in place a county ordinance that would prohibit individuals under 16 years old from riding an electric bicycle that can reach 20 miles per hour in Marin County. Additionally, the bill would require a person operating a class 2 electric bike to wear a helmet. Lastly, the county will be required to submit a report to the Legislature including information related to the number of violations, if arrests were made, etc. SFMMS has prioritized improving safety related to e-bikes in San Francisco and Marin.
• AB 1975 (Bonta)
This bill requires medically supportive food and nutrition intervention plans that are determined to be medically necessary by a provider to be a Medi-Cal covered benefit.
• AB 2115 (Haney)
This bill would authorize hospitals, ERs, and primary care clinics that do not provide methadone to dispense a 72-hour
supply of methadone treatment to initiate patients on the medication and provide some linkage medication supply while they await intake at an Opioid Treatment Program for ongoing methadone treatment for opioid use disorder.
• AB 977 (Rodriguez)
This CMA-sponsored bill increases penalties for violence against Emergency Room health care workers.
• AB 2442 (Zbur)
This bill would expedite physician and other provider license applications if the provider is performing gender-affirming care and mental health services. This expedited licensure process mirrors existing accelerated processes for providers who intend to perform abortions. Improving access to gender-affirming care prioritizes health equity, an SFMMS priority.
• AB 3218 (Wood)
This bill would require each manufacturer/importer of tobacco products to submit to the Attorney General a list of all brand styles of tobacco products that they manufacture or import for sale or distribution in or into California, and state that it lacks a characterizing flavor. The list would be called the "Unflavored Tobacco List," and the bill would prohibit a distributor from selling any tobacco product not listed on the Unflavored Tobacco List to any person. Anti-tobacco bills are a priority for SFMMS.
• SB 959 (Menjivar)
This bill would require the Health and Human Services Agency (HHS) to develop, maintain and regularly update a website for the public to access information and resources to support and care for the transgender, gender diverse, and intersex (TGI) community. The website would provide information such as health insurer directories that identify in-network providers that offer gender-affirming services, and support services to assist an individual in accessing trans-inclusive health care. Improving access to gender-affirming care prioritizes health equity, an SFMMS priority.
• SB 966 (Wiener)
This bill creates a licensing and regulatory scheme for pharmacy benefit managers (PBMs) under the Board of Pharmacy in the Department of Consumer Affairs. The bill would prohibit PBMs from:
• Manipulatively steering patients to preferred or affiliated pharmacies.
• Entering spread-pricing contracts (where the cost to the plan is more than what the PBM pays the pharmacy for the medications and keeps the difference).
• Getting revenue from any other source except for management fees for plan formularies, including coupons.
• SB 1120 (Becker)
This CMA-sponsored bill would require a health care service plan or insurer to ensure that a licensed physician supervises the use of artificial intelligence decision-making tools when those tools are used to inform decisions to approve, modify, or deny requests by providers for authorization prior to, or concurrent with, the provision of health care services to enrollees or insureds.
• SB 1132 (Durazo)
This bill would empower county health officials to conduct public health inspections at private detention facilities, including those used to detain immigrants in California.
• SB 1253 (Gonzalez)
This bill requires an individual to have a valid, unexpired firearm safety certificate to purchase or possess a firearm. An individual must obtain a firearm safety certificate within 60 days of bringing a firearm to the state. Additionally, the bill would
require the department to notify an individual their certificate is nearing expiration and needs renewal. Bills seeking to reduce gun violence are a priority for SFMMS.
• SB 1395 (Becker)
This bill builds on existing streamlining laws for homeless shelters by eliminating and extending sunset provisions, and specifying that interim housing and shelter are eligible projects under existing state homeless programs. Its goal is to give local governments additional powers to build interim housing units quickly and inexpensively. Improving access to shelter and housing for those experiencing homelessness is an SFMMS priority.
To learn more about state and local legislation, and how you can be involved, please consider joining the SFMMS Advocacy and Policy Committee: https://tinyurl.com/SFMMS-APC
Adam Francis is Senior Director of Policy and Advocacy for the SFMMS.
Mayor Breed recently released her 2024-25 budget proposal. San Francisco is facing a nearly $800 million shortfall. The Mayor seeks to address this shortfall by leaving non-critical government positions vacant across departments and limiting the addition of new General Fund-funded positions; reducing contract spending; funding new capital and IT projects at reduced levels; and leveraging one-time revenue sources (from state and federal funds) largely in the Department of Public Health (DPH). The proposed DPH budget, which makes up roughly $3 billion of the county’s $15 billion total budget, is $47.0 million (1.5 percent) higher than the 2023-24 budget. This is primarily due to increases in salaries mandated by labor agreements, new programs supported by opioid settlement funding, and state and private funding for capital improvements and mental health services. The Mayor’s proposal avoids large cuts to DPH through Medi-Cal expands to cover all individuals regardless of immigration status, and no longer needing to support community COVID testing and vaccines, as that is now handled by individual health systems.
Physicians are increasingly aware of the risks, both clinical and legal, for treating pain with opioids. Fearful of regulatory scrutiny, faced with reluctance of pharmacists at the large chains, and surrounded with rising stigma and misunderstanding, the pace of prescribing for opioids has dropped considerably. Despite this, the rate of illicit and dangerous opioid use, outside of medical care, has brought the death rate of overdoses and morbidity to an all-time high.
Our medical practice has been in the fields of addiction and pain medicine for three decades. We were early adopters of buprenorphine for pain in the 1990's and for addiction after FDA approval in 2002. We have introduced and published several innovations regarding the uses of this versatile medication and lectured on buprenorphine both locally and nationally. For the patient population with pain that is unresponsive to nonpharmacologic and non-opioid interventions, we have seen this medication be transformative in hundreds of situations.
Furthermore, buprenorphine is quite effective in discouraging and preventing the emergence of addictive behavior and to a significant degree, can also directly prevent overdose deaths by blunting the activity of other administered opioids. Relevant to pain medicine, buprenorphine is recognized for efficacy against opioid induced hyperalgesia, as well as in neuropathic pain, which is often unresponsive to other opioids.
Although recent regulatory changes at the federal level have removed barriers to prescribing buprenorphine for addiction, it is not clear that there is any such momentum in the treatment of pain with buprenorphine. Despite decades of review papers in highly placed peer reviewed journals highlighting buprenorphine’s remarkable efficacy and safety in treating chronic pain, neither pain specialists nor primary care physicians in our community often propose or even mention buprenorphine.
For example, few physicians are prescribers of the two FDA approved forms of buprenorphine for chronic pain: transdermal buprenorphine (Butrans and generic)—and—mucoadhesive/ buccal buprenorphine (Belbuca). Fewer still are skilled at repurposing the more available and affordable forms of buprenorphine that are approved for addiction towards pain conditions.
(Buprenorphine, like other opioids, induces a physiological dependency, but much more so than other opioids, is particularly
suited to a gradual tapering process. In those with or highly vulnerable to addiction, or with a high level of severity of symptoms, buprenorphine can be maintained indefinitely. Much more or in contrast with other opioids, buprenorphine is associated with relief of depression, anxiety, and other psychiatric syndromes, rather than the exacerbation of these co-occurring disorders. In this regard, treatment with buprenorphine can facilitate tapering patients off of unnecessary or harmful medications including benzodiazepines, zolpidem like drugs, anti-psychotics, and SSRI's, when appropriate. For those who stay on buprenorphine over time, the benefits in pain and symptom management are often seen to increase, while the side effects remain stable or decrease. )
Like other opioids, buprenorphine is associated, but less so, with hypogonadism and constipation. Both of these conditions are highly responsive to thoughtful intervention. Buprenorphine, compared to other opioids, is not thought to contribute to immunodeficiency, nor to complications when used in renal and hepatic dysfunction.
Since the publication by the CDC of the 2016 Guidelines for Prescribing Opioids for Chronic Pain, millions of patients with chronic pain have undergone opiate dose reductions or eliminations. Although the risk of addiction and overdose were undoubtedly reduced for many, at least for the short run, a significant minority of these patients suffered setbacks, including turning to street drugs, rather than experiencing better outcomes.
Large numbers of other patients with more recently diagnosed chronic pain , irrespective of severity, have been denied both standard opioid pharmacotherapy as well as a consideration of buprenorphine.
The adoption of buprenorphine in pain medicine has likely been slowed by other factors. At the highest level of government science, unlike the case with buprenorphine for addiction, the potential of this medication for pain is rarely discussed. A case in point can be found in the pages of the NIH Pain Consortium, where buprenorphine is mentioned only once in a pediatric context (2020 NIH Pain Consortium Symposium Summary, 2020).
If clinicians are even aware of the availability of buprenorphine for chronic pain, there are more often than not misconceptions, five of which are listed in the chart on page 13.
1) Buprenorphine is often thought of as too powerful, as it is also used in addiction, but this is based on either stigma or inexperience in reducing the initial dosing.
2) Buprenorphine is alternatively thought of as too weak as it is a "partial agonist," but this conception is considered outdated for pain and applies more directly to respiratory depression.
3) Buprenorphine is expected to interfere with the actions of other opioids that would be given for post surgical or breakthrough pain, but in practice, adjusting the dose upwards under careful monitoring is quite successful.
4) Buprenorphine is often not "liked" by patients, but this is often a function of "euphoric recall" of the regular opiate. With tincture of time and careful dose calibration, patients learn to appreciate and "like" the steady support of the buprenorphine, as opposed to the roller coaster of previous opiate prescriptions.
5) Buprenorphine should not be used for chronic pain as it is associated with physiological dependence and is hard to taper off of. Misconceived, notwithstanding the surface truth of these observations, is that the patients who would benefit from buprenorphine are often already being managed with dependency producing medications, such as opioids or benzodiazepines, with negative outcomes. With poorly managed pain, these patients and others face significant morbidity and mortality, sometimes from suicide, that make the cost/benefit ratio favorable. With experience, buprenorphine prescribers can develop skills at tapering and discontinuing the medication. Due to its long duration of action and tight binding properties at the mu opioid receptor, buprenorphine is uniquely suited to dose reductions.
Another instance is the otherwise excellent 2018 Neuropsychopharmacology review article on opioid mechanisms, coauthored by Nora Volkow, Director of the National Institute of Drug Abuse (Valentino & Volkow, 2018). She and her co-author describe the two primary intracellular second messenger pathways activated by classical opiates, the G protein pathway that leads to the desired analgesic effect of opiates and the β-arrestin pathway that leads to less desirable effects such as respiratory depression, euphoria, withdrawal, and addiction. Experimental drugs have shown potential or "bias" in favoring the beneficial G protein pathway. The authors, like others, see this as an opportunity for industry to patent new drugs. Not mentioned, however, even by such an erudite author is time tested buprenorphine, that displays the desired G protein bias.
In the last year, there has also been much publicity about the novel non-opioid molecule “VX-548” developed by Vertex Pharmaceuticals to target the sodium channel in peripheral nerves. It was favorably studied in a postoperative acute pain model, and Vertex plans to submit it for review by the FDA this year. It is being hailed as the long sought after alternative to standard opioids and the possible answer to our opioid dilemma. Not mentioned in the media coverage, is buprenorphine's current availability and FDA approval and how extensively it has been studied. For example, there are over 10,000 PubMed entries for buprenorphine.
In retrospect, it may have been the proprietary marketing of such products as OxyContin and Duragesic (sustained release oxycodone and transdermal fentanyl) in the late 1980's and 1990's that drove out consideration of the better studied buprenorphine, already known for analgesia and lower abuse potential.
We need innovation and the pharmaceutical industry. Buprenorphine itself was an invention of the private sector. But let's not let the vision of a new crop of theoretical and expensive drugs eclipse the need for public health funding and guidance to further study and implement buprenorphine therapeutics for severe pain.
Howard Kornfeld, MD is Medical Director, Recovery Without Walls in Mill Valley; Founding Medical Director, Pain Management and Functional Restoration Clinic, Highland Hospital, Alameda Health Systems, 2010-2017; Clinical Faculty, UCSF School of Medicine; Pain Fellowship Program Distinguished Fellow, American Society of Addiction Medicine (ASAM); Board Certified in Addiction Medicine, Pain Medicine, and Emergency Medicine (1984-2023).
Joshua Dov Epstein is a graduate of Cornell University who is applying to medical school.
References
1. 2020 NIH Pain Consortium Symposium Summary. (2020). Www. painconsortium.nih.gov. https://www.painconsortium.nih.gov/ meetings-events/annual-symposia/2020nih-pain-consortium-symposium
2. Jones, J. W., Correll, D., Lechner, S., Jazić, I., Miao, X., Shaw, D. M., Simard C, Osteen, J. D., Hare, B., Beaton, A., Bertoch, T., Asokumar Buvanendran, Habib, A. S., Pizzi, L. J., Pollak, R., Weiner, S. G., Bozic, C., Negulescu, P. A., & White, P. F. (2023). Selective Inhibition of NaV1.8 with VX-548 for Acute Pain. The New England Journal of Medicine, 389(5), 393–405. https://doi. org/10.1056/nejmoa2209870
3. Valentino, R. J., & Volkow, N. D. (2018). Untangling the complexity of opioid receptor function. Neuropsychopharmacology, 43(13), 2514–2520. https://doi.org/10.1038/s41386-018-0225-3
The shocking increase in overdose deaths among young people in recent years has provided a wake-up call about the need for innovative drug education strategies that have the potential to prevent harm and save lives.
After a quarter century and an uphill battle, Safety First, the onceshunned harm reduction drug education approach created by the Drug Policy Alliance is finally gaining acceptance.
It’s been quite a journey.
As the mother of teenagers in the ‘90’s, I was regularly bombarded with urgent messages that implored me to listen to Nancy Reagan so my children would “just say no.” My kids, too, were constantly exposed to anti-drug messages in school, on TV, and in community-based programs. I began to worry about the content of these messages when my daughter, after “graduating” from the DARE (Drug Abuse Resistance Education) program in 1988, announced “Mom, you may not know this, but when a person smokes marijuana, half of their brain cells are erased forever.” I knew this “information” was designed to ensure abstinence among young people, but I was skeptical it would succeed.
Marsha Rosenbaum, PhD
not inevitably lead to the use of hard drugs; and drugs’ dangers, despite frightening media depictions, failed to materialize and instead provided ample material for mockery.
But with little credible information offered to them by adults, teens were on their own. I believed a reality and science-based approach would capture teenagers’ attention, helping them to make safer choices.
Let me be clear, if I had believed that total abstinence from alcohol and other drug use was achievable and realistic, it would have been my first choice.
But as a National Institute on Drug Abuse grantee, and a savvy San Franciscan, I knew it was unlikely that curious teenagers (like mine) would simply “just say no.”
As a sociologist, I set out to learn about the content of schoolbased programs, and found that in the quest for abstinence, most contained questionable assertions: any drug use was a sign of pathology or deviance; drug use was indistinguishable from drug abuse; marijuana was a “gateway” drug that would lead inevitably to the use of harder drugs; and if teenagers understood the dangers of drug use, they would simply abstain. I also learned that despite significant government funding for prevention, national surveys like Monitoring the Future were finding that a significant population of teens continued to experiment with alcohol and other drugs.
Why had “just say no” failed for so many of the “DARE generation”? Most American teenagers had grown up observing healthy adults imbibing responsibly, so use did not automatically equal abuse; they saw with their own eyes that marijuana use did
In partnership with the San Francisco Medical Society, in 1999 we hosted “Just Say Know: New Directions in Drug Education.” It was the first-of-itskind harm reduction drug education conference. We convened researchers, academics, teachers, parents, practitioners, and even politicians from around the world. The message coming out of the conference was simple: Abstinence was the best choice, but drug education should provide comprehensive, scientificbased information, not scare tactics; messages should distinguish between use/experimentation and drug abuse/problem use; information about the very real legal consequences of drug use should be provided; and safety should be stressed above all else.
We were attacked, of course, by anti-drug zealots. They were afraid of harm reduction, claiming that abandoning abstinenceonly education would facilitate drug use. Thus, harm reduction drug education was prohibited in schools.
Since we had hit a wall, our education efforts focused on parents of teenagers, providing them with credible information and ways to deal with the real possibility that their teens might experiment.
We set out to find the greatest number of parents we could reach, and the million-member California State Parent-Teacher Association seemed an appropriate, if bold, place to start.
The first of my series of booklets about harm reduction drug education, Safety First: a Reality-Based Approach to Teens, Drugs, and Drug Education, had been published shortly before our 1999 conference, and written primarily for parents. Our goal was to provide the booklet to every local PTA in California.
After numerous, sometimes painful “auditions,” PTA leadership said yes. In an amazing move, the Safety First Project was deemed an Allied Agency of the PTA, and thousands of copies of the booklet were distributed to parents and teachers. Addi-
tionally, I travelled the world lecturing, and regularly led parent workshops all over California.
It was evident that parents, and especially teachers, wanted more. They were looking for a high school curriculum that could replace those ineffective abstinence-only programs they were forced to teach. Educators were ready for harm reduction drug education!
Our goal was to be included in the national list of approved programs. Beginning in 2016 we worked with educators to create a program that would align with National Health Education Standards and Common Core State Standards so they could easily be integrated into high school health classes. Safety First: Real Drug Education for Teens was a 15-lesson curriculum that would help students use critical thinking skills to access and evaluate information about alcohol and other drugs; learn decision-making and goal-setting skills that would help them make healthy choices related to substance use; develop personal and social strategies to manage the potential risks, benefits and harms of alcohol and other drug use; and understand the impact of drug policies on personal and community health.
We piloted the program at high schools in New York and San Francisco. The evaluations conducted by the Research Foundation at the City University of New York were encouraging, showing significant increases in students’ knowledge of harm reduction, abstinence, and how to detect and respond to a drug overdose—essentially ensuring their safety.
Teachers loved the curriculum, saying “I saw my students being unafraid to ask questions. They were all engaged the whole time.” Regarding the harm reduction approach, teachers
agreed that it empowered students not only to help themselves but to help their friends, family, and others in their community. As another teacher said, “It puts them in the position to be a hero. There’s such little empowerment in students’ lives. This gives them that opportunity.”
To expand exposure, in 2022, Safety First joined the HalpernFelsher REACH LAB at Stanford University’s Division of Adolescent Medicine in the Department of Pediatrics. Later the curriculum was revised and extended, and through extensive outreach, interest in and requests for Safety First teacher trainings continue to increase.
Imagine my delight when learning, just recently, that Safety First had hit another milestone. The Health Education Framework (part of the California Department of Education) now includes Safety First in their drug education program recommendations.
After a quarter century, Safety First has finally made “the list”!
Marsha Rosenbaum, PhD earned her doctorate in medical sociology at the University of California, San Francisco in 1979. Her research on drug issues was funded by the National Institute on Drug Abuse as she completed studies of opioid addiction, crack cocaine, MDMA and drug treatment. Dr. Rosenbaum’s publications include three books and numerous articles and opinion pieces.
Special thanks go to Stefanie Jones, Sasha Simon, Amani Rushing, Nina Rose Fisher, Camilla Field, Rhana Hashemi, Bonnie Halpern-Felsher, and Steve Heilig for their immense contributions to the evolution of Safety First. (https://med.stanford.edu/halpern-felsher-reach-lab/prevention-interventions). (https://californiahealtheducation.org/pages/9-12-Alcohol-Tobacco-Other-Drugs.aspx)
July 30, 12:15-1:15PM
Workplace violence (WPV) in ambulatory settings has become increasingly prevalent due to factors common within all healthcare settings with others being unique to ambulatory care settings. Chronic and complex health conditions are treated more frequently in the outpatient causing risk for patients and families to become increasingly frustrated while demonstrating escalating behaviors that HCW are not trained to safely respond to. Security resources are also not prevalent in the outpatient setting creating a vulnerable environment whereas angered individuals may use to their advantage in a violent manner.
The objectives of this webinar are:
• Discuss the prevalence of workplace violence in the ambulatory care setting.
• Adopt strategies to implement a comprehensive workplace violence prevention plan and preparedness plan
• Promote de-escalation skills to provide health care workers with tools that can be used in their daily interactions with patients, families, and visitors when confronted with escalating behavior.
Register here:
https://www.cmadocs.org/event-info/sessionaltcd/CMA24_0730_TDC/t/webinar-workplace-violence-prevention
Every June, the San Francisco Marin Medical Society hosts a conference co-chaired by Steve Hellig and myself, titled ”Addiction Medicine, Healing and Recovery In A New Era.” This year’s conference was held on June 7, the anniversary of the opening of the Haight-Ashbury Free Clinic in June, 1967.
Besides updates on treatment, public health efforts and drug education, the webinar included a presentation by Andrew Penn of UCSF on psychedelic therapy based on his work at the UCSF psychedelic research center, and one by Todd Y, cofounder of psychedelics in recovery, a 12-step oriented group in which psychedelics are used to facilitate recovery from substance use disorders. We are well aware of the historical irony of such substances being used to reduce the harms of substance use disorders.
My involvement with LSD began in 1965 at UCSF, first with animal studies followed by human exploration involving the therapeutic and spiritual effects of LSD. At that time I took LSD and had a spiritual experience that was transformative and helped me create the idea of a free clinic for those suffering the adverse effects of these drugs. More recently I also experienced psilocybin to deal with PTSD after a traumatic athletic accident, in a setting with an experienced physician guide.
I had first become aware of adverse effects of LSD in 1967 when thousands of young people took the drug during the ”Summer of Love” in 1967 in the Haight Ashbury. The bad publicity surrounding these adverse reactions triggered aggressive action by the DEA to schedule LSD and all psychedelic drugs in a restrictive scheduling reserved for drugs of abuse with no therapeutic indication, such as heroin. Such restrictive scheduling put a halt to most scientific research with psychedelics, but I retained an interest in their therapeutic potential.
A new generation of researchers has been interested in harvesting the therapeutic benefits of psychedelics such as psilocybin, ayahuasca and Ibogaine for the treatment of drug and alcohol dependency. Treatment of alcoholism is considered one of the most promising clinical applications for LSD and classical psychedelics. Bill Wilson, alcoholics anonymous cofounder, extolled the benefits of LSD for spiritual growth consistent with the goals of AA viewing alcoholism as in part a spiritual disease. But opposition to his theories on psychedelics from the general services board of AA and placement of LSD
David Smith, MD
along with other classical psychedelics in the Schedule I by the DEA mostly stopped controlled research with this drug group. The research is exploding in a more mainstreamed and careful manner than decades ago, to avoid the previous abuses and backlash; some are calling this the “third wave” of psychedelics use, following longtime indigenous ritual use and the sixties explosion.
Integration of psychedelics into long-term recovery has been quite complicated.
Searching through all of the information and resources is a complicated task for the healthcare professional. To facilitate this we have formed a San Francisco chapter of Psychedelics in Recovery (PIR) that meets monthly. Most of the members also participate in traditional 12 step programs, but I found that psychedelics can help overcome barriers to spiritual growth. In addition, at UCSF there is an educational group called Psychedelic and Entheogen Academic Council (PEAC) that is composed of researchers, clinicians and trainees, who are actively engaged or interested in the scientific study of psychedelics.
Also advancing this agenda is our Haight Ashbury psychedelic center in San Francisco. This is a psychedelic therapeutic community, bringing together researchers, clinicians, and others to curate educational resources from trusted sources. One purpose of our center is to better educate the healthcare professional on the therapeutic potential of classical psychedelics as well as potential adverse effects when taking them. As FDA approval moves forward it is important that the healthcare provider be informed about the potential benefits and risks of classical psychedelics so they can accurately inform their patients when these questions arrive.
It is our hope that these resources can help achieve this goal as the world of psychedelics gets more complicated for health care practitioners making decisions for this fascinating drug group.
David E. Smith, MD, a graduate of UCSF, founded the Haight-Ashbury Free Clinic in 1967; co-founded and named the specialty of Addiction Medicine and served as president of its California and American medical societies; received UCSF’s highest awards for contributions to medicine and community health; and has been an SFMMS member since 1968.
I had the honor of testifying before the U.S. Senate Budget Committee on May 8, 2024, to address the critical issue of administrative burdens in healthcare. As an assistant professor of neurological surgery at UCSF, I was also privileged to represent the dedicated physicians of San Francisco and Marin County, who tirelessly advocate for better patient care despite the significant challenges we face daily. My co-witnesses were Dr. David Cutler of Harvard University and Mr. Noah Benedict of Rhode Island Primary Care Physicians Corporation. I hope my testimony did justice to our humble community.
I spoke to the committee about the increasing administrative burdens on clinicians, which detract significantly from patient care and lead to physician burnout. I’ve written extensively on this topic, highlighting how quality metrics and electronic health records burden physicians, and how we can keep a promise to put patients over paperwork. I was thrilled when I received an email from Congress asking if I would share my thoughts. The staff were all very knowledgeable, personable, and before I knew it, I was on a flight to DC.
In my testimony, I focused on administrative burdens stemming from federal regulations. This gave me an opportunity to help educate our lawmakers on steps they could take to reduce these burdens. Physicians today are overwhelmed by tasks mandated by federal regulations, particularly from the Centers for Medicare and Medicaid Services (CMS). These regulations consume a substantial portion of our time, leading to stagnant labor productivity growth in healthcare. Meanwhile, the expansion in the healthcare workforce has been predominantly in administrative roles rather than in patient-facing ones.
CMS's myriad quality metrics, billing regulations and electronic health record (EHR) mandates have exacerbated this issue. These mandates significantly contribute to physician burnout—a critical issue, with nearly two-thirds of doctors reporting burnout symptoms. Medical students fare no better, with many recognizing the burdens that come with clinical practice; that 61% don’t plan on practicing medicine after graduation.
Quality programs, such as the Merit-Based Incentive Payment System (MIPS), though well-intentioned, have created a complex web of requirements that often hinder rather than help. While any firm in any industry should measure quality, the top down, heavy-handed methods employed by CMS have had disastrous consequences. Many metrics, such as the Hospital Readmission Reduction Program, have harmed patients. These metrics have also driven the increased administrative burdens, tethering phy-
Anthony DiGiorgio, DO
sicians to computers and necessitating the hiring of numerous administrative staff to collect and report metrics.
It's not just metrics that are tethering physicians to computers. Despite their potential benefits, EHR systems worsen administrative burdens due to their inefficiencies and the onerous documentation they require. The “meaningful use” mandates from CMS have resulted in a consolidated EHR market full of cumbersome products. This has transformed physicians into data and order entry clerks, taking us away from patients. Numerous studies demonstrate how EHR use has eroded clinical time. Repealing meaningful use would alleviate many of these burdens.
To tackle these administrative challenges, we must promote competition in the healthcare market. A system driven by patient choice and provider efficiency can alleviate many of the current burdens. Increasing the penetration of Medicare Advantage and Medicaid Managed Care Organizations can shift CMS from being a plan operator to a plan regulator, focusing on risk adjustment and payment approaches rather than micromanaging care delivery. Additionally, addressing hospital consolidation and fostering competition can lead to more innovative and efficient healthcare solutions.
Speaking on behalf of the physicians in our community was a great honor, as we push for a healthcare system that prioritizes patient care over administrative paperwork. By reducing regulatory burdens and promoting a competitive market, we can enhance the efficiency and quality of care, ultimately benefiting both patients and healthcare providers. It is time to give the market a chance to drive meaningful change in healthcare delivery, allowing frontline physicians to focus on what matters most: providing quality care to patients without the suffocating weight of unnecessary administrative tasks.
In closing, I want to thank the Senate Budget Committee for addressing this vital issue and for giving me the chance to represent the voices of my colleagues in San Francisco and Marin. Together, we can work towards a healthcare system that truly supports its providers and delivers the best possible care to patients.
Dr. DiGiorgio is an assistant professor of neurosurgery at UCSF and an SFMMS delegate to the CMA House of Delegates.
Dean-David Schillinger, MD is a primary care physician, scientist, author, and public health advocate. He is an internationally recognized expert in health communication and has been widely recognized for his work related to improving the health of marginalized populations. He is the inaugural recipient of the Andrew B. Bindman Professorship in Primary Care and Health Policy at the University of California San Francisco (UCSF). Dr. Schillinger has served as chief of the UCSF Division of General Internal Medicine at San Francisco General Hospital, and chief of the Diabetes Prevention and Control Program for the California Department of Public Health. In 2006, he co-founded the UCSF Center for Vulnerable Populations, a leading research center committed to addressing the social, environmental and commercial determinants of health through research, education, policy, and practice. He currently directs the UCSF Health Communications Research Program.
His new book Telltale Hearts: A Public Health Doctor, His Patients, and the Power of Story is published by Polity Press.
Q: TELLTALE HEARTS begins, not with a patient’s medical emergency, but with your own health scare in 2010. The complicated diagnosis was uncovered by a doctor who took the time to carefully listen to your story. How did that experience inform this book?
There are a number of ways that my experience with what was ultimately diagnosed as a mid-life, mid-career episode of major depression provides a roadmap for this book. First, it was only through the unique efforts of a doctor who elicited my own story of my illness that I was able to get accurately diagnosed and treated. Stories, when combined with science, hold the key to healing and recovery. Yet, in modern medicine, stories are rarely elicited—especially from marginalized populations in public hospitals such as San Francisco General Hospital. Second, my story also revealed the root cause of my illness—a series of toxic environmental exposures. Most diseases in our country, in fact,
are a result of untoward social and environmental causes, a fact that disproportionately affects marginalized populations and contributes to health inequities. Third, the extent of the physical symptoms I experienced during the course of my illness demonstrated to me how powerful mood and mood disorders are in shaping the extent of a patient’s suffering. And finally, my experience of being a physician with a depressive disorder made me especially aware of the profound effects that stigma can have on the illness experience and made me more sensitive to the importance of destigmatizing the kinds of diseases that unduly affect marginalized populations.
Q: You write that doctor burnout and bias can result in patients being overlooked, treated as individuals without specific life histories and considered more as members of a collective, often inferior, group. How have you tried to avoid that in your career, and what steps can be taken to solve the problem overall?
I have been subject to these very pressures, and, on a few occasions, I even was complicit in such acts of dehumanization—acts that, in one instance, led to an unnecessary death of a patient who was addicted to heroin. These pressures are only increasing as healthcare becomes more industrialized and as private equity takes increasing ownership of entire health systems and their clinicians. I think the most important step one can take as an individual clinician, beyond constant vigilance, is to connect with each patient on a personal level, while still maintaining one’s professionalism. This can come in many forms. The most effective means to advance a more humanizing form of medicine is the elicitation of each patient’s story. Doing so, particularly if one reciprocates, grounds the relationship with a sense of shared humanity. And having a sense of shared humanity—like a story I tell about a down-and-out saxophone player—makes it very difficult to cause harm to another; rather it fosters actions that promote the well-being of the other. Knowing that your patient with diabetes is a former master auto mechanic who had to stop working due to severe spinal arthritis; that he is in debt, food insecure and struggling to pay the mortgage; that he has three children who love and care for him; and that he owns a vintage 1966 Ford Mustang is very different from knowing that your patient is simply a “59 year old Black male with poorly-controlled diabetes and chronic arthritic pain.” It’s game changing, actually. So, as individual clinicians, we need to be allowed to make these connections, and health systems need to incentivize us to do so, not prevent us from doing so.
Q: Who was Melanie, and why did her story affect you so deeply?
I first met Melanie when she was about 30 years old, and she already had type 2 diabetes. This was a result of having consumed many more times her own body weight in added sugar, mostly in the form of sugar-sweetened beverages (SSBs). This was not her personal choice. As a low income, Black and Latinx child, she lived in a neighborhood where SSBs were ubiquitous, where advertisements for SSBs specifically targeted her, and where the SSB industry had succeeded in creating whole communities that were and are addicted to their disease-causing products. In a very real sense, she was a product of her environment. And her body had already begun to deteriorate. By the time she neared age 40, she had developed kidney disease, eye disease, and had lost sensation in her feet. She was already on 9 medications and required twice daily insulin injections. But on her 40th birthday, catastrophe struck. Her birthday wish had been to go to a water park slide to enjoy an activity she hadn’t done in over 20 years. That day, as she stood in line on the sun-scorched stairs up to the water slide, she burnt both feet without sensing any pain. By that night, the burns had turned into gangrene, and over the next few days she had to have both feet amputated so the gangrene wouldn’t spread. But the infection did spread, and she quickly died a preventable death—a death whose root cause was overexposure to toxic beverages, an overexposure that is all too common in our country today, but especially among the patients I serve in my public hospital. For me, Melanie became a sort of “poster child” for my public health war against the American Beverage Association, a war that has featured a series of battles for which the spirit of Melanie has been a powerful presence. You could say that her story has served as a catalyst for public health action. I believe that stories such as hers can be powerful catalysts for lots of much-needed public health action, and that we should harness such stories to improve unhealthy social and environmental conditions in our nation.
Q: You include stories from your family history in the book: your father’s experience in a concentration camp; his doing surgery on a former Nazi torture victim; another relative surviving WWI when an enemy soldier unexpectedly spared him; your mother’s roots in Chile. What is the throughline between those stories and your experiences working as a doctor caring for very diverse and marginalized patients, from the AIDS crisis in San Francisco to the height of the COVID-19 pandemic?
The throughline here is that we humans toggle very closely (and dangerously) between two extremes: acceptance and support of “the other,” or fear, dehumanization and destruction of “the other.” In times of stress and division, as we see in our own nation today, people can veer towards dehumanizing the other. In Nazi Germany in the 1930s, a time not so unlike our own, it was organized medicine and public health itself that advanced the argument to annihilate whole groups of populations deemed unworthy. Working in a public hospital as I do places one at the epicenter of “otherness”—be it in relation to race, ethnicity, immigration status, disability status, substance use disorders, homelessness, mental illness, you name it. Patients in public hospitals, by societal design, come from the margins of society. The lessons
of my family have taught me that our species is vulnerable to taking advantage of, and even destroying, those deemed to be at the margins. And that medicine and public health can be used as a force for good or for evil. As such, we in medicine and public health must be especially vigilant and proactive in ensuring that all of our actions honor and protect our shared humanity.
Q: You write, “Public hospitals are much more than just places where poor people who are sick go to receive care. They are where health care meets social reality and where a reckoning with our nation’s legacy of racism and inequality cannot be avoided.” Can you explain what you mean?
Public hospitals are one of very few places in US society where individuals from different social classes, educational backgrounds, income levels, and racial and ethnic backgrounds can interact in intimate ways. Here, we see in stark reality the disproportionate burden of illness borne by people of color, people of lower income, and people who are undocumented (among others). It is also here that the curious mind can observe, and validate through scientific inquiry, that the overwhelming majority of illnesses that our patients suffer from are a result of unhealthy social and environmental conditions: unhealthy food supplies, dilapidated and unaffordable housing, unfair zoning practices, air pollution, chemical exposures, traumatic childhoods, occupational risks, unsafe neighborhoods, etc. It is also here that one begins to realize how the risk of exposure is maldistributed across our society, this exposure drives the high burden of disease, and is the consequence of decades upon decades (and even centuries) of social policy and practice. The federally approved practice of redlining, for example, a housing practice outlawed over 75 years ago, still has profound impacts on the health of those who now live in redlined neighborhoods. All of these forces mean that we need to get away from blaming our patients for the illnesses they have, and that we need to take a serious look at how social and environmental policy can improve health not only for marginalized populations, but for all of us— because all but the most privileged in our society are subject to these same forces, albeit in differing doses.
Q: Are primary care doctors being trained to deal with the root cause of disease? Can the real medical needs of patients only be sussed out by taking the time to speak with them? In other words, how well does a doctor need to know their patient?
I’m going to answer those questions indirectly. First, I believe that half of the solution to our healthcare problems today could be solved by strengthening our primary care system. Longitudinal care provided by a trusted, well-trained, generalist clinician and primary care team is an absolutely essential component to a high functioning healthcare system. And, yes this means skilled clinicians who know their patients deeply, who know their stories, and who incorporate the root causes of the patients’ illness into their management plans. However, in our country today, we have a real crisis in primary care. We have a desperate national shortage of primary care clinicians—in rural and in urban regions—and
continued on page 20
we have health systems (both non-profit and owned by private equity) that continually increase the productivity expectations of primary care clinicians without providing additional support. Throw in the burdens of the electronic health record and one can easily see how primary care is getting squeezed from all sides (of note, a recent study revealed that it would take the average primary care clinician 27 hours a day seven days a week to complete her work to a standard level).The other half of the healthcare solution has nothing whatsoever to do with healthcare. To deal with the root causes of disease, we need to move beyond the clinic walls. We need to address our unhealthy social and environmental conditions; this is the real work of public health. Yet our nation is stuck on thinking that improving our health only requires fixes to our healthcare system. What the stories in this book clearly convey is that progressive social and environmental policy action will be key levers of health improvements, and a key means to drive down healthcare costs. In an impending election season, this message couldn’t be more salient.
Q: Where do medical schools fit in with the ideas expressed in this book? Are they teaching students how to carefully listen to their patients?
All medical schools have required curricula in doctor-patient communication, and education in this arena has been gradually improving. That said, there remains tremendous variation in what is taught and how it is taught, and an undue focus remains on how the doctor communicates to, or educates, the patient, rather than how the doctor elicits the patient’s story. An additional problem with existing curricula is that the communication practices themselves often represent expert opinion, rather than scientific evidence of their efficacy. This gap is largely due to the NIH (National Institutes of Health) failing to invest in the science of health communication, a serious oversight that I describe in my book, and whose untoward consequences we have suffered from in the COVID context. Finally, I do want to point out that a limited but increasing number of medical schools have developed curricula related to “narrative medicine,” a broad term that often does include the elicitation of story. All in all, I believe medical schools are moving in a positive direction in this space. The problem is that it is challenging to refine these skills once one is in practice if/when the health system does not prioritize relationship-centered care.
Q: How will AI impact the patient-doctor relationship?
This is one of the most fascinating and exciting questions facing those of us who think and work in this field, and one that will be of utmost importance to all patients. The short answer is we do not know. But I can share some preliminary thoughts based largely on the few studies that have been done with simulated patient encounters in highly constrained circumstances. First, in such simulated and controlled settings, it seems clear that AI is as good or better than real-life doctors at communicating in understandable ways, in being empathic, in being comprehensive, and even in being more accurate from a diagnostic standpoint. And when patients do not know whether the question or response is coming from AI vs a real-life doctor, they seem to find the AI to be more trustworthy.
Q: It is interesting to consider whether AI could be used to train doctors to be more understandable, empathic and trustworthy. Or whether AI could be used in a “copilot” model, allowing the doctor to focus more time on eliciting stories and establishing and reinforcing the shared humanity I discussed earlier. Depending on how AI is implemented in primary care, it also could offload a number of doctors’ mindless administrative tasks, such as medical charting, again allowing for a much richer relationship to develop.
My own deep experience, backed up by some research and described in the stories of my book, is that a healthy and intimate doctor-patient relationship, otherwise known as the “therapeutic alliance,” is as powerful as any medicine and can be as potent as wielding a surgical scalpel. Can AI serve as a substitute for the doctor? I will summarize AI expert Dr. Thomas Fuchs who said: “The complex work of interpretive understanding cannot be done by an AI apparatus. No machine can see through the patient’s behavior in its contrasts between speech and action or in its latent conflicts, recognize the meaning of symptoms on the basis of the patient’s life situation, and derive conclusions from it. The dialogue with the robot remains on the surface; it can be momentarily pleasant and supportive, but never insightful in the therapeutic sense.” In other words, AI cannot and will not serve as a substitute for the very human clinical connections I write about in my book. My hope is that AI can be harnessed to enhance these connections, and not for only the most privileged among us.
Maria Raven, MD, MPH
As an emergency physician in San Francisco, I’m currently seeing more patients with mental health and substance use crises than ever before in my two-decade career. Our emergency department and others like it across the region are overwhelmed.
Last year, the governor signed SB43, which promised to help. It took existing conservatorship rules for those with extreme mental health conditions and applied them to those with substance use disorders alone. Advocates for this bill said it would save the lives of those with severe addiction issues, especially those living on the streets, by forcing them into care. The legislation envisioned such individuals being detained on involuntary holds in emergency departments like mine until they can eventually be transferred to a longer-term treatment facility and conserved—after which treatment for substance use can be mandated.
Despite what SB43 legislates, substance use disorders in the absence of underlying mental illness can’t be grounds for holding patients or treating them involuntarily. Substances wear off. And when they do, most patients don’t demonstrate the type of cognitive damage that would require me to continue an involuntary hold — even if they are refusing medical treatment that I might consider necessary.
The law has been in effect since Jan. 1. But it won’t work if it relies on emergency departments.
Before SB43’s enactment, patients considered a danger to themselves or others, or “gravely disabled”—meaning they could not feed, clothe or shelter themselves—were brought to emergency departments and placed on 72-hour involuntary psychiatric holds that prevented them from leaving. If their condition persisted, they could be held longer, brought before a judge and eventually conserved.
SB43 expanded the definition of “gravely disabled” to include individuals with severe substance use disorders alone—if they are refusing necessary medical treatment. Nearly every shift, I already see the patients SB43 aims to help. They are brought in for acting erratically, unsafely or violently. Behaviors can include running through traffic, repeated overdoses reversed by Narcan or brandishing weapons in public. I have learned that psychosis due to methamphetamine is no longer something I can differentiate from serious mental illnesses such as schizophrenia. Sometimes, they occur in tandem.
After SB43 took effect, the city provided guidance that said patients targeted by the new law could be held involuntarily in emergency departments. While this may be true while patients are acutely intoxicated, once they are sober, I can’t continue this hold in perpetuity.
As long as emergency departments have been in existence, they have treated people with severe alcohol use disorder, a condition eligible for conservatorship for those “gravely disabled” by it long before SB43. While we at times need to admit these patients to a hospital for withdrawal symptoms that we cannot get under control in our emergency department, if they stabilize, they must be discharged — unless we find evidence of cognitive impairment. We try to refer these patients to treatment, and sometimes it succeeds. We are also beginning to offer new treatments such as naltrexone, which reduces cravings and hopefully will help some folks cut down or quit altogether. But only if someone wants it.
Witnessing the challenges faced by our patients with alcohol use disorder can make us feel a bit helpless. But we cannot do more than the law allows.
That’s now true of drug users as well.
If conservatorship were a quick and efficient process with abundant treatment facilities ready for those in need, perhaps this wouldn’t be an issue. But that’s not the case.
Implementing conservatorship is challenging and timeconsuming. Emergency departments like mine are already filled with countless patients on involuntary psychiatric holds due to serious mental illness. A shortage of available inpatient beds in locked psychiatric facilities means these patients — disproportionately poor, often homeless and on Medi-Cal — must typically wait days for a bed to open elsewhere. When a patient does require conservatorship for a serious mental illness, they must often wait weeks or longer.
Patients often live in hospital rooms and hallways while they wait.
continued on page 22
This situation is already untenable. Emergency departments are loud, brightly lit and often add to the stress or confusion of our patients with behavioral health diagnoses. This in turn can lead to violence. Recent surveys have found that 66% of emergency physicians had been physically assaulted while at work, and even higher rates of violence have been experienced by emergency nurses.
Many patients with severe substance use disorder don’t want to stay for treatment if physical signs of withdrawal kick in. And I’m not allowed to treat withdrawal without consent.
SB43 doesn’t allow for mandated substance use treatment or other forms of forced medical care until after a patient is conserved. According to current law, forcing medical care upon a patient who is refusing it is considered battery.
Some psychiatric medications can be given to patients without their authorization if a judge issues what is called a Riese order. But any forced medical treatment beyond that requires a legal authorization called an Affidavit A, which can only be obtained once someone is conserved. That can take weeks, months or even years.
Many patients with severe substance use disorders also have serious medical problems. I have seen devastating wound and skin infections stemming from substance use and other conditions such as poorly controlled HIV or untreated cancer.
But if a patient doesn’t want to be treated and has the capacity to decide against it — which most do — the law requires I let them go.
SB43 is already creating confusion. It empowers law enforcement officers and others to bring more patients to our already crowded department on involuntary psychiatric holds for severe substance use alone, thinking we will provide a path to conservatorship. However, that path breaks down if a patient has decision-making capacity once no longer intoxicated.
Without an ability to enforce an involuntary hold once someone is sober, and without an ability to mandate treatment if a person is not conserved, the law’s purpose is questionable.
The patients whom SB43 aims to help need two main things: more low-barrier access to substance use treatment and permanent supportive housing. Emergency departments are a crucial part of our nation’s medical, mental health and substance use safety net. They are not prisons.
Maria C. Raven is a professor of clinical emergency medicine at UCSF. She is a Public Voices Fellow of the OpEd Project and the UCSF Benioff Homelessness and Housing Initiative. This piece originally appeared in the San Francisco Chronicle; reprinted with permission.
The phone rang as I sat down to dinner with our guests. It was Sam.
“Bill, I am calling to say goodbye.”
“Where are you going Sam?”
“To heaven, I hope, but probably not.”
“What do you mean?”
“I am going to die. I just shot myself up with a whole bottle of insulin.”
“Sam, that’s not a good idea.”
“Maybe not, but it's the only choice I have. My life is over. I just called my three other friends and told them. They wished me well and said they understood. You are the last person on my list, and I don’t want you to feel bad when they find my body in the morning.”
“Sam, we should call an ambulance.”
“That wouldn’t do any good. You don’t know where I live and, besides, I moved the refrigerator up against the door to make sure nobody can get in. I also called you on your home phone, not through the answering service, so there will be no record of this call.”
“But Sam…”
“Bill, you’ve been a great doctor to me for the past four years and I appreciate everything you have done for me. Because of you, I have been able to stay in my hotel, and out of a nursing home, but I can see the writing on the wall, I can’t stand the thought of going to a place like that.”
“Sam, I appreciate the call, and understand how you feel, but I wish you had sent me a letter.”
“Goodbye Bill, and thanks again for everything you have done. You will be a fine doctor.”
And then he hung up.
I walked back into the dining room, poured myself a glass of wine, and proceeded to tell our dinner guests about Sam, without including any information that would identify him.
Sam was nearly eighty. He had lived a hard life. He killed a man in Cleveland with a crowbar when he was in his twenties and spent his thirties in the penitentiary. When he got out, he moved to San Francisco to start over. That explains his reluctance to be incarcerated again in a nursing home. He struggled with alcoholism and had been an insulin dependent diabetic for over fifteen years. He came to see me every month, regaling me with stories of his life in the Tenderloin, the price of street drugs, the
William Andereck, MD
pimps, and the con men. Sometimes I wasn’t sure if the visits were for him, or for me.
But his diabetes was getting the best of him. One of his sources of extra income was playing poker with the ladies in his single room hotel building on the day the Social Security checks arrived. He had always been a bit of a card shark and I often accused him of dealing from the bottom of the deck. He denied nothing, but admitted that his worsening neuropathy was making it difficult to deal the cards.
Even worse, his peripheral vascular disease resulted in festering, non-healing ulcers on his legs. He lost his right leg three months earlier, and it was clear that his left one would have to go soon. We both realized that he could no longer live independently when that happened.
To complicate matters further, I had filled out some disability forms for him a few days earlier, and I remembered his address, on Eddy Street.
Our guests were shocked and horrified. “Clearly, this is a call for help” they exclaimed. “You must do something.”
But I was not convinced. I knew Sam was serious and determined in his actions. He was not looking for a way out. He just wanted to say goodbye. His friends accepted this, why couldn’t I?
And then I thought back to Doctor Ed Pellegrino. He was my Chancellor at the University of Tennessee Medical School a few years earlier. I first met him at orientation my freshman year. Somehow my interest in philosophy came up and it led to an invitation to visit him in his office a few weeks later. That is when I told him that I had one question for him. “How do my responsibilities to others change when I become a doctor?” That question cemented our friendship until the day he died.
We talked about role responsibility and supererogatory behavior. He compared it to a lifeguard on the beach when someone is struggling in the surf. The beachgoers had limited responsibility to risk their lives to save someone they didn’t know. Maybe the strong swimmers might feel obliged to help, but that would be above and beyond their responsibilities as a citizen, supererogatory. Certainly, the non-swimmers should feel no obligation beyond calling the lifeguard. But the lifeguard, based on their role, must act. I was the lifeguard, or in this case the doctor. My responsibility was clear. I called an ambulance and gave them Sam’s address. They broke down the door with an ax, moved the refrigerator, and brought him to the hospital.
I finished my wine and, much to the relief of my guests, walked up the hill to see my patient.
continued on page 24
As soon as I walked into the emergency department, I could hear him bellowing from a room down the hall.
“I screwed up! I always screw up! I used NPH (long-acting insulin) instead of Regular!”
He spent several days in the ICU with blood sugars ranging from forty to four hundred. But he survived. Unfortunately, we had to remove his left leg. Afterward, he was sent to a nursing home.
I went to visit him about a month after he was discharged. A few weeks before he died it turned out. He was glad to see me. We talked about the old times, the good and the bad. His other friends had stopped by as well, to say goodbye again.
As I got up to leave, he turned to me with a smile.
“Bill, I understand what you did, and why you did it. You were being a good doctor. I don’t blame you for that.”
And then he winked, and said, “But I wish I would have sent you a letter.”
Epilogue:
Sam died over 40 years ago, and his memory continues to haunt me. I have presented his case to students, interns, medical residents, ethicists, and practicing physicians dozens of times since then. I focused on the physician’s unique responsibility based on the medical ethic espoused by Dr. Pellegrino. This fireman/lifeguard/hero model is clear for doctors to understand and leaves less room for ambiguity. In general, the outcomes are pretty good. Despite the lessons imparted in my lectures, however, Sam’s case has stayed with me over the years due to the realization that I may have made the wrong decision. At the time, I felt that injecting an interpersonal element into the doctor/ patient relationship would hinder the objectivity necessary to be a good physician.
As a young physician, I was dedicated to the concept of objectivity. Science dictated all. Pneumonia needed antibiotics, appendicitis needed surgery, regardless of the poor soul suffering the ailment. The roles and responsibilities of the physician were clear. Some years later I was asked by Dr. Pellegrino’s longstanding colleague, David Thomasma, to contribute a chapter to a book he was editing entitled: The Health Care Professional as Friend and Healer. I found the title odd and wrote a chapter about the effect of commercialism on clinical medicine. But the idea of a physician as the patient’s friend stuck with me.
Sam’s life was over, and we both knew it. His only future was to return to incarceration in a nursing home until his body died
along with his spirit. Now, 40 years later, we could have considered physician-aid-in-dying, but at the time his actions were considered suicide —morally unacceptable and illegal. Despite the social circumstances, I now realize the appropriate course of action would have been to forgo the heroics and, like his other three friends, said goodbye, hung up the phone, and returned to dinner to engage in pleasant conversation.
As I approach the conclusion of a long career in clinical medicine, I realize that I never discussed Sam’s case with retired physicians. Perhaps they might have seen things as I do now. David Thomasma taught me that healing requires more than technical skill and knowledge. It requires trust. Real trust requires you to know someone at a deeper level, to know their values and character. It requires a personal connection. This connection leads to my sense of fulfillment as a physician.
Many of my patients have been with me for over 20 years. We have been through the highs and lows of their lives and come to wherever we are now as a team. This type of doctor/patient relationship rarely develops in an urgent care center visit, or even an outpatient clinic with short, focused appointments and providers who change from visit to visit, relying on the electronic record for continuity. The idea seems to be to shift the focus of trust from the individual provider to the institutional brand.
The Pellegrino model of the physician as virtuous savior/ lifeguard can still hold in brief encounters and remains an aspirational standard for those entering the profession. With time and familiarity, the relationship becomes deeper however. It saddens me that many of the young, idealistic physicians entering the profession now may never have a chance to get to know their patients as I have. The constraints of modern medical practice may confine them to being always the lifeguard, and never the friend.
William S. Andereck, MD, FACP is an internist at CPMC and founder of the Sutter Program in Medicine and Human Values. This piece appeared in the Cambridge Quarterly of Healthcare Ethics.
Kennedy Baskin, Kaycee Branche, Allison Chang, Jameson Floyd, Alyssa Fuentes, Caitlin Hendricks, Christian Jimenez, Toyosi Oluwole, Sophie Oubaha, Lora Randa, Matthew Yee, Seth Zupanc
These student pieces inaugurate what we hope will be a regular feature, courtesy of the student authors and their teacher Shieva Khaysm-Bashi MD, Professor of Family and Community Medicine at UCSF and a longtime member of the SFMMS editorial board. We thank her trust and hope you will enjoy them! – The Editors
In January 2024, twelve UCSF medical students embarked upon a two-week medical humanities course taught by Drs. David Elkin and Shieva Khayam-Bashi. While our individual interests led us to enroll in the course, our collective spirit transformed it into a meditation on doctoring. Paintings such as Andrew Wyeth’s Christina’s World and poems like Naomi Shihab Nye’s "Kindness" were catalysts for extended discussions on what it means to be becoming physicians and how to—even in the context of this becoming—keep sight of the humanity that led us to medicine.
At the course's end, we authored a poem together as a class. This poem was written one line at a time, with the first writer writing their line and then passing the paper to the second writer. The second writer wrote their line, folded the paper to cover the first writer’s line, and then passed the paper to the third writer. The third writer repeated the actions of the second writer, writing only in response to the second writer’s line and then folding the paper so that only their line, the third line, was the only one visible to the fourth writer. We continued in this way until every student had written a line for the poem.
Our poem, "Collectively," captures the essence of the course. It highlights how, in our words, we grapple with growing not only our medical knowledge, but our compassion and capacity to bear witness. It is a testament to the importance of integrating medical humanities into medical education.
The UCSF Medical Humanities course occurs every winter, and is one of several electives offered to 1st year Medical Students as part of UCSF School of Medicine's Inquiry Immersion Curriculum.
A class about the medical humanities became a meditation on doctoring:
On who to be, and how to not lose who we are now. On remaining true to oneself, even while questioning who we are.
Being bold enough to admit when we don’t know, and brave enough to seek the answer. Recognizing that failure is not missing a diagnosing, but not listening to who our patients are.
Walking the line between knowledge and knowing, living in the purgatory between knowing and feeling, and feeling that just knowing will never be enough.
The very idea of “enough” beginning to escape your grasp.
Losing your sense of self, thinking “Who am I?”
“What have I become?”
While, simultaneously, finding yourself in the moments of humanity we get to share.
We get to share the good amidst the bad, love amidst despair, and a trust that transcends any opposition.
Your story is one that will take root, so: In our own mysteries, that are too marvelous to be understood except in the passing of time, may our stories and our questions be the delight that grants us our answer.
continued on page 26
I got the call during anatomy lab, while holding your heart in my palms.
Otosan has heart failure, said my mom. Two days and 5,000 miles later, I held my grandpa’s hand, his JVP a butterfly amidst a chorus of monitor alarms and jagged breaths.
Later, when I unnestled your lungs from the thoracic cavity, I wondered, if halfway across the world, someone was doing the same thing, examining Otosan’s lungs, now dense and shrunken from interstitial pneumonia.
I was given your age, sex, profession, and cause of death.
But I want to know—
Who are you?
Who did you love?
Who did you leave behind?
I thumb through your muscles like pages in a book, tugging on pearly tendons, pushing aside tough muscle to prod a deeper layer, illuminating parts of you that no one else has ever seen.
I ask for your forgiveness before moving your arm to an unnatural position to look at your brachial plexus, a network of nerves, pale and glistening, that braid down your shoulder and arm. I wonder who you have held.
We put socks on your hands and feet, for your privacy. I think it makes you look like a baby, mittens covering long yellowed fingernails and socks rubbing on exposed ligaments.
I pat your hand before zipping you up.
During exams,
I identify structures on twenty donors, each draped with light blue cloth, and I almost forget that this could be Otosan, who became a donor like you.
You don’t feel like my first patient, but you taught me my first lesson in medicine: never forget the heart of it.
Manami is a first-generation Japanese-Colombian immigrant and medical student at the University of California, San Francisco, and is part of the Program in Medical Education for the Urban Underserved.
Some say that the goal of a provider is to help others feel seen and heard
To be the sieve for which a person may pour out their life story
Meticulously sifting for clots that compromise care and threaten to stop the flowing nectar of life
To be the one that lays upon the ground listening to the earth
Feeling for rumblings that portend danger further beyond the immediate horizon
As I train and learn such an art, however, I wonder What does it all really mean?
Have I ever experienced that level of care?
Do I know what it’s like to bare my soul in the way we ask of others?
Having been on the other side of the provider-patient divide:
To be seen and heard is to stand upon the precipice of your being and take a leap of faith into the arms of your perceiver
To see the staggering distance that separates two disparate souls and feel the terror of not being caught suffuse every part of your body
To understand the risk of abandonment, sacrifice, and rejection, yet take the plunge all the same, trusting that you will connect at the end of it all
However, some attenuate such dread
They are people who climb and construct a new foundation upon the mountainside to make jumping a safer proposition
They are our sentries who detect even the most silent of suffering and beckon from below, guiding us to safety
Even with the weight of their own lives upon their shoulders, they ascend great heights simply to be there for others
They are the thoughtful stewards of compassion we wish we had since the very beginning and their simple embrace at terminal gravity is nothing short of curative
Even after several falls, I continue to descend my mountains
But, unlike before, I now spring off the edge with confidence and security, falling now feeling like soaring
For I now know that at the bottom awaits wonderfully loving, accepting safety arms open wide
Ethan Tanchoco is a 3rd year medical student at UCSF originally from Walnut, California. Though life can be hectic, he uses poetry as a medium to reflect on his experiences in and out of the medical world, hoping to find continued meaning and purpose through it all.
Paul Brandfonbrener
Empathy has been shown to decrease the further trainees progress through medical education. 1 We enter medical school with our highest levels of empathy and soon that is replaced with medical knowledge. How can we prevent further loss of this essential aspect of patient care?
Through my experience as a third-year medical student in clinical rotations, I have seen that having people who model empathetic care is the most effective way to prevent the loss of empathy. On my internal medicine rotation, I began by having an attending who was a perfect example of this. On our first day together, he took the time to pull up a chair for me so I could sit at eye level when I talked with my patients. He did the same for every other trainee each day we worked together. He would praise us for spending time with our patients. Soon, I would instinctively find chairs for myself and my team. The residents and I felt supported to go out of our way for our patients and form connections rooted in empathy that made our work more meaningful.
However, this attending left and for the last few days of my rotation, I had an attending who did not have the same perspective. After presenting outside of the room of one of my patients, Ms. M, we entered the room as a full team. Ms. M had been with us for a week already. She was suffering from a very painful soft tissue infection due to injection drug use which had made her lose all movement in her left arm. To help build her trust in our team and to show that we cared about her, I sat with her for hours each day and talked with her about her care and her life. Ms. M appreciated the company, and this connection allowed us to move her care forward as she was managing a severe infection which would require weeks of IV antibiotics and continued severe pain.
As I was sitting next to Ms. M on this day, answering her questions and taking time to update her on her care plan, I could tell that the new attending was ready to move to the next room. After we wrapped up, we walked into the hallway and he said to me, “You’ll outgrow talking that much to patients.” I was surprised that someone could see this type of connection as something that was to be outgrown. Talking to patients is why I became a doctor in the first place and is what made this
patient feel cared for. While this attending might have entered the field for the same reasons, it was clear that now he did not have the emotional reserve to continue to form empathetic connections with patients. This is unfortunate but understandable in a medical system that commonly prioritizes patient turnover over patient connection. His perspective was rooted in a feeling of being overworked and wanting to get through our patient list so we could go home sooner. While this attitude compromised patient care for this attending’s patients, it also had a huge impact on the care the rest of the team gave. Our patient visits became shorter and shorter. The residents focused more on finishing tasks quickly and spent less time with the medical students. Our overall positivity in the workroom dissipated and our priority went from providing good care to providing quick care so we could leave.
Upon reflecting on these two experiences, I’ve realized that trainees are constantly being exposed to the culture of medicine and with it, are developing values and habits that they will carry with them throughout their career. With that in mind, it is vital to have role models who instill values rooted in patient-centered care if we want to have any hope of creating future physicians who hold on to the empathy that they enter medical school with. Mentors have a lasting impact on trainees. I urge them to be very mindful with what values they pass on, and if they aren’t sure what to do, just pull up a chair.
Paul is a third-year medical student at UCSF. When he is not learning about medicine, Paul enjoys writing, exploring the outdoors in the Bay Area as a climber and surfer, and playing guitar in his medical student band “Radial Head.”
Decline in the Clinical Phase of Medical Education? A Nationwide, Multi-Institutional, Cross-Sectional Study of Students at DO-Granting Medical Schools. Academic Medicine 95(6):p 911-918, June 2020. | DOI: 10.1097/ACM.0000000000003175
Jessie Mahoney, MD
Light is Medicine
Natural light is nourishing, grounding, healing, and repleting for mind, body, and spirit. Our own and those of our patients.
Light is extremely important to health and wellness. It’s but one reason why 24-36 hours straight in a hospital is challenging for our health and our spirits. Operating rooms have no windows or natural light. Most exam rooms don’t either. We talk about seasonal affective disorder but not about the quality and quantity of beautiful natural light in our lives. Imagine if light were something we talked about just like movement, sleep, and food?
Play Is Medicine
Kids play, develop, grow, learn, transform, and build trust and confidence. Play in children is not seen as indulgent. It is “necessary” for their health, happiness, and growth.
Adults equally need play for a well-lived, healthy, and whole life. Not work hard, play hard play. We need play that
Mindful Yoga for Healers in Old Mill Park Sponsored by SFMMS: Did You Miss Mother's Day Mindful Yoga? Join Us in October!
“What a wonderful event. It was so great to connect with friends and colleagues I haven’t seen in years while practicing yoga amongst the Redwoods!” – SFMMS Member
SFMMS members and their families attended the SFMMS Mindful Yoga for Healers and community building at the Old Mill Park Amphitheatre in Mill Valley on Mother’s Day. Special thanks to Dr. Jessie Mahoney for hosting this beautiful event.
SFMMS will host our next Mindful Yoga for Healers on Sunday, October 6th. Visit the SFMMS Events Page for event information and to register: https://www.sfmms.org/news-events/events
feels really good to every cell in our body. We need play that isn’t scripted, with an ulterior motive or exercise disguised as play.
True play involves curiosity, creativity, lightness, presence, joy, and laughter. It usually involves some exercise, but that is not the goal.
Play in the flowers, in the grass, on a mountain top, in a river, in a tree, during yoga, cooking, or coaching. When we play, heal, learn, grow confidence, and build trust our children benefit. Our partners benefit. Our patients benefit. Our colleagues benefit. Even our institutions benefit. Most importantly we benefit. We become healthier, happier, and more whole. Learning to care for ourselves “as well” is magic to sustainable successful relationships and careers. In medicine. Outside of medicine.
How can you add more play to your life? What might happen if you do?
Join Dr. Mahoney on Zoom most Saturdays at 9am or anytime on YouTube.
For more information visit: https://mindfulyoga.jessiemahoneymd.com/ or https://youtube.com/c/JessieMahoney.
Jessie Mahoney is a pediatrician, a certified life coach for physicians, and a yoga instructor. She is the Chair of the SFMMS Physician Wellness Task Force. She practiced pediatrics and was a Physician Wellness leader at Kaiser Permanente for 17 years. She is the founder of Pause and Presence Coaching where she supports and empowers her physician colleagues using mindfulness tools and mindset coaching.
The SFMMS Membership Engagement Committee (MEC) was established by the SFMMS Board of Directors. Delegated to and directed by the SFMMS Board of Directors, the MEC plans, facilitates, and reviews proposed SFMMS membership engagement opportunities, including but not limited to: in-person, virtual, or hybrid convenings of members and non-member physicians; communications campaigns; educational and practice support opportunities; wellness activities; the Annual Gala; Annual General Meeting; socials and mixers; networking opportunities; and raffles and other promotional initiatives.
This opportunity is right for you if you want to foster a sense of community among physicians in San Francisco and Marin Counties and believe that physician engagement is key to improving the conditions of medical practice and outcomes for patients.
To learn more and apply, visit https://www.surveymonkey.com/r/P8RRGJT or scan the QR code with your smartphone.
ENTER THE SFMMS RAFFLE TO WIN A SPONSORED SPOT AT THE OCTOBER RETREAT!
Scan the QR Code with your smartphone to learn more and enter the raffle.
Healthy community and human connections with colleagues are protective against burnout. Retreats increase satisfaction, health and sustainability.
Honoring Diastole at Pie Ranch in Pescadero, CA Mindful Coaching, Yoga and Culinary Medicine. CME available. Oct. 5th, 2024
Connect in Nature at Green Gulch, Muir Beach, CA Mindful Coaching, Yoga and Culinary Medicine. CME available. September 6-8th, 2024
(TPMG, PAMF, Dignity Health,UCSF, & SCVMC attending retreats)
Retreats for you are amazing. Retreats for your team add an added element of healing, optimism, and growth. The work we do in medicine is hard. Well teams are a key component of not making hard jobs harder. Well-facilitated and expertly planned team wellness experiences make a HUGE difference—to the health and wellness of physicians, patients, and institutions. Physicians with burnout are twice as likely to be involved in patient safety incidents, to exhibit low professionalism, and to receive low satisfaction ratings from patients. While there are many competing demands for money in healthcare currently, these experiences are a worthy investment. There are also many creative and impactful ways to make them happen. Find out more about both individual and team retreats here https://www.jessiemahoneymd.com/retreats.
Read our Monthly SFMMS Wellness Blog
Each month, as part of the Physician Wellness leaders' work, they curate wellness resources around a common theme for our monthly wellness blog. Read, listen, and attend the monthly resources the committee has curated for SFMMS members by visiting: https://www.sfmms.org/news-events/sfmms-blog.aspx? Category=physician-wellness. Have you missed a recent Wellness Event?
You can learn more about upcoming wellness events or view recordings of past events on the SFMMS Wellness Page at www. sfmms.org/get-help/physician-wellness
The annual statewide poll offers a comprehensive look at the health issues Californians are most worried about — and what they hope state policymakers will prioritize this year. CHCF has been publishing its policy survey annually for five years. In doing so, it has identified shifting trends in the health care landscape, as well as emerging issues like the impacts of climate change on health and Californians’ views about the use of artificial intelligence in health care. The complete findings can be found at: https://www.chcf.org/ publication/2024-chcf-california-health-policy-survey/
Key Takeaways from the Poll
While the survey includes many new and interesting insights about the health care experiences and policy priorities Californians share, my top five takeaways from this year’s research are:
1. California’s mental health system is strained. This year’s CHCF poll finds more than half (52%) of those who tried to make a mental health care appointment in the last year had trouble finding a mental health provider who would accept their insurance. And a similar proportion (55%) reports unreasonable wait times for mental health treatment. When asked about treatment for serious mental illness, more than two in three Californians (67%) believe improvement is needed. Increasing access to mental health treatment is now an “extremely” or “very” important health policy priority for four in five Californians (81%).
2. Health care costs and medical debt are making Californians sicker. More than half of Californians (53%) say they skipped or postponed care due to cost in the last year — a number that rises to a startling three of four when it comes to Californians with low incomes (74%). This is leading to greater health challenges, as more than half of those who skipped care (54%) say their condition got worse as a result. Meanwhile, close to 4 in 10 Californians (38%), and over half of those with low incomes (52%), say they are carrying medical debt, with nearly one in five owing $5,000 or more.
3. Significant work remains to improve racial equity in health care. Despite renewed efforts to acknowledge and respond to racial inequities in the health system, Californians have mixed views on the pace of improvement. While 42% of Californians overall believe the state has made “a great deal” or “some” progress toward racial and ethnic health equity in the last several years, 44% of Black Californians and 33% of
Kristof Stremikis
Latino/x Californians say the state has made “only a little progress” or “no progress at all.” Nearly half of Californians (45%) say the health system “regularly” or “occasionally” treats people unfairly because of their race — a number that climbs to 67% for Black Californians. A recent CHCF study, Listening to Black Californians, identified a range of policy actions and practice changes at the clinical, administrative, and training levels that could reduce the impact of racism on Black Californians’ health care experiences and improve their health outcomes.
4. California’s health workforce shortage continues to affect many communities. Nearly half of Californians (46%) think their community does not have enough mental health care providers, including psychologists and therapists, to meet the needs of residents. And 42% say their community does not have enough nurses or primary care providers. These numbers have climbed since 2022 for many health professions. Multiracial (69%) and Black Californians (56%) are more likely than Asian (37%) and White Californians (45%) to say their community lacks sufficient mental health providers.
5. Extreme weather is a growing health issue in the Golden State. With the impacts of climate change becoming part of everyday life, more than half of Californians (53%) say they are “very” or “somewhat” worried about the effects of environmental factors such as extreme heat, floods, wildfires, and poor air quality on the physical or mental health of someone in their family. That number climbs to 65% for people with low incomes. Among Californians who speak Spanish, 82% say they are “very” or “somewhat” worried about the effects of weather on their health compared with those who speak English (52%) or Chinese (51%). One in five Californians (21%) — and 29% of state residents with low incomes — report that extreme weather has had an impact on their health.
The full health policy poll report has much more detail on these and many other health-related issues concerning Californians, including housing and homelessness, as well as challenges with navigating the health system.
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