San Francisco Marin Medicine, Vol. 95, No. 2, April/May/June

SAN FRANCISCO MARIN MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M A R I N M E D I CA L S O C I E T Y

Special Section:

REPRODUCTIVE HEALTH AND RIGHTS Gun Violence Is Our “Lane” | Two Years of COVID Responses | Physician Wellness Governor Signs MICRA Modernization | Food As Medicine | Surviving Assault | Treating Bridge Survivors Volume 95, Number 2 | APRIL/MAY/JUNE 2022

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IN THIS ISSUE

SAN FRANCISCO MARIN MEDICINE

FEATURE ARTICLES

MONTHLY COLUMNS

10 Two Years of COVID: Meeting the Many Challenges Michael Schrader, MD, PhD

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Membership Matters

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President's Message Michael Schrader, MD, PhD

SPECIAL SECTION: REPRODUCTIVE HEALTH & RIGHTS 12 SFMMS Interview: Daniel Grossman, MD, FACOG Steve Heilig, MPH

14 A Streamlined Model for Medication Abortion Access Ushma Upadhyay, PhD, MPH and Marji Gold, MD 15 Victims of Injustice David E. Smith, MD

16 "The Moral Property of Women": Bringing Medical Abortion to the United States Steve Heilig, MPH 18 Roe Under Attack: How Can I Help?

Ari Friedman, MD, PhD

19 The San Francisco 9 - An Abortion Milestone Carole Joffe, PhD

20 Meet the Co-Presidents of Med Students for Choice Sarah Siddiqui

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Executive Memo Conrad Amenta

COMMUNITY NEWS 33 Kaiser News Maria Ansari, MD

33 Kaiser Permanente San Rafael Naveen Kumar, MD

OF INTEREST 7

Press Release: Governor Newsom Signs Legislation to Modernize California's Medical Malpractice System

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Highlights from the SFMMS 2022 Gala

22 Meet Your SFMMS CMA/CDPH Leadership 36 Advertiser Index

24 22-Year History of Treating Golden Gate Bridge Fall Victims at Marin Health Medical Center John Maa, MD and Edward Alfrey, MD

26 Surviving an Assault and Saving a Life, All on Overtime Toni Brayer, MD 28 Health Care Plans Must Embrace Food and Nutrition-Based Medical Interventions Katie Ettman

26 Becoming a Physician is Hard. Being One is Even Harder.

Jessie Mahoney, MD

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Editorial and Advertising Offices: San Francisco Marin Medical Society 312 Sutter, Suite 608 SF, CA 94108 Phone: (415) 561-0850 Web: www.sfmms.org

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MEMBERSHIP MATTERS CMA sponsored bill would reduce administrative burdens in Physician Practices The California Medical Association (CMA) is sponsoring a legislative effort to reduce administrative burdens in physician practices, so physicians can spend less time on paperwork and billing and more time dedicated to patient care.

Senate Bill (SB) 250 introduced by Senator Richard Pan, M.D., will reduce administrative burdens by reforming prior authorization and billing processes. As it stands, health plans already collect all the data needed to streamline the prior authorization process in their current utilization review system.

The bill would relieve physicians from repetitively submitting prior authorizations for a set period of time, with a review at the end of that period to determine if that physician may continue to be exempt from prior authorization requirements. The bill would also streamline the billing process for physicians in hospital settings by requiring payors to collect enrollee costsharing amounts directly (including deductibles) – based on the agreements they make with their enrollees – freeing physicians from having to act as collectors, and, instead, allowing them to provide quality, coordinated care to their patients.

Physicians are spending increasing quantities of time filing paperwork, fighting with health plans and inputting redundant information into their electronic health records (EHR) instead of spending time with their patients. These administrative burdens cost time, money and other resources that could be better spent coordinating care for patients with chronic and/ or complex conditions or seeing more patients.

In a 2019 physician survey, the American Medical Association (AMA) found that, on average, providers complete 32 prior authorizations per week; taking nearly 2 working days out of the week to complete. Burdensome prior authorization processes also contribute to more adverse events, especially because they can result in treatment delays. In a follow-up AMA physician survey, 91 percent of physicians said that prior authorizations interfere with continuity of care for patients and have a negative impact on clinical outcomes.

The COVID-19 pandemic will have a lasting impact on the health of our communities. SB 250 will help to ensure that patients receive the care they need in a timely and efficient manner.

SFMMS Joins Day of Action Against Gun Violence

continue to plague our nation,” said California Medical Association (CMA) President Robert E. Wailes, M.D. "As healers, physicians are often on the front lines of gun violence, but the latest shooting in Oklahoma targeted physicians in a space that should be devoted to peace and healing. This cannot stand. CMA calls for reform to end this terrible epidemic of gun violence.”

The Tulsa hospital shooting comes just eight days after 19 school children and two teachers were slaughtered in Uvalde, Texas, and two weeks after a white supremacist attack in a Buffalo, New York, supermarket killed 10 people and an attack at a church in California where one of our own—John Cheng, M.D.—took heroic measures to stop another act of senseless gun violence, and in the process gave his life to save others.

“We cannot become numb to the nearly daily reports of gun violence and mass shootings. We cannot sit idly by and do nothing while more than 45,000 Americans die each year by gunfire,” said Dr. Wailes. “This is a uniquely American public health crisis. We must come together with a united front and call for meaningful action to save lives.”

Since 1975, more Americans have died from firearms than in all the wars in U.S. history going back to the American Revolution.

Gun violence is a public health crisis, and as with other public health areas, evidence-based interventions are needed for reducing deaths and injuries.

CMA has long-standing policy recommendations for reducing firearm-related trauma, injury and death. CMA strongly supports H.R. 7910, the “Protecting Our Kids Act,” an omnibus package of eight bills focused on preventing firearm violence. With gun violence soaring, it is imperative for Congress to act now.

“CMA declared gun violence a public health crisis in 2016 and physicians will continue to demand action to end this senseless epidemic of indiscriminate violence, whether in our schools, our health facilities or our streets,” said Dr. Wailes.

Physicians across the Bay Area participated on Saturday in a day of action against gun violence.

SFMMS leaders marched with hundreds of others across the Golden Gate Bridge in an event organized by Moms Demand Action.

Meanwhile, an SFMMS-sponsored gun buyback program in Marin County attracted a surprisingly high number of participants who turned in their firearms to be destroyed.

SFMMS President, Dr. Michael Schrader, and SFMMS Immediate Past-President, Dr. Monique Schaulis, are quoted in the Chronicle's coverage.

CMA calls for immediate action to address epidemic of gun violence Over the past month, a series of tragic and senseless mass shootings have, once again, ripped communities and families apart, destroyed and ended lives far too soon, and further exposed the epidemic of gun violence that grips our nation.

The latest attack hit very close to home, when a man opened fire in a medical office building on the campus of Saint Francis Hospital in Tulsa, Okla., killing four people—including two physicians—and injuring several others before taking his own life.

“The physicians of California stand in solidarity with our health care colleagues in Oklahoma and send not just our deepest condolences, but our outrage that such senseless acts of violence 2

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What You Can Do As physicians, our mission is to heal and to maintain health. Physicians are in a unique position to assess risk, provide education and change behaviors related to firearm violence.

In 2017, the CMA Firearm Violence Prevention Technical Advisory Committee, composed of physician experts, performed a comprehensive review and analysis of CMA policy, epidemiological data and current scientific research and developed a CMA position statement on the prevention of firearm violence.

“Physicians have a responsibility as trusted public health figures to respond to the harms associated with firearm violence, both as individual clinicians and as community advocates,” says Dr. Wailes. “I ask my fellow physicians to make a commitment to ask your patients about firearms when appropriate and follow through with support and resources to keep them safe. We can make a difference, one patient at a time.”

In 2019, California Assembly Bill 521 authorized three years of funding for the California Firearm Violence Research Center at UC Davis. Building on the prior work of the UC Davis What You Can Do Initiative, the BulletPoints Project gives clinicians the knowledge and tools they need to reduce the risk of firearm injury and death in their patients.

Visit BulletPointsProject.org for more information on what you can do, as physicians, to help stop gun violence.

San Rafael’s outdoor smoking rules applauded

As the former chief of general surgery at MarinHealth Medical Center and past president of the San Francisco Marin Medical Society, I would like to thank the San Rafael City Council for banning smoking in open spaces and adopting new rules for smoking outside multifamily housing complexes (“San Rafael bans smoking year-round in open space,” May 4).

Cigarette smoking is one of the leading causes of wildland, home and workplace fires.

It has caused approximately 30% of all fire-related deaths in America. San Rafael’s action will also reduce exposure to secondhand smoke. It moves our state one step closer to achieving the California Tobacco Endgame Center for Organizing and Engagement’s goal of eliminating tobacco-related health disparities by 2035.

— Dr. John Maa, San Francisco

SFMMS President Michael Schrader, M.D. Speaks Out to Defend Abortion Rights San Francisco City Attorney David Chiu joins the Bar Association of San Francisco, representatives of major law firms, and health care providers at a press conference to announce the formation of new coalition to provide legal services to those who will be impacted when the U.S. Supreme Court strikes down Roe v. Wade.

SFMMS Addiction Medicine Conference Recording Available The Annual SFMMS/David E Smith MD addiction conference featured well-received presentations on timely and tough topics, and is now available via the SFMMS website: https://www.sfmms.org/news-events/events.

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April/May/June 2022 Volume 95, Number 2 Editor Gordon L. Fung, MD, PhD, FACC, FACP Managing Editor Steve Heilig, MPH Production Maureen Erwin SFMMS OFFICERS President Michael C. Schrader, MD, PhD, FACP President-elect Heyman Oo, MD, MPH Secretary Jason Nau, MD Treasurer Dennis Song, MD Immediate Past President Monique Schaulis, 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 Staff Associate Ashley Coskey 2022 SFMMS BOARD OF DIRECTORS Edward Alfrey, MD Melinda Aquino, MD Ayanna Bennett, MD Julie Bokser, MD Kristina Casadei, MD Anne Cummings, MD Manal Elkarra, MD Mihal Emberton, MD Beth Griffiths, MD Robert A. Harvey, MD Harrison Hines, MD Ian McLachlan, MD Jason R. Nau, MD Heyman Oo, MD Sarita Satpathy, MD Monique Schaulis, MD Michael C. Schrader, MD Yalda Shahram, MD Neeru Singh, MD Dennis Song, MD Kristen Swann, MD Kenneth Tai, MD Melanie Thompson, DO Matthew D. Willis, MD, MPH Joseph W. Woo, MD Andrea Yeung, MD

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PRESIDENT’S MESSAGE Michael Schrader, MD, PhD

THIS IS OUR LANE The recent slaughter of children at the Robb Elementary School in Uvalde, Texas has focused our national attention on the carnage toll that gun violence takes on children. The Centers for Disease Control have reported that in 2020 gun violence and accidents had become the leading cause of death among children ages 1-19.

The recent massacre at the Tops supermarket in Buffalo, New York reflects the terrible toll that firearms take on Black communities. Black men are 37% of homicide victims in the United States. This is a health equity issue.

In addition to these highly reported tragedies, there are multiple mass shooting events (defined as more than four victims) that occur regularly in the United States. More than 110 Americans are killed daily and more than 200 are shot and wounded.

This rampant gun violence also results in post traumatic stress disorder (PTSD), adverse childhood events (ACE), and perpetuates a cycle of violence.

The firearm industry has promoted a false narrative. Namely, that guns offer security and protection. We know that gun ownership is linked to higher rates of homicide and suicide.

Guns are are not defensive weapons: the notions of deterrence and a good guy with a gun are disproved by recent events.

Deterrence does not work when the suicidal aim of the shooter is to be shot and killed. The good guys with the guns don’t have firearms and tactical gear to match an automatic weapon.

The deaths of children and minorities are not simple collateral damage for an over armed society: they are victims of the firearm industry and its powerful lobby, the NRA. Every mass shooting and school shooting causes a surge in gun buying and a boost for politicians who espouse Second Amendment rights for political expediency.

The Second Amendment protects the right to bear arms contingent on the necessity for a well regulated militia. Let us focus on the words “well regulated.” And let us define what “well

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regulated” means: background checks, red flag laws, gun safety education and research, and a ban on ghost guns.

A majority of Americans supports rational restrictions on firearm ownership. Many gun owners concur. Over the past several decades the NRA has transformed from an association of sportsmen that promoted gun safety and responsible gun ownership.

The current NRA opposes any restriction on firearms because it is the tool of the firearm industry. An industry that uses government to profit from using human lives as a commodity.

The NRA isn’t about the right to own guns. It is about the right of the gun industry to profit from carnage.

In 2018 the American College of Physicians published an update of a 2014 policy paper, “Reducing Firearm Injuries and Deaths in the United States,” that proposed commonsense policies to reduce gun-related injuries and deaths. The response from the NRA: “Someone should tell self-important anti-gun doctors to stay in their lane.” This gave rise to the reaction from physicians using #ThisIsOurLane hashtag.

What can we do?

• Increase purchase age for semi-automatic rifles from 18-22 • Ban high capacity magazines and bump stocks • Close ghost gun loophole • Create federal requirements for safe gun storage • Reinforce red flag laws • Community violence prevention measures This is our lane.

Dr. Schrader chairs the SFMMS delegation (with Dr. Ameena Ahmed, newly-elected vice-chair) and is president of the SFMMS.

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EXECUTIVE MEMO Conrad Amenta, SFMMS Executive Director

SAN FRANCISCO MARIN MEDICAL SOCIETY WILL FIGHT FOR REPRODUCTIVE RIGHTS The news arrived on Monday, May 2022, and what has been the source of speculation, fear, and anxiety for many millions of American women and men was confirmed: the Supreme Court of the United States, featuring three newly appointed justices establishing a clear conservative majority, had drafted an opinion that will overturn the federal constitutional protections on abortion rights determined by its 1973 decision, Roe v. Wade.

Should this draft opinion become the opinion of the court, a gulf will open in America between states that allow abortion and states that ban or restrict it. More than ever, there will be two Americas, defined by a partisan divide, where very different values and laws determine how citizens are permitted to live. It is expected that 13 states will ban abortion immediately or very quickly, and 11 could restrict access, affecting access to vital care for up to 69 million Americans. The number of patients traveling to California to access abortion services could increase from 46,000 to 1.4 million, with drastic implications for statewide access to medical care.

In San Francisco and Marin, we were quick to assert our values and dedication to longstanding policy that “abortions are medical decisions to be made by the patient and her physician, and […] no woman should be denied the right to have an abortion if that is the decision she reaches in consultation with her physician.” San Francisco City Attorney and former Assemblymember for San Francisco, David Chiu, has partnered with the San Francisco Bar Association and SFMMS to establish a pool of pro bono lawyers to advise women from out-of-state who are seeking an abortion in California. SFMMS President, Michael Schrader, MD, appeared at a press conference at City Hall to announce our support and collaboration in the effort. Earlier that week, Dr. Schrader had also appeared at a Planned Parenthood press conference and declared that we stand shoulder-to-shoulder with American women in defense of their reproductive rights.

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SFMMS has a proud history of fighting for access to abortion services, including: • Authored policy adopted by the American Medical Association (AMA) making the national association for physicians explicitly pro-choice.

• Authored California Medical Association (CMA)/AMA policy declaring that European medical abortion medications should be available in the US. • Conducted two national mailings to over 60,000 US medical students urging them to learn about and provide abortion.

• Participated in UCSF medical education forums on reproductive health issues.

• Authored CMA/AMA policy denouncing harassment and murder of physicians providing abortion.

• Authored CMA/AMA policy denouncing the deceptive anti-choice “clinics” pretending to provide reproductive health services.

• Joined with Planned Parenthood and other such groups to oppose proposed ballot and other initiatives that would restrict access to the full range of reproductive services.

• Authored CMA policy urging that approved medical abortion medications be promptly evaluated by the FDA for wider availability via pharmacies.

Much about the recent Supreme Court opinion is uncertain and may change in the coming weeks. No matter the outcome, I pledge that SFMMS will continue to partner with local and state legislators to protect women’s reproductive rights, including access to abortion services; the sanctity of physician-patient relationship; the right to privacy; and the practice of an evidencebased medicine that is free from political interference.

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GOVERNOR NEWSOM SIGNS LEGISLATION TO MODERNIZE CALIFORNIA’S MEDICAL MALPRACTICE SYSTEM PUBLISHED: MAY 23, 2022 SACRAMENTO – Governor “ I ’ m p ro u d to h ave G av i n N ews o m to d ay worked together with all signed AB 35, legislation stakeholders to get this to modernize the system done. AB 35 provides a for awarding damages better system for both in medical malpractice providers and patients, cases in California. The creating a fair process that legislation, put forth by will have a real impact on Assembly Majority Leader Californians for decades Eloise Gómez Reyes to come,” said Assembly and State Senator Tom Majority Leader Eloise Umberg, was supported Gómez Reyes. by consumer groups, trial “With today’s signing of attorneys, health care AB 35, we have achieved Governor Newsom signs MICRA modernization legislation insurers, and health care what few thought was providers – marking the end to one of the longest running possible. This historic moment happened because the two sides political battles in California politics. of the ballot measure campaign put differences aside, found The measure is co-sponsored by the Consumer Attorneys of common ground, and recognized a rare opportunity to protect California and Californians Allied for Patient Protection. It makes both our health care delivery system and the rights of injured two significant changes to the Medical Injury Compensation patients. We are immensely grateful to the Legislature and Reform Act (MICRA) by restructuring MICRA’s limit on attorney Governor Newsom for helping to codify this landmark agreement fees and raising MICRA’s cap on noneconomic damages. in law. California’s new modernized MICRA statutes will provide “After decades of negotiations, legislators, patient groups, predictability and affordability of medical liability insurance and medical professionals have reached a consensus that rates for decades to come, while protecting existing safeguards protects patients and the stability of our health care system,” against skyrocketing health care costs. The modernized law will said Governor Newsom. also bring greater accountability, patient safety and trust by Existing law places limitations on the contingency fee an making it possible for physicians and patients to have a full and attorney can contract for or collect. The current system ties open conversation after an unforeseen outcome. CMA is proud to the limits to the amount recovered. An attorney can collect 40 have been part of this landmark achievement for the benefit of all percent of the first $50,000 recovered, 33 percent of the next Californians. We look forward to a new era of long-term stability $50,000, 25 percent of the next $500,000, and 15 percent of around MICRA that will allow California’s physician and provider anything that exceeds $600,000. This legislation instead ties communities to focus on other ways to improve access to care tiered fee limits to the stage of the representation at which the and public health for all Californians,” said California Medical amount is recovered.

Association President Robert E. Wailes, M.D. Additionally, this legislation increases the existing $250,000 “Injured patients deserve to be fairly compensated when their cap on non-economic damages and provides for future increases rights have been violated, and we commend the leadership of to account for inflation. The legislation establishes two separate Governor Newsom to help get this done. Injured patients and their caps, depending on whether a wrongful death claim is involved. families are better off under the modified MICRA, and we look In a wrongful death case, the cap increases to $500,000. Each forward to continuing to serve in the best interest of our clients,” January 1st thereafter, this cap increases by $50,000 until it said Consumer Attorneys of California President Craig M. Peters. reaches $1 million. If the medical malpractice case does not For full text of the bill, visit: http://leginfo.legislature.ca.gov. involve wrongful death, the cap starts at $350,000, and increases https://www.gov.ca.gov/2022/05/23/governor-newsom-signseach year by $40,000 until it reaches $750,000. legislation-to-modernize-californias-medical-malpractice-system/ WWW.SFMMS.ORG

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MEMBER MILESTONES 50-Year Members

On April 29th, after a two-year hiatus, SFMMS hosted our Annual Gala at Fort Mason in San Francisco. The evening included the recognition of Monique Schaulis, MD, SFMMS Outgoing President, for her dedication and leadership to the SFMMS membership and communities of San Francisco and Marin during her 2021 Presidency, and a commendation from Mayor London Breed; the welcoming of Michael Schrader, MD, SFMMS Incoming President; a recognition of previous Executive Director, Mary Lou Licwinko; and a recognition of our SFMMS Public Health Awards recipients for their outstanding contributions to local public health efforts during the COVID-19 pandemic: Kim Newell-Green, MD, Tomás Aragón, MD, Alice Chen, MD, Grant Colfax, MD, Susan Philip, MD, Matt Willis, MD, MPH, and Lisa Santora, MD, MPH. We are so thankful to our SFMMS members and leaders for making this such a lovely and memorable evening. We look forward to seeing everyone at next year’s SFMMS Gala!

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William Armstrong, MD Marjorie Belknap, MD Richard Bohannon, MD Calvin Chang, MD Rober Collins, MD Morey Filler, MD Joseph Goldberg, MD James Gorder, MD Harold Griffeath, MD William Heggli, MD Horton Hinshaw, MD

Charles Hoffman, MD James Krajeski, MD Jack Leibman, MD Lawrence Lonn, MD Alan Margolin, MD William McAllister, MD James Neely, MD Bethel Reimer, MD Joel Renbaum, MD Harris Simmonds, MD H. Hugh Vincent, MD

Donald Abrams, MD James Adams, MD James Allison, MD Lesley Anderson, MD George Bach-Y-Rita, MD Larry Bedard, MD Wm. Budge, MD Patsy Callahan, MD Shu-Wing Chan, MD Chester Chin, MD Allan Chinen, MD Bruce Cohn, MD Quita Cruciger, MD

William Dickman, MD Djamshid Ghatan, MD Jerold Green, MD Yoel Haller, MD Larry Isbell, MD Ronel Lewis, MD Barbara Silvestri, MD George Susens, MD William Sweeting, MD Leong Tan, MD Raymond Tom, MD Andrea Wagner, MD

Wayne Anderson, MD Carolyn Carr, MD Frank Farrell, MD Towie Fong, MD Vernon Giang, MD Michaela Glenn, MD

Jerome Jew, MD Berty Liau, MD Arturo Martinez, MD Joan Pont, MD Edmund Tsoi, MD Kevin Turley, MD

40-Year Members

30-Year Members

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TWO YEARS OF COVID: MEETING THE MANY CHALLENGES Michael Schrader, MD, PhD (Dr. Schrader’s remarks at the SFMMS Gala were especially well-received, outlining our multifaceted response in a time of crisis. We asked if we could share them here - The Editors) One in 400 Americans have d i e d o f Cov i d - 1 9 . We a re nearing the milestone of 1 million American deaths which is almost certainly an undercount. But a recent model has projected that 2 million Americans were saved from Covid deaths by our efforts.

People ask me if I could ever have imagined the Covid pandemic. Of course, I reply. We have seen pandemics and near misses. Polio, AIDS, Zika, Ebola, West Nile, SARS, MERS, Swine flu. Before that, smallpox, 1918 flu, Bubonic plague, cholera. It has happened before. It will happen again. It is still happening.

I came to San Francisco as a medical student and then an intern and resident during the AIDS epidemic. I was drawn to the AIDS crisis because I thought it was the most important health issue of the time. As a 4th year medical student I went to Africa for 2 months to witness the care of AIDS there. I learned HIV care in Ward 5A and Ward 86 of SFGH and later in Floor 5 North A at Mt Zion. We were fighting an impossible battle with no defined end. And somehow it ended with protease inhibitors, a pharmacological revolution.

Those were tough times: an end stage AIDS patient was an incredible time and emotional investment, and a learning experience. AIDS patients were vilified and discriminated against and feared. I can’t describe what it’s like to work on the cusp of life and death of young patients. But we lived this: succeeded and failed and lived the drama of life and death every day. I would like to think we were better for the experience but no doubt it changed many of us forever. I trained as a physician scientist and when I finished my residency I briefly flirted with becoming an AIDS researcher. Ultimately being a clinician is what I enjoy most.

George Santayana said: “Those who cannot remember the past are condemned to repeat it.” It’s actually the same deal for those who do remember the past but at least it gives us some perspective. We first heard about Covid-19 a little over two years ago. Another SARS coronavirus initially identified in Wuhan, China. Wuhan was locked down. And we waited for whatever would come next. Waited for that inevitable ill wind to blow it ashore. There was an outbreak on a Princess cruise ship and 10

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the passengers were stranded offshore waiting. Governor Newsom formulated a plan to offload them into quarantine in the east bay. He called the CMA and they called SFMMS for some white-coats to stand behind him during his press conference. This was a successful containment operation but it was too late to stop the tide. It was already here.

Next Covid was seemingly everywhere, sweeping through our nursing homes and infecting our front line physicians. We navigated the quickly changing recommendations to attempt to slow the spread and avoid overwhelming critical care. Dr Ameena Ahmed had SFMMS commission a graphic video explaining the rationale for slowing the spread.

Dr Grant Colfax and Mayor Breed declared a city and county lockdown ahead of other municipalities. Dr Matt Willis organized the Covid response in Marin and was an early victim of Covid himself. He recorded and published his personal account of illness. Our frontline physicians in the ED, hospitalists, critical care and infectious disease were among the first to face Covid.

Covid tests were in short supply and difficult to obtain. SFMMS provided information and guidance about availability.

Physicians were rapidly running short of PPE. The SFMMS secured a supply of K95 masks from China. Longtime member Dr Sandra Hernández facilitated a major grant to fund them. They are still being doled out from Steve Heilig’s garage. CMA distributed millions of dollars of PPE through county medical societies.

SFMMS members loaded boxes into cars at AT&T ballpark for both member and nonmember physicians.

Then-President Donald Trump gave destructive wrong advice about hydroxychloroquine and bleach. People died from following his wrongheaded nonsense. We debunked this misinformation as fast as he could spew it. We reached out to media. We educated our patients. Then Trump tried to change Covid into a racial epithet calling it the Kung flu. There was an upsurge of anti-Asian and Pacific Islander hatred fueled by this careless and cruel language.

Dr Joe Woo organized a press conference at Chinese Hospital where many prominent politicians and several SFMMS members spoke out including Dr Woo, Dr Beth Griffiths and Dr Brian Grady.

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School closures were a continuing source of controversy and were less than well managed by the SFUSD. Dr Kim Newell Green advocated for school reopening for the benefit of the health of children. In addition Dr Newell Green moderated the ongoing CMA Covid webinar to keep us abreast of the latest thinking and developments.

When the vaccines finally became available through Trump’s operation Warpspeed many of us volunteered and vaccinated at the City College Drive Thru and later at Moscone Center. Dr Monique Schaulis worked at this Kaiser and Dignity sponsored vaccination effort. Dr Joe Woo and Self Help for the Elderly led an effort to vaccinate the homebound. SFMMS co-sponsored and many of us volunteered to vaccinate people in their homes.

Throughout all of this our doctors have tested and treated patients in our clinics, nursing homes, and hospital wards. We have disseminated information and debunked misinformation.

We have provided comfort to our patients and support to each other. I am honored to serve you as the President of the San Francisco Marin Medical Society. SFMMS is a professional collective founded more than 150 years ago to improve our

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profession. We recognize that the individual is benefited through the promotion of the common good. We benefit when the least among us is protected. I want to thank all who came before and all who will continue to carry SFMMS forward through the next 150 years. I want to thank the SFMMS staff and leadership for their hard work and mentorship.

Physicians and our medical society have played an important role during the past 2 years of Covid. This is who we are: physicians doing our job. Working together to achieve a common goal. Medicine is a noble profession: Thanks to all of you.

Dr. Schrader chairs the SFMMS delegation (with Dr. Ameena Ahmed, newly-elected vicechair) and is president of the SFMMS.

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Special Section: Reproductive Health and Rights

SFMMS INTERVIEW Daniel Grossman, MD, FACOG Steve Heilig, MPH to access that seem to be possible with the advent of medication abortion here.

Daniel Grossman MD is a leading researcher in and advocate for improving reproductive health, widely known for his work in numerous aspects of that field. He is Professor, UCSF Department of Obstetrics, Gynecology & Reproductive Sciences and Director, Advancing New Standards in Reproductive Health (ANSIRH). He earned his MD at Stanford and did his residency at UCSF. A list of his extensive public and professional publications can be found at: https://bixbycenter.ucsf.edu/daniel-grossman-md-facog How did you first decide to devote much of your career to working in the reproductive health and abortion arena?

When I was an undergrad at Yale, I got a fellowship to go to what was then called Zaire for the summer, at a very rural missionary hospital, and then in residency I did some work in Indonesia, and after I finished residency in OB/Gyn at UCSF I did some work with other organizations there. I was first interested in global health, and some of my first experiences in places like subSaharan Africa where I saw firsthand how challenges in maternal and child health caused so much morbidity and mortality and saw so many people suffering from the consequences of unsafe abortion. I was just really shocked how many were having very serious medical complications and even dying, not because we didn’t know how to diagnose or treat their problem, but because of bad policy. That really got me very interested in working at this intersection of medical care and public policy.

You’ve been very focused on medication abortion, and we’re now almost 22 years since the first approval of that by the FDA. How do you see that as having played out thus far?

There were immediately regulatory requirements applied to mifepristone that were codified in the REMS – Regulatory Evaluation Mitigation Strategy – and that in addition to various state laws and regulations have really limited the number of providers who can provide it and patients that can use it. That said, at least there’s been some progress at the FDA level in recent years – in 2016 the label for mifepristone was updated to be more in line with medical evidence, in particular the component concerning a requirement for in-person dispensing in a clinic, medical office, or hospital, and couldn’t be dispensed from a pharmacy or mailed to a patient. That was then suspended in 2020 due to the COVID epidemic, and in 2021 the FDA announced they would permanently get rid of the in-person requirement.

That said, they added another requirement that pharmacies would have to be certified to dispense, and we’re still waiting to see the details of that policy, and how easy it will be for clinicians to sign up and start providing. So the progress has been very slow and we have not seen the hoped-for reduction in barriers 12

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Just last year it was reported that just over half of all abortions are now being provided via medication. Do you think that it would be significantly higher without these restrictions?

I don’t know if it would be a lot more but do think that there would be some increase, and that there would be more clinicians who provide it. It just can be challenging and cumbersome for some clinicians who do not have a lot of these patients to order it and have it on hand.

So one improvement would be to make it available on a regular prescription basis?

Yes, it should be possible to just transmit a prescription to a local pharmacy, or a mail-order pharmacy for mailing to patients.

That would make a big difference.

You’ve also written about the possibility of “advance provision” of these pills; how would that work?

This was something we did back when emergency contraception was only available via prescription – we would give patients a prescription or the actual pills so they could take them in advance of need so they could take it as soon as possible, and that is still done. This could theoretically be done with medication abortion as well, considering the common delays and difficulties in getting to a clinic given geographic and financial barriers. People could take them as soon as they learned they were pregnant and it's likely they could get the abortion earlier in pregnancy. This might not comply with laws in every state now, but from a medical perspective it seems it would be very reasonable to screen for some of the contraindications for medication abortions that are unlikely to change in advance when medications are given to the patient, and encourage them to call right before they are about to use it to confirm it is appropriate for them to use, and of course there could be appropriate follow-up as well.

Do you think the awareness of the availability of medication abortion has altered the epidemiology of abortion, such as making more abortions occurring earlier in pregnancy to take advantage of the option?

We do have some evidence that expended access to medication abortion that there was a decrease in second-trimester abortion, with some people reporting that having access to the pills was a factor. So a concerted effort to medication abortion can help people access abortion early in pregnancy. That said there will always be many who for various reasons will need to acquire an abortion after the first trimester.

You mentioned telemedicine – how does that figure into this picture going forward?

We now have a lot of evidence from the US and UK in particular demonstrating that telehealth provision of abortion is a model that reaches people in their homes and other places where we WWW.SFMMS.ORG

can evaluate people for their eligibility for medication abortion based on their history and symptoms. Certainly some need to be seen in person, for ultrasound, blood work, and so forth, but the majority can be assessed via a telehealth basis and have the medication mailed to them. The FDA reviewed this data in a report last December which really came out in favor of telehealth abortion, strongly supported by the evidence. But about 19 states have now banned telemedicine for abortion and thus people in those states are already being denied access to medical progress.

Mail-order provision is also being targeted in this regard.

This brings up Over-the-Counter status and access, and what are your thoughts there?

Just looking at the criteria for OTC status, I think medication abortion meets many of those criteria – it’s very safe, there’s no risk of overdose, patients decide on their own whether they need and want it, and we have a lot of evidence that patients can figure out whether it’s appropriate for them, and use it on their own.

There is a growing use of self-managed abortion particularly where it is now easily available or is restricted. So FDA would require specific kinds of studies to be done to demonstrate that these criteria are met, and we are starting to do some of that kind of research. We just did a “label comprehension” study, with over 800 people, including many young ones, and showed that they could read and understand the key concepts in using this product.

Next we are doing a self-selection study using previous research on how people can identify how far along they are in pregnancy and if they are eligible for medication abortion, comparing that to clinicians evaluation. And then we are planning an actual use study where you follow people in an OTC scenario where you see how well they figure out if they are appropriate for using it and how they do.

But actually getting it to be OTC would require a company to have a suitable product, such as a combi-pack product with both mifepristone and misoprostol, such as is already available in some other countries but not here. So I think it’s probably on the order of 5-10 years down the line before we see a serious application to the FDA for OTC approval. But in the process I think this research we are developing, like the simple label, an electronic screening tool for patients to help self-manage use, and ever-increasing evidence about safety and efficacy, can help bring that about. From an advocacy perspective if we have all this evidence it surely makes no sense to force people to come in, or not let nurse practitioners provide it.

The expansion of nurse practitioner scope of practice can be controversial, but your perspective is that it’s justified here?

There is a lot of evidence that nurse practitioners, nurse midwives, and physician assistants can all safely provide medication abortion, as they now can in California, but in a lot of states they are not allowed. Those restrictions are not based on any medical evidence.

What is your short “elevator speech” on the efficacy and safety of medical abortion?

The regimen for medication abortion, mifepristone with misoprostol when used up through about ten or eleven weeks is about 97% effective, with about 3% needing a vacuum aspiration or procedural abortion to complete the process. It’s very safe, WWW.SFMMS.ORG

with less than .5% of people who use it having any serious complications; it's safer than a lot of medication that are approved without any REMS restrictions for OTC access, such as Viagra and even Tylenol, to give a couple examples.

What would be your wish for the average non-specialist physicians to help this picture?

It would be great to have more getting educated about medication abortion. There are a lot who still don’t know about this option, but it’s important, and as it becomes more possible to provide it via a prescription or otherwise, I hope more will learn how to provide what is really a very simple service. We really hope there will be increased uptake to meet patient needs better.

How about medical organizations?

I think advocating at the federal level to get rid of the REMS for these medications would be good. In the bigger picture, some sort of federal legislation, like the Women’s Health Protection Act that would limit the ability of the states to impose additional restrictions on abortion care that are not evidence-based would be good. And I think there’s a role for medical organizations that encourages the FDA to treat this medication like any other medication would, and to really look at the research in an unbiased fashion to explore the possibility of OTC access. We’re also looking at how we might be able to provide tele-medication abortion across states lines, which would protect providers here so that even if breaking a law in another state we’d be protected here.

The current controversy and probability of Roe vs Wade being reversed would seem to be making all of this more urgent. The implications for healthcare and women’s health appear severe.

It’s a looming disaster. It’s clear that patients’ health will suffer. Some will be able to travel to access the care they need, but even then they can be delayed. It's going to take lots of financial support to help them access what they need. Some will try to self-manage their abortions in areas where there are not easily accessed other options, and that is possible, but we also know there are higher legal risks associated with that, with women and even doctors being investigated and charged with having or helping others have any kind of abortion. And we know more will continue unwanted pregnancies to term, which some evidence shows can lead to a 20% increase in maternal mortality in those forced to do so, and even higher risk for, say, Black women. And Dr. Diana Green Foster did the ‘Turnaway” study here at UCSF which showed that women denied abortion are much more likely to be living in poverty, tethered to an abusive partner, with worse outcomes to the children born, and so forth.

You started with the experience of seeing the consequences of illegal abortion and lack of access firsthand. It’s now half a century since Roe, and not many people are still practicing who saw this here in the US. Do you think that leads to this being an abstract risk, historically, and thus less of a sense of urgency about preserving access to safe abortion?

Maybe so. It's really sad to think that we might have to experience that here, to see these awful consequences, to convince lawmakers to change the law back again. But very sadly, maybe that will be what it takes.

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Special Section: Reproductive Health and Rights

A STREAMLINED MODEL FOR MEDICATION ABORTION ACCESS Screening patients for abortion pills using history alone is highly effective and low risk Ushma Upadhyay, PhD, MPH, and Marji Gold, MD The recently leaked Supreme Court draft decision on abortion recently revealed that our nation is on the edge of a major shift in the abortion care landscape. As the federal right to abortion may soon be overruled, patients in many states will be forced to travel hundreds of miles to get care, endure higher costs, and miss time from work, school, and/or family. Clinics and providers in states where abortion remains legal will be hard pressed to manage the influx of patients.

Many are asking what can be done to make abortion care easier and more convenient, particularly in states where abortion is restricted. One answer is to make abortion pills more accessible.

Our new study in JAMA Internal Medicine shows that prescribing the pills doesn't require expensive equipment or even a pelvic exam. We found that among the nearly 4,000 medication abortions provided by 14 clinics nationwide without pelvic exams or ultrasounds, the vast majority were completed without additional medical intervention (95%) or adverse events (99.5%). Given these findings, people can feasibly receive abortion care from the same person who sees them for colds and coughs. This is the model at the family health center where one of us (Marji Gold, MD) works as a family medicine physician.

We found that people can safely and effectively obtain an abortion up to 11 weeks of pregnancy, simply by confirming a few details about their pregnancy. This streamlined process would allow a broader range of clinicians, including primary care physicians and nurse practitioners (in states where it is permitted), to offer abortion pills -- and it would allow people to access abortion care just like they get any other basic healthcare.

This process may seem unorthodox to clinicians who use ultrasounds as a matter of course for abortion provision, and to patients who expect one. However, using an ultrasound is a relatively new practice, popularized in the 1990s when the technology became more readily available. As a primary care provider who is not an ob/gyn, I (Gold) have been providing abortions safely without ultrasounds for decades. My patients 14

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are relieved to learn they can go to their regular primary care provider for this kind of care.

More family medicine physicians should feel empowered by our new data to follow this example and offer more people this convenience.

Our study also builds on other evidence that patients can be trusted to know their own bodies. Indeed, previous studies show that people seeking early abortion can accurately estimate how far along their pregnancy is using the date of their last menstrual period. Adding other screening questions -- such as whether individuals believe they are more than 11 weeks pregnant, more than 2 months pregnant, or have missed more than two periods — can help clinicians accurately determine if a patient is eligible for medication abortion. The American College of Obstetricians and Gynecologists, Planned Parenthood, and the National Abortion Federation have already updated their guidelines to reflect that a clinical consultation without ultrasounds or a pelvic exam is sufficient for medication abortion.

Shifting to this new process could expand and expedite access to abortion — a necessity at a time when many states are shrinking the window for care or doing away with it altogether. It also gives providers in abortion-friendly states the opportunity to expand abortion care. The FDA's recent ruling that mifepristone — one of the drugs used in medication abortion — can now be dispensed by pharmacies and mail will further expand access.

Our findings also open the door for more abortion via telehealth. A patient can call a virtual clinic, answer a few questions, and get the medication mailed to them without going to a clinic. In addition to offering greater convenience and privacy, this new process is aligned with trauma-informed care. Ultrasounds, especially transvaginal ones, and pelvic exams are invasive and may be triggering for some patients. Avoiding them could, by extension, avoid unnecessary distress.

However, this new process is not a panacea. Nearly a dozen states have non-evidence-based laws in place mandating WWW.SFMMS.ORG

providers perform ultrasounds on abortion patients. Other state laws require patients be given the option to view an ultrasound image; force patients to receive counseling in person before their appointment; or ban abortion via telehealth outright.

FDA guidelines require licensed clinicians to have additional certification by the distributor to write a prescription for mifepristone, which creates yet another potential and arbitrary hurdle. In addition, logistical, financial, and legal challenges can still stand between a patient and their necessary care. This is especially true for people of color, those living on low-incomes, and those living in rural areas, who are all more likely to live in states with restrictive policies.

All of these hurdles will only become much worse with the impending fall of Roe, especially in states that ban abortion, both procedural and medication abortion. However, this model of care might still help residents in these states to some degree — rather than trying to get an appointment with overburdened providers in states where abortion remains legal, people could travel across their border to a state that offers telehealth, and have the abortion medications mailed to the nearest post-office after the telehealth consultation. This option may help relieve the surges we expect to see in protected access states.

Ultimately, this model could help expand access to abortion, lower costs, and shorten time to treatment. It can also empower a broader range of clinicians to provide abortion care at a time when the options are shrinking for so many. For patients and providers, that's a win-win.

Ushma Upadhyay, PhD, MPH, is an associate professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the UCSF and core faculty at Advancing New Standards in Reproductive Health.

Marji Gold, MD, is a family physician in the Northeast. This piece originated on MedPage, May 2022.

VICTIMS OF INJUSTICE In June 1964, right after I graduated from UCSF, I was on duty as an intern in the SFGH emergency department on the final night of the Republican convention here. I was watching an attending physician stitch cuts on the face of a drunk Rockefeller delegate who’d been hit by a drunk Goldwater supporter at the Republican convention. A call came through the hall for all surgeons: There was an incoming car accident victim with legs amputated to mid-thigh. “Finish up,” my supervisor told me, as he sped out of the room. The last stitching I’d done was to place electrodes in the back of a hibernating hamster, but there was no time for my insecurities. I got to work on my patient. Just like my hamsters the patient did well; it was a great lesson in county hospital emergency medicine. But simple cases like those would never truly prepare me for the heartbreaking losses– especially those cases that piqued my awareness of social injustice.

So, another time, a woman came in feeling “very sick.” She spoke Spanish, and the teenage daughter who accompanied her translated for me as I did the intake, took her vitals, and inserted an IV for fluids. She had shaking chills but no fever, which suggested she was in septic shock. I asked the daughter what had happened. Suspecting that I was seeing the aftermath of a botched abortion, I explained that this could kill her mother.

The daughter said her alcoholic father had left the mother raising three children alone. The mother became pregnant and, despite being a devout Catholic, had gone for an illegal abortion.

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David E. Smith, MD

With that information, we rushed her to the operating room for an emergency hysterectomy. It was too late. She died on the table. She lost her life because the law forbade the prompt medical care she needed, and because her family felt they had to delay treatment as her condition worsened. I have been prochoice ever since. And now a teenage girl would be responsible to raise two children without a mother or a father.

I can’t fathom how anyone who has had to care for a woman brutalized in this way could ever be against the right to choose.

In my childhood, I witnessed my mother giving dedicated nursing care when she herself was suffering. I saw my father get the care he needed, even though it did not save his life.

I wasn’t prepared for this: I watched a woman die because judgmental others stood between her and medicine’s ability to save her life.

David E. Smith founded the Haight-Ashbury Free Clinics in 1967, was a co-founder of the specialty of Addiction Medicine and a President of the American Society of Addiction Medicine, has received UCSF’s highest awards for service to medicine and public health, and is a 53-year member of the SFMMS.

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Special Section: Reproductive Health and Rights

SFMMS Advocacy Case Study

“THE MORAL PROPERTY OF WOMEN”: BRINGING MEDICAL ABORTION TO THE UNITED STATES Steve Heilig, MPH In late 2021, it was reported that just over half of all abortions in the United States were done via oral medications. Now these pills are a central element in the political battles over abortion. And therein lies a story.

Way back in the late 1980s, scattered reports begin to appear in the European medical literature about an oral medication that could interrupt early pregnancy both safely and effectively. It was called RU-486, for the French pharmacological company Rousell Uclaf. From these earliest papers it seemed clear this could be an extremely significant development. Abortion was of course a highly politicized issue, and for years those opposed to it had found ways to make it hard to obtain safely, and even mounted physical attacks on clinicians – some of whom were

murdered – and clinical settings where it was provided. Such a medication would make it difficult to target those who provided or took it. And of course most women, given the choice, would prefer a medication option to a surgical one, even if that surgical procedure was the most common one in the nation.

At UCSF campus newspaper, I began to cover this developing medication, publishing some of the first stories on it in the country. The Europeans were far ahead of us and soon RU-486 had garnered enough evaluation to be approved in nations such as France and England. At the San Francisco Medical Society we already had a good track record of bringing new policy positions to the California and American Medical Associations, so I drafted a policy resolution stating that American women

“I joke with my patients and say, ‘I missed the day in medical school when they taught us about when life begins. Is it at implantation? Is it just when sperm meets an egg? No one knows’.”

– Isaac Sasson, MD, PhD, reproductive endocrinology/ infertility specialist, American Society for Reproductive Medicine, New York Times

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and physicians should have access to this medication already approved overseas. Our physician delegation adopted it and it was only a little surprising that so did the CMA and AMA – the latter garnering some national media stories. I also published a survey of California OB-GYNs indicating that many would prescribe the medications if allowed. We also drew up a research protocol to confirm what was already known about the pills in France, a scientifically but not medically-indicated effort, for RU486 had already been called “the moral property of women” by the French minister of health.

At the same time, a small group of physicians and other health advocates began to meet at the SFMS headquarters, seeking to find a way to speed approval of this breakthrough medication in our politicized nation. Working with a veteran New York abortion rights advocate, Lawrence Lader, we hatched a rather audacious plan: We would find a pregnant woman who wished to use RU-486, fly her to Europe to pick up the pills, fly her back, and intentionally have her “busted” for smuggling an unapproved drug into the United States, with major media there to cover it. It was also the time of a heated Presidential election between Bill Clinton and incumbent George H.W. Bush, and we wanted to insert this issue into the campaign debates if possible too.

In short, this “stunt” worked just as planned. The patient was detained, her medications impounded, and the story hit the front pages and television news nationwide, vastly expanding awareness of this medical option and the politics surrounding it. Court battles ensued, expedited due to the patient’s condition.

We prevailed. Clinton vowed to bring RU486 to American women, and other leading figures weighed in in agreement. Back home, we had to hide the patient from massive media interest – we’d tried to protect her name, but one theory was that an enterprising reporter bribed the airplane seating chart out of an airline employee - but she got the care she needed. TIME magazine then called RU486 “The Pill That Changes Everything.”

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However, due more to political than medical factors, it still took eight years, until 2000, for the FDA to approve mifepristone/ misoprostol in this country. That was better than delaying forever, as many feared would occur, but even when approved there were restrictions attached many experts felt unwarranted by evidence, and still do, for now vast clinical experience has shown such regulatory barriers aren’t needed. Primary care providers can safely use them with patients, and many now even believe they should be available over-the-counter. Thus there is concerted research into how these medications can be used safely and effectively without such restrictions, and new advocacy for increased availability, especially in light of the likelihood of Roe v. Wade being overturned and very many patients in need in areas where abortion becomes unavailable.

The SFMMS has already proposed policies to CMA and AMA on these fronts.

Three decades on, it is ironic, frustrating, and sad that this is all necessary at this late date. But we won’t abandon what is right for those in need.

Steve Heilig, MPH is the Director of Public Health and Education for the SFMMS.

References Heilig, S. New French Abortion Pill Stirs Hopes, Fears, Debate UCSF Synapse (31):15:January 29 1987 Heilig S. RU-486: The Pill that Could End the Abortion Wars and Why American Women Don’t Have It JAMA. 1991;266(8):1141.

Heilig S: RU-486: What Physicians Know, Think, and (Might) Do – a Survey of California Obstetrician/Gynecologists Law, Medicine and Health Care 1992; Fall 20(3):184-187 Heilig S, Wilson T: The Need for More Physicians Trained in Abortion: Raising Future Physicians' Awareness Cambridge Quarterly of Healthcare Ethics , Volume 8 , Issue 4 , October 1999 , pp. 485 – 488 Hilts P: Abortion Pills are Confiscated by US Agents New York Times, July 2, 1992 Bellack P, Stolberg SG: Abortion Pills Stand to Become the Next Battleground in a Post-Roe America New York Times, May 5, 2022 Medical Abortion: UCSF Medical Abortion | Conditions & Treatments | UCSF Health https://www.ucsfhealth.org/ treatments/medical-abortion

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Special Section: Reproductive Health and Rights

ROE IS UNDER ATTACK: HOW CAN I HELP?

There are many unique actions clinicians can take that put our specific training to work Ari Friedman, MD, PhD In the leaked decision in Dobbs v. Jackson Women's Health Organization that would strike down Roe v. Wade, Justice Samuel Alito seemingly a l l o w s s t a t e s t o t a k e a ny approach they would like to intervene in patients' healthcare decisions. Healthcare workers need to view this as an opening salvo on fundamental rights, an d wo rk to m i n im i ze t h e substantial, documented harms to our patients this decision would cause.

Like everyone else, healthcare workers can support abortion access and abortion patients by volunteering at abortion clinics and donating to abortion access funds. But there are additional actions that physicians, nurse practitioners, and PAs can take that specifically use their medical training and position.

Even if you're not in a state that is about to ban abortion: Our local abortion providers will soon be inundated with out-of-state patients seeking healthcare. Anything you can do to increase local health system capacity to safely provide abortion care helps. This will become particularly important if the FDA shuts down Aid Access, thereby banning telemedicine access to medical abortion. What actions can you take?

First, stop thinking of abortion care as something that happens in a standalone "abortion clinic." Hospital operating rooms and procedure suites are perfectly suited to procedural abortion care, yet these procedures are often restricted or prohibited.

Advocate to expand abortion care at your hospital. Support your obstetric colleagues in advocating for change to your hospital's policies on offering abortion up to state limits.

Organize colleagues against the often silent policies that have driven abortion care out of the core of the health system. If your hospital already performs abortions, make sure this information is publicly available and known to referring physicians. Figure out how much your hospital charges for abortion care, and advocate for parity with clinic costs, and for charity care policies as part of hospitals' nonprofit obligations.

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Consider proactively advertising your hospital and emergency department (ED) as being a safe space for patients with abortion needs, ectopic pregnancies, miscarriages, and related issues, just as rainbow lapel pins and waiting room stickers have performed a similar role for marginalized LGBT populations.

Become comfortable with prescribing medical abortion, regardless of your specialty.

Research the drugs, dosages, side effects, patient counseling, follow-up, and protocols just like you would any other drug.

Explore ways your specialty can contribute. Pilot new initiatives and promote them through national thought leaders such as podcast hosts and specialty societies. For instance, anesthesiologists could volunteer to provide light or moderate procedural sedation at a local clinic -- this can greatly improve the experience of patients with more involved procedures or anxiety. Sedation is uncommonly offered, and can be prohibitively costly when it is. Emergency physicians can become familiar with local abortion clinics and practitioners, and refer patients seeking these services. Beyond that, they can explore prescribing abortion medications directly from the ED, and become proficient in first trimester abortion procedures like vacuum aspiration when indicated if ob/gyn coverage at their hospital is spotty.

If every clinician did just one of these things, hospital policies would rapidly change, promoting abortion access.

Ari Friedman, MD, PhD, is an assistant professor of emergency medicine at the Perelman School of Medicine at the University of Pennsylvania. This is excerpted from a longer piece on Medpage, May 2021.

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THE SAN FRANCISCO 9 — AN ABORTION MILESTONE Carole Joffe, PhD In 1966, nine highly respected obstetrician/gynecologists affiliated with UCSF and other leading medical institutions in San Francisco suddenly found themselves threatened with the loss of their licenses.

The California Board of Medical Examiners decided to prosecute them for "professional misconduct" because they had been performing hospital-based abortions on women who had been infected with rubella (German measles). Such abortions became increasingly common in the 1960s, due to growing evidence of the link between this disease and birth defects.

(Between 1962 and 1965, some 15,000 babies were born with defects attributed to a rubella epidemic.)

The case of the "San Francisco 9," as the group came to be known, illustrates the tremendous uncertainty under which responsible physicians performed abortion before the Roe vs.

Wade decision in 1973. Even before legalization, physicians were permitted some leeway to provide abortions when the life or the health of the woman was at risk. But they had to make subjective judgments in these cases – there was no one standard of a sufficiently serious "threat to a woman's health."

As a result, doctors of that era felt themselves operating in a gray area between illegality and legality, not knowing if their judgments would be called into question by the legal system, or by fellow physicians with different attitudes toward abortion.

In fact, just one individual – a strongly anti-abortion member of the Board of Medical Examiners – instigated the decision to charge the nine San Francisco doctors.

Ironically, this prosecution had an unintended effect. The case galvanized the medical community, both locally and nationally.

The predicament of the San Francisco doctors crystallized how untenable the situation was with respect to abortion. If physicians acted in accord with their best medical and ethical judgment, they could suffer dire consequences. Edmund Overstreet, then vice-chair of the department of obstetrics and gynecology at UCSF, and a leading spokesman on behalf of the nine physicians, said, "We do not believe that violation of an archaic statute is unprofessional conduct."

A group of influential professionals, drawn mostly from the legal and medical communities, organized a Citizens Defense Fund on Therapeutic Abortion, which raised money to defray the doctors' legal expenses. More than 200 professors of medicine, including the deans of 128 medical schools from across the WWW.SFMMS.ORG

country, signed an amicus brief on behalf of the San Francisco 9.

Ultimately, the charges against them were dropped. The case reverberated in California and across the nation. In California, it gave new momentum to a bill, previously introduced in the Legislature, that reformers had designed to broaden the grounds on which abortion would be legally permitted in the state. In 1967 this law passed, and a reluctant Gov. Ronald Reagan signed the California Therapeutic Abortion Act. The San Francisco incident also contributed to a growing dissatisfaction by medical organizations with the abortion situation: In 1968, the American College of Obstetricians and Gynecologists endorsed more liberalized abortion laws; two years later, delegates at the annual meeting of American Medical Association for the first time voted in favor of legalizing abortion. In subsequent years, however, the San Francisco medical community and many of their counterparts in other states took different approaches to abortion. In San Francisco, abortion care has long been well established in mainstream medical institutions. For example, faculty in the department of ob/gyn at UCSF has pioneered new models of service delivery, researched new abortion techniques and developed training programs for residents that are a model for the nation.

The San Francisco medical community can offer a powerful lesson to its colleagues elsewhere: that medical schools with strong programs in abortion care, research and training do not suffer any loss of reputation. UCSF is consistently ranked among the top 10 medical schools in the country, and its women's health program was recently rated by U.S. News and World Report as No. 2 in the country. And doctors who provide abortions deserve the support of their colleagues.

Carole Joffe PhD is Professor, Department of Obstetrics, Gynecology & Reproductive Sciences, UCSF. This is an excerpt from a historical piece originally in the San Francisco Chronicle.

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Special Section: Reproductive Health and Rights

MEET THE CO-PRESIDENTS OF MED STUDENTS FOR CHOICE Sarah Siddiqui Note: Medical Students for Choice was founded at UCSF in the 1990s and has become a lasting national organization. The SFMMS was supportive from the start and twice sent mailings to all 60,000+ American medical students, urging them to learn about the need for safe reproductive health services including abortion and to consider joining MSC. These mailings resulted in thousands of new MSC members and helped launch MSC. This interview with the current MSC leaders appeared recently in the UCSF student newspaper, The Synapse. – The Editors

In our latest podcast episode, pre-med student and Synapse contributor Sarah Siddiqui talks to the co-presidents of the UCSF chapter of Med Students For Choice, second year UCSF medical student Neha Pondicherry and second year UC Berkeley-UCSF Joint Medical Program student Meredith Klashman, about the fight for reproductive justice at a time when a woman’s right to bodily autonomy, which was constitutionally protected 50 years ago under Roe v. Wade, is poised to be rescinded.

Sarah Siddiqui: What is the mission of Med Students for Choice?

Meredith Klashman: A lot of people really only end up learning about how abortion works and what it looks like and how family planning works and contraceptive works in a clinical space if they are going into specializing in that. But the way we feel about it is that no matter what, it’s going to be something that shows up in your patient history. It’s going to be something that comes up in every sort of profession within the medical field. So, we really want our classmates to know be educated about that. A lot of the work that we do is the recognition that the reproductive justice movement has been one that — especially in terms of family planning and contraceptives — that has been really inequitable. It’s one that is also rooted in eugenics, especially in the state of California. So, you want to be really mindful of that as we move forward. And just make sure we’re also educating ourselves and our classmates about some of the really, really harmful history of this field and how we can do better as we are looking to forge the future in terms of advocating for access.

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Neha Pondicherry: My goals with this organization were mostly to bring awareness. I think there’s this inherent taboo of talking about reproductive rights and abortion. And I think the more we talked about it, and really foster the conversations and bring awareness to the issue, the more people are willing to talk about it and willing to give basic access to rights that all women, and not only women, but all people who are capable of being pregnant deserve. And so I think for me, opening those conversations, fostering those conversations, having the elective having the panel, having places where people can really talk about those experiences, and open them up is the reason that I really wanted to do this work.

SS: Can you explain how you became interested in Med Students for Choice?

NP: The reason that I was very interested in this is because I think inherently, we have the right to our own body, and that entails the right to any medical decisions that we need to make for our own bodies. And I don’t think that anyone else has the right to really dictate where we stand on that. And so that’s something that I’ve been very firm about my body, my choice.

And that’s why I was very passionate about this.

MK: I came into this space with a lot of experience with reproductive and gynecologic illness. And so, from having that experience, I think I learned how important a part of the conversation abortion is even in situations of IVF. The right to one really equates to the right to the other. So, and I think that that plays out in many different ways in healthcare. The right to choose is something that permeates a lot of autonomy in the medical space. So, I really wanted to be a part of Med Students for Choice to really contribute towards that conversation and movement in our healthcare system.

SS: What is one thing you learned after being involved with this organization?

MK: One thing that we engage with a lot — and that has really been driven home by a few of the speakers — is just how important California physicians are in the fight for national access to abortion. It’s something that COVID really interferes with, because especially at the beginning of the pandemic, WWW.SFMMS.ORG

when we saw a lot of issues with travel restrictions, we really saw a decrease in abortion access in a lot of different states because physicians from the state of California could not go to, you know like, Texas for a week and provide abortion. That’s something that has really shifted my perspective in terms of what we should be fighting for. Because as physician trainees in the state of California, I think we have a lot of privilege and a lot of access to information. So, I think because of that, we have a lot of responsibility to the people who are not able to access that information or access those services.

NP: I think the most important thing that I took away from this was Meredith and I tried to advocate for increased abortion access in our curriculum. And it was a really fascinating process to learn more about the history and learn about the legal aspects of abortion curriculum. UCSF is doing a great job, but even in such a progressive institution like UCSF, there is always room for improvement. And it’s hard to gain the momentum, that real push to change. And I think unless Meredith and I are like standing there, begging the deans to add abortion and access more into the curriculum, things won’t happen. Basically, we learned that in order to make any change, it really starts from a few dedicated passionate individuals who are willing to put in the time and the energy and really bring issues to the forefront. Because there are so many issues that are important, and everyone is passionate fighting about different things.

And sometimes what happens is issues that some people may say aren’t as important get kind of pushed aside. But it’s our responsibility if we’re passionate about it to really bring it to the forefront of the conversation.

SS: What’s been the student response?

MK: Since the legislation that Texas recently put into place [banning abortions after six weeks of pregnancy and empowering private citizens to sue anyone viewed as helping a woman get a forbidden abortion] we’ve received a lot of interest. That really does speak to the power of conversation and destigmatizing. That was really a turning point, I noticed, in terms of our attendance, in terms of our communications with people across all the different schools. We saw so much energy right after that had happened.

NP: I absolutely agree. And honestly, it was really inspiring to see how many people were passionate about it. There are so many issues that people are passionate about and, yes, it’s important that we have Roe v. Wade, and we thought nothing would happen. And until the Texas legislation was passed, I think people didn’t really realize how precarious the reproductive health situation in America was. I think that was the spark that really lit a lot of people’s attention. And they’re like, ‘Oh, wow, we

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really have a problem. We need to do something now.’ I think that galvanized a lot of students at UCSF, and I hope with more access, and more reproductive health electives, and more panels, more and more students start to realize it’s an important issue. We’re really capitalizing on this momentum right now. And I think it’s only going to grow from here in terms of student engagement and participation in turnout and interest.

SS: How has COVID-19 impacted your organization?

MK: Some things have actually been made easier. There is so much presence in a virtual space that we can actually convene more people than maybe we would otherwise be able to. In the spring of last year, we were able to present a doula midwifery training video. We also had Carol Joffe, who is a sociologist who studies abortion practitioners. She talked about the struggles a lot of practitioners have been facing during COVID and providing the care that they want to provide. And then this semester, we’ve also been putting on virtual panels, virtual elective courses.

There are some parts, especially about learning some strategies like how to insert an IUD, that’s something that really does need to be hands-on. And so that’s definitely something that I hope can make a return in the coming months.

NP: The virtual platform has allowed people from all over to come and present on topics that we probably wouldn’t have heard other people speak. For example, we had an abortion panel on what the perspective is of providers giving abortions, we had providers from all over—one from Tufts University, one from USC, and then a few from UCLA. And so the virtual platform has allowed not only our audience to grow, because students from all those three schools were able to come, but also exposure to providers from different areas of the country, which is important, because obviously, as you know, abortion access differs greatly depending on where you live.

SS: When does your organization typically meet?

MK: We can’t meet in person. So, for now, the family planning and reproductive choices elective is occurring every Wednesday at noon across the different schools at UCSF, the School of Medicine, the School of Pharmacy, the School of Nursing. We’re catering the classes and the speakers to have something for everyone in the different schools and what they need to know regarding different topics. We also have events that either are going to occur at night or have occurred in the evening time that people can come— especially to our really popular talks like the abortion provider panel.

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MEET YOUR SFMMS CMA/CDPH LEADERSHIP Ian Knox The San Francisco Medical Society has a long and rich history of leadership at the state level, with 2022 being no exception. The members below are those that have and/ or currently hold important leadership positions at CMA/ CDPH, acting as both representatives for SFMMS, the citizens of California, as well as intermediaries between CMA/CDPH and SFMMS.

Lawrence Cheung, MD, FAAD, FASDS Dr. Cheung is a solo private practice dermatologist and the principal investigator of a clinical trials unit that focuses on phase III trials on dermatologic treatments. He also is an active volunteer instructor, teaching responsibilities at UCSF, St. Mary’s Medical Center, and CPMC. A Past-President of SFMMS, Dr. Cheung served multiple terms as Chair of the SFMMS Delegation to the CMA, and as the CMA Chair of the California Resolutions Committee to the AMA. Dr. Cheung is currently serving as an AMA Delegate representing CMA. Dr. Cheung also sits as a CMA Trustee for District VIII/ SFMMS. In the spring of this year, Dr. Cheung announced his candidacy for the seat of Vice-Speaker at CMA.

Shannon Udovic-Constant, MD Dr. Udovic-Constant is a pediatrician with The Permanente Medical Group in San Francisco and the past Chair of the California American Academy of Pediatrics (AAP) State Government Affairs committee.

Dr. Udovic-Constant has served as a CMA Trustee since 2013.

She has served as Chair of the CALPAC Independent Expenditure Committee and part of CMA’s Diversity and Inclusion Technical Advisory Committee (TAC) and Firearm Prevention TAC. She has also served as the AAP representative on CMA’s Council on Legislation. Dr. Udovic-Constant is currently serving as Vice Chair of the CMA Board of Trustees and is in line to become CMA President-Elect in 2023.

Peter Bretan, Jr., MD, FACS Urologist and kidney transplant surgeon Peter N. Bretan, Jr., M.D. is a three-time Marin Medical Society President (now San Francisco Marin Medical Society).

Dr. Bretan is CMA’s Immediate Past-President and was the first Filipino-American physician to serve as CMA president (2019-2021). He also served for three years on the CMA Executive Committee and three years on the Board of Trustees. Dr. Bretan also served on the Board of CalPAC, the CMA Presidents Forum, and is currently serving another term as SFMMS Delegate to CMA. Dr. Bretan is also a District X CMA Delegate to the AMA. In 2015, Dr. Bretan was the Recipient of the CMA Ardarsh S. Mahal MD’s Access to Health Care and Disparities Award.

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George Fouras, MD Dr. George A. Fouras is a Psychiatrist currently practicing in the Los Angeles County Department of Mental Health, specializing in Child and Adolescent Psychiatry. Dr. Fouras has served in SFMMS leadership positions for over 20 years, including President (2011), multiple terms as SFMMS PAC Chair, and over a decade as an SFMMS Delegate to the CMA House of Delegates. Dr. Fouras has also served as the Chair of the California Psychiatric Association PAC. In 2019, Dr. Fouras was appointed to a seat as CMA Alternate Delegate to the AMA and then to Delegate in 2021. Dr. Fouras currently sits on the CALPAC Board of Directors and the CMA Council on Legislation.

John Maa, MD Dr. John Maa practices General Surgery in Marin County and served as SFMMS president in 2018.

Dr. Maa has sat on several SFMMS Boards and Committees, including the SFMMS Board of Directors, the SFMMS PAC, and the SFMMS Delegation to CMA. He has also served on multiple city and statewide committees including the American Heart Association Western States Affiliate Advocacy Committee, as a member of the SF Sugary Drinks Distributor Tax Advisory Committee and is a PastPresident of the American College of Surgeons (ACS) Northern California Chapter.

Dr. Maa currently sits on the CMA Council on Legislation, is a CALPAC Board of Directors Representative, and is an SFMMS Delegate to CMA.

Tomás J. Aragón, MD, DrPH Tomás J. Aragón, MD, DrPH specializes in public health (primary internal medicine, infectious diseases, and epidemiology) and is the former health officer of San Francisco and Director of Public Health Services at SFDPH. Dr. Aragon served as technical consultant to SFMMS, as well as on the SFMMS Board of Directors. His contributions to the society extended to collecting and editing the public health articles for the SFMM journal and remains a frequent partner with SFMMS on numerous public health issues.

After working in public health leadership roles for more than 20 years, Dr. Aragón was appointed as Director of the California Department of Public Health by Governor Gavin Newsom in 2020, serving as the chief public health officer in the state of California.

Ian Knox is the SFMMS Director of Governance and Operations.

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22-YEAR HISTORY OF TREATING GOLDEN GATE BRIDGE FALL VICTIMS AT MARIN HEALTH MEDICAL CENTER John Maa, MD and Edward Alfrey, MD Over the 85-year history of the Golden Gate Bridge (GGB) since it opened on May 28, 1937, an estimated 1,800 victims have taken their lives through an intentional fall from the bridge walkway into the San Francisco Bay1. The bridge is 1.7 miles long and 90 feet wide, over which 40 million motor vehicles drive annually2.

The GGB is reportedly the most photographed structure in the world, and also one of the most common destinations for suicides in the world. A fall from the GGB is one of the most effective ways to commit suicide, as the average rate of speed upon entering the water is 75 mph. The mortality from the 220foot fall has been estimated over the years from longitudinal studies around 98%3.

For many years, victims recovered by the Coast Guard were transported to Letterman Hospital in the Presidio, until Letterman’s closure in 19914. After 1991, patients were transported to San Francisco General Hospital if recovered on the San Francisco side of the Bay, or to Marin General Hospital (MGH) if they were retrieved on the Marin County side of the Bay. More recently, a change in emergency medical services triage policy resulted in all patients being transported to MGH, as the sole receiving facility. MGH was renamed Marin Health Medical Center (MHMC) in 2019.

MHMC is an American College of Surgeons (ACS) Level III verified trauma center with 24/7 neurosurgical coverage located in Greenbrae in Marin County. A trauma activation results in the in-hospital response by emergency medicine, trauma surgery, with the availability of surgical specialists, critical care, interventional radiology, blood banking, nursing services and support services. The institution has become adept at the resuscitation and care of this patient population, as the primary receiving facility for most of the past decade.

Over the past 22 years, MHMC cared for 26 patients who still had signs of life after being recovered by the Coast Guard following a fall from the GGB. Of these, 14 survived, and 12 expired. There were seven consecutive deaths from 2002 to 2010, whereas 8 of the 9 most recently treated patients between 2017 and 2022 survived. Our survivors averaged 24

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nine years younger than those who died (24 versus 33). Ten of the fourteen survivors were aged 25 or younger. The injury severity score was significantly lower over the past decade (43.9 vs 22.8). For the entire 22-year period, the leading injuries were: hemo/pneumothorax 70.8%, spine fractures 62.5%, lung contusions 50%, and rib fracture 50%. Major cardiovascular injuries were associated with an 87.5% mortality, and intracranial injury with a 66.7% mortality.

About half of the patients with a hemothorax, pneumothorax, or pulmonary contusion died. A spine injury was associated with death in 26.6% of cases. Five patients required transport to a higher level (ACS Level I) of care for treatment of either unstable pelvic fractures or advanced orthopedic injuries.

Survivors were more likely to have injuries confined to the ribs, vertebral spine, and pelvis, which are associated with a higher survival. Massive intra-abdominal or intra-thoracic hemorrhage, cardiac injury or disruption of the great vessels, tension pneumothorax, flail chest and intracranial injury are less likely to be survivable. Associated injuries such as long bone injuries, friction burns, multiple contusions, and less complex orthopedic trauma were frequently noted, and more likely to be associated with survival.

In the literature, three previous studies have focused on the traumatic injuries sustained after a fall from the GGB, through either autopsy series and/ or chart review. The largest published series of survivors (n=16) was from Letterman Hospital in 19954.

As the hospital closest to the Golden Gate Bridge, Letterman cared for many of the GGB patients before its closure in 1991. In their comparison of survivors (n=16) to fatalities (n=281), they observed that major cardiovascular and intracranial injuries were uniformly lethal.

The previous studies noted key patterns of death – some patients sustain minimal injuries from the fall, but then drown, or are attacked by sharks or other marine wildlife. Those who survive the initial fall and then brought to the hospital are noted to have a high rate of mortality, including delayed death after a period of initial relative stability after being admitted (most often from pulmonary contusion). A third category of patients WWW.SFMMS.ORG

represent deceased patients whose bodies are not recovered for days or weeks after the fall, and suffer from the ravages of marine wildlife.

Among survivors – a pattern of injury and mechanism of survival has been described. The fatally injured patients often enter the water horizontally, experiencing maximal deceleration with the largest body surface area exposed to the violent impact.

Survivors often report entering the water in a vertical position, feet first, at a slight angle and with more gradual deceleration.

Distributing the force of the impact over a longer distance allows the kinetic energy to be transferred. One survivor reported touching the bottom of San Francisco Bay. A vertical impact may result in a spine injury or long bone fracture that is more likely to be survivable. Acapulco cliff divers who plunge 150 feet into the Pacific Ocean demonstrate that vertical entry into the water can result in minimal injuries, so long as the divers are not caught by winds and land horizontally.

In the first 26 years of the bridge’s history (until 1963), there were only two survivors seen after nearly 303 deaths, for a mortality of 99.3% percent. Our published study5was referenced in the San Francisco Chronicle 6, and brings the number to approximately 40 known survivors in the history of the Bridge. The majority of survivors were seen after 1968, and the modern reported survival rate around 2% likely reflects the improvements in emergency medical response and the capabilities of modern medicine, which include Advanced Trauma Life Support, care coordination, and the advances of interventional radiology, trauma surgery, critical care/ anesthesia, and emergency medical services.

We observed a decrease in the injury severity score over the last decade on presentation to MHMC (which may be reflected in the improved outcomes), which likely resulted from two key factors. First, there was a change in the practice of the Marin Coroner’s Office. Before 2011, all GGB fall victims who did not survive underwent an autopsy to confirm anatomic injuries, which resulted in a higher ISS. As of 2010 the practice of routine autopsy was discontinued by the Coroner, and as a result the ISS for deceased patients afterwards were lower as they are based on clinical and radiologic findings alone. Second, the average age of the patients in the past decade was nearly ten years younger, which may have contributed to their lower severity of injury. One might also speculate that better organization in care resulted in improved outcomes and efficiencies. We identified system improvements after individual cases that strengthened the care processes and increased survival for future patients.

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The lethality of a fall from the GGB has catalyzed a number of suicide prevention efforts including a safety net which is now under construction and scheduled to be completed in 20236.

Hopefully these types of injuries will no longer be witnessed afterwards, and our recent paper will represent the final chapter in this portion of the history of the Golden Gate Bridge.

John Maa, MD, a general surgeon, is an SFMMS past-president.

Edward Alfrey, MD is a General Surgery Specialist.

References 1.

2.

3.

4.

5.

6.

https://www.marinij.com/2019/12/12/golden-gatebridge-suicide-barrier-could-be-delayed-two-years/ Accessed May 22, 2022.

Blaustein M, Fleming A. Suicide from the Golden Gate Bridge. Am J Psychiatry. 2009 Oct; 166(10):1111-6.

Bateson J. The Final Leap, University of California Press 2012. 328pp Lafave M, LaPorta AJ, Hutton J, Mallory PL 2nd. History of high-velocity impact water trauma at Letterman Army Medical Center: a 54-year experience with the Golden Gate Bridge. Mil Med. 1995 Apr;160(4):197-9.

Maa J, Levin J, Minnis J, Stahl B, Carroll M, Pajari L, Alfrey A. Surgery Open Science, In Press 2022.

Swan, Rachel. Doctors studied more than 2 decades of Golden Gate Bridge jumps. Their research shows why some managed to survive. San Francisco Chronicle, Mar 22, 2022.

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SURVIVING AN ASSAULT AND SAVING A LIFE, ALL ON OVERTIME Toni Brayer, MD Editor's Note: The following article contains depictions of sexual assault and homicide.

Feb 11, 2022 I was all alone in my medical office, hours after closing.

Overhead, the fluorescent light was harsh. It was dark outside. Only a few years past residency, I wanted nothing more than to be home drinking a glass of red wine with dinner. Instead, I was returning phone calls, reviewing test results, and charting after a swamped day.

It seemed the paperwork would never end.

A moment later I heard a rustling in the outer office. I immediately sat up in my chair, hyper-alert, my mouth dry. Any former fatigue was gone. I was no longer alone. Then I saw him—a stranger in the hall, wearing a dark hoodie and looking very out of place.

How did he get in? I rose from my desk and walked toward him, resolute to show no fear.

“Who are you? We’re closed. You’re not supposed to be in here,” I said in my most authoritative voice.

“Uh, I’m looking for a job,” he replied. Being nighttime, everything should have been locked up tight.

“You’re in the wrong place, Sir! Leave now.” I pointed to the door and stood with my backbone straight, talking tough, in control. But my knees felt weak.

He didn’t leave, instead taking two quick steps and pulling a black gun from his waist. My chest fluttered, my heart rate raced while my gut seemed to fall. Grabbing my arm, he pushed me through my open office door. My purse was sitting on the desk amid the stacks of paper and half-empty cup of cold coffee. “Take it,” I stammered, “just leave.” He gripped my arm tighter, pointed the gun to my head and dumped the content of my handbag on the desk. Small change fell out. How I wished there had been more money.

“Come on,” he snarled and grabbed my arm again, this time pushing me toward the small bathroom in the back of the office. I knew deep in my gut, deep in the synapses of my brain, that he had been through the entire office and knew its layout. And he knew that I was alone. I suddenly realized that it wasn’t just money he was after. In my profession, I have seen how quickly a person’s life can change. I know that bad 26

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things, terrible things, can happen to people in a blink of an eye.

Something I had once read flashed across my mind: Don’t ever let an assailant move you to a different place. Fight to stay where you are.

But that advice wasn’t practical when he had a loaded gun to my head and I had nothing but a pen in the pocket of my white coat.

He forced me into the tiny bathroom in the back of the office and clicked the door lock. I knew this was bad, really bad, and my options had gone from terrible to really terrible. I could feel his hot breath. The black gun loomed large and to my horror I could see down the barrel to the bullets.

He pushed me over the sink. I could see the sweat dripping down his forehead. There was no room to maneuver and the gun was actually touching my head. Every screaming fiber of my being was on high alert. I couldn’t think. I started talking. Rambling actually. Without any strategy except to stall.

“Come on, man. You seem like a nice guy. You don’t have to do this.”

“Shut up.” he barked. “Take off that coat and your clothes.”

I could feel my chest constrict, yet I kept talking.

“Hey, you must have a girlfriend. Tell me about her.” He pulled at my lab coat.

“What would your mom say if she knew you were here?

Think about your mom. You’re too nice a guy.” He pawed at my clothing and broke the button on my pants.

“If you want drugs, let’s go to my drug cabinet. I think we can find something there.”

As he pushed the cold steel against my temple and tore at my clothing, I tried everything to relate to him and have him see me as a human being, not a thing. I was running out of both talk and time.

“Shut up, bitch. This gun is loaded. Do you get it? Quit talking,” he shoved me hard and ripped my pants down.

By now I was dripping sweat. I realized my attempt at bonding was failing, despite slowing the inevitable down.

Suddenly my attacker stopped clawing when we both heard WWW.SFMMS.ORG

muffled sounds a few feet away, just outside the locked door.

“Help!” I shouted. The door flew open and two security guards stood there, mouths agape, eyes like saucers.

Pop! Pop! that fire-cracker sound reverberated through the air as one of the two men slumped to the floor. The other bolted, running away while the shooter stepped over the fallen victim and suddenly he was gone too. Alone in the eerie silence, I watched those same fluorescent lights create strange shadows. There was no one left but myself and the young bleeding security guard at my feet. There I was, a traumatized young doctor, partially undressed, my vision reduced to black and white. A pool of black blood slowly expanded under his head onto the ground. My mind was a total blank. I wasn’t even sure where I was.

But still, I instinctively kicked into doctor mode, knelt down beside the crumpled stranger, felt for his pulse, and tried to assess the damage. I rolled him onto his back with difficulty, for he was heavy and limp. His shredded lower face was pumping blood. I used my white lab coat and the pants I’d been stripped of to apply hard pressure as he went into shock, going gray color, and breaking out with diaphoresis.

“You’re OK. Stay with me. You’re going to be OK,” I kept whispering. “We got this. Look at me. Look at me.” His eyes saw nothing.

Another unarmed hospital security guard, making rounds, appeared down the hall. He took in the unfathomable scene: a half-dressed woman kneeling by his fellow worker laying in a pool of blood.

“Get help! Call 911!” I hollered. The guard wouldn’t come closer.

After what seemed like hours, help finally did arrive. I happily let the paramedics take over. The narrow hall soon filled with police and detectives. Even the hospital CEO showed up. “If I’m ever stranded on a desert island, I want you there,” he said, studying the bloody floor. I managed a weak smile.

The young security guard was taken to a trauma hospital and underwent surgery for a lacerated facial artery, transfusions, and jaw reconstruction. He surely would have bled out and died, had he been alone. After he recovered, he came back for a visit and was even my patient for a time until he moved away. He never worked as a security guard again and started college instead.

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The would-be murderer and rapist was never found. The gun was recovered weeks later and I went to a line-up, but I couldn’t identify the shooter. For a long time after that night, I couldn’t be alone in an elevator with a man because it felt like that tiny bathroom where I had been confined. Even now, decades later, I experience a wave of fear if a man steps into an empty elevator with me You never know how you’ll react in a life and death situation and hopefully you’ll never have to. Only when put to the test do you know if you’ll pass. I knew that night that I was a hero.

I also knew I was a doctor. I understood viscerally what I have always known intellectually: that life can end in an instant and even the most ordinary events can suddenly become dangerous without warning. We are all vulnerable and face tragedy wearing many different cloaks. How we react can mean the difference between life and death. I survived a potentially lethal assault while reflexively using my professional training to save a man’s life under maximal stress. That night, I felt proud that I passed the test. All while working overtime.

If you or someone close to you has experienced sexual violence, please call the National Sexual Assault Hotline at 800.656.HOPE or visit the resources available at RAINN.org.

Dr. Brayer has practiced internal medicine in San Francisco for over 30 years and has served in numerous medical leadership roles.

A trailblazer for women doctors, she was the first woman Chief of Staff at her hospital, was President of the San Francisco Medical Society, and she is the immediate past CEO of Sutter Pacific Medical Foundation. She has recently made more space in her life for writing and social activism.

She just returned from a medical teaching mission to Rwanda.

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HEALTH CARE PLANS MUST EMBRACE FOOD AND NUTRITION-BASED MEDICAL INTERVENTIONS How healthy eating can become part of S.F.’s health care strategy Katie Ettman Introduction by SFMMS Past-President and Pediatrician Kimberly Newell Green, MD: In 2019 I was asked to be a Champion Provider Fellow. CPF is a statewide two-year fellowship with the goal of training healthcare providers to engage in policy, systems and environmental (PSE) change activities around obesity, and dental and chronic disease prevention. The goal of the fellowship is to give providers the skills and support needed to partner with their local health department to affect policy change in their communities and throughout California. Recognizing that this process could arm me with skills to magnify the health advocacy work that I was doing through SFMMS and CMA, I jumped at the chance.

Along with trained chef and San Francisco fellow Emma Steinberg, MD, I partnered with Dr Rita Nguyen, the lead of San Francisco Department of Public Health’s Food as Medicine Collaborative and her colleagues Priti Rani and Erin Franey. This powerful trio of health advocates steered us to join a coalition doing work to find tangible ways for health systems to think about food insecurity and to treat it as a medical issue.

Through work with an incredibly passionate coalition of advocates from many organizations including leaders from SFDPH, SPUR and several community-based organizations including food providers and advocates, we focused much of our work on the CalAIM process. After months of advocacy and efforts, facilitated in part by SFMMS’ relationships with state legislators and DHCS leaders, we were thrilled to have an important success. The words “medically-supportive food and nutrition” were inserted into the CalAim legislation. With these 5 words, a universe of food supports became possible for patients who need them.

Now, when the treatment for your patient’s diabetes, cardiac disease, or renal disease is food, condition appropriate healthy food can be covered by Medicaid. The food supports come in many forms, including direct prescriptions to hospital-based food pharmacies, medically-tailored meals, and “vouchers for veggies” which can be brought to local markets. The legislation also supports counseling to promote nutritional behavior change.

But the work has only begun. As health plans begin to implement the complex and comprehensive new approach to care delivery encapsulated in CalAIM, they will need to build the infrastructure and systems to support this work. And so the work continues. The OpEd that we reprint here by my partner and colleague Katie Ettman begins to outline the work to be done.

Please join us in the vital work towards moving the healthcare system to provide the appropriate, cost-effective and high quality treatment for many chronic diseases that cause so much suffering and death: food.

– Kimberly Newell Green, MD

At the end of 2021, the federal agency that oversees Medicare and Medicaid made a big decision that made little news. With all the fanfare of papers getting a stamp of approval, California received permission to pilot new approaches to providing healthcare to the more than 13 million Californians who rely on Medi-Cal. With that approval, the onus is now on local health plans, including the San Francisco Health Plan, to implement strategies that could profoundly improve people’s health and lives. One cutting-edge aspect of the reforms is Community Supports, of which there are 14 designed to address social drivers of health, such as lack of access to food.

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But these are optional services, meaning individual health plans must opt into providing them. To prevent, treat and reverse chronic conditions, the San Francisco Health Plan and health plans across California should opt into providing medically supportive food and nutrition, one of the 14 Community Supports. Medically supportive food and nutrition interventions include produce prescriptions, food pharmacies, healthy groceries and medically tailored meals.

Evidence strongly suggests that this spectrum of interventions can help reduce average blood sugar in those with diabetes, blood pressure and preterm birth. Many of these conditions put individuals at greater risk for COVID-19 hospitalization WWW.SFMMS.ORG

A San Francisco Department of Public Health staff member supporting the Food as Medicine Collaborative’s Southeast Health Center Food Pharmacy. (Photo by Chris Gill)

and death. By investing in upstream interventions, California can be better prepared for our current health crisis — and the next one.

But is San Francisco, and California generally, prepared to greatly expand access to these food-based interventions?

My sense is yes. SPUR — in collaboration with the UCSF Center for Vulnerable Populations, the Harvard Center for Health Law and Policy Innovation and the Food as Medicine Collaborative — recently published “Integrating Food into Health Care,” a report based on a survey of 145 organizations across the state. The research shows there is already a strong network of community-based organizations, government agencies and traditional health care providers offering — and poised to expand — food-based services. In San Francisco, more than a dozen organizations provide at least one medically supportive food and nutrition intervention. However, to build upon the existing network of providers, the Department of Health Care Services, which administers Medi-Cal, and health plans must address barriers to growth.

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Nearly 70% of providers surveyed reported a lack of sustainable funding as a barrier to offering food and nutrition services. These interventions are primarily funded through philanthropy, hospital community benefit dollars and other external sources, rather than insurance. In other words, they lack long-term financial sustainability.

Yet researchers have estimated these interventions could save $40-$100 billion in health care costs nationwide.

Transitioning these services from pilots to standard plan benefits would ensure their sustainability and enable more patients to improve their health while also reducing overall health care costs.

While some may argue that inadequate healthy food access is a problem to be solved by social services agencies, Dr. Kim Newell Green, former president of the San Francisco Marin Medical Association, explains, “If a new drug came to market that showed these health outcomes and no side effects, we would immediately prescribe it to patients.”

A future where we pay for the prevention — and not just the treatment — of chronic disease is within our grasp. The San Francisco Health Plan must take the lead by seizing this rare opportunity to improve care by providing medically supportive food and nutrition interventions.

“An apple a day keeps the doctor away” isn’t just a wise adage. It’s evidence-based medicine that health plans should embrace.

Katie Ettman is the food and agriculture policy manager at SPUR, a nonprofit public policy organization in the San Francisco Bay Area.

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WELLNESS

BECOMING A PHYSICIAN IS HARD. BEING ONE IS EVEN HARDER. Jessie Mahoney, MD This is why I became a physician wellness leader in 2002 and it is why I continue to do this work twenty years later.

Practicing Warrior 3, amidst wind gusts, on an old and unstable pier is much like practicing medicine these days. Many of the challenges are the same and many of the solutions are the same.

This pier, on Tomales Bay, could and should be more stable. Ideally it would not be rotting. The circumstances could be better. No wind for example. I could choose to practice yoga somewhere else. Perhaps where there is no wind, no tipping pier, perhaps in a place with props, and even with some heat. But then I would also have no view and no fresh air.

What helps the most for both a successful warrior 3, and practicing medicine "well" is inner work.

Being intentional, finding calm, strength, and equanimity.

Focusing purposefully on choice, simplicity, and ease.

Transitioning with mindful intention. Choosing not to waste unnecessary energy and allowing the challenging pose to happen without resistance.

Enjoying the pleasure of accomplishment and "relaxing in" when you get there.

A successful warrior 3 in the wind on a rotting pier requires attention to your health, strength, and wellness.

It requires setting yourself up well. It requires ongoing strength, stability, and health to stand on one leg and balance in the wind.

Practicing medicine "well" requires similar approaches.

Purposeful choices, strategic support, and decision-making.

Knowing there will be a lot of balance and challenge and chaos along the way. Success- being a whole and healthy human and healer- requires a decluttered mindset.

It requires focusing on simplicity and ease amidst the heavy winds. It requires a healthy and stable inner core.

All of this is what coaching and mindfulness (and yoga) can help you do.

Physicians are currently asked to live their lives and practice medicine in ways that aren't healthy or sustainable. We are practicing in the wind and on rotten tippy piers. Our healthcare system is a big problem that makes it hard to be a well and healthy human healer. The system should be different. AND we, as both individuals and communities of healers, can also still improve our own lives and take control of our experience practicing medicine and living our lives.

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When we do this is when change happens.

Not because we are the problem but because we are smart amazing humans with tremendous brains creativity and determination.

We ultimately want to be healthy humans who are showing up as the best most healthy versions of ourselves, living our best lives, and helping others do the same.

Decluttering our mindsets and healing and nourishing ourselves fully allows us to become the healthiest and highest functioning humans we can be. In this state, we also make the best and most impactful healers. Unhelpful thought patterns that are trained into physicians in medical training get in our way often. Until we notice them and “unlearn" them we don’t show up with optimal empowerment, clarity, and energy.

“We can make ourselves miserable or we can make ourselves strong the amount of effort is the same.”

– Pema Chodron.

When we step out of victimhood, depletion, and exhaustion, we advocate more effectively. When we are calm, grounded, nourished, and present, we can contribute to creating systemic solutions that actually work. In medicine and beyond.

Why am I sharing these thoughts?

Because it’s possible to become healthy, whole, inspired, hopeful, and alive again.

Even when the system hasn't changed YET. Practicing warrior 3 on a broken rotten tippy pier in the wind can still be of value and even fun.

True Wellness Are you done with token wellness offerings?

Most physicians I know are over watching videos, and signing up for “programs” and talks they hope will help but ultimately don’t lessen burnout and exhaustion. Most physicians I know are tired of goody bags, branded trinkets, sweatshirts, water bottles, and conferences and lectures in large, windowless ballrooms.

True wellness does not come through a checklist, a lecture on wellness, a meal, or a sweatshirt. It comes from nourishing yourself fully, slowing down, learning to listen and then acting accordingly.

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True wellness comes from quieting the snow globe, becoming clear, calm, and grounded. And then choosing to move forward from a place of mindful intention and alignment.

How do you achieve this when you are burnt out, exhausted, busy, and frustrated?

In my experience, through coaching, mindfulness, community, connection, and full mind, body, spirit, and soul nourishment.

When you are depleted and your nervous system is in fight or flight, it is hard see what's in the way and how to make effective changes.

When diastole is sufficient, your heart is full, you can breathe deeply and you feel safe and calm and grounded, it is possible to learn and implement effective tools and strategies with ease.

In order to find true wellness, you have to slow down enough to listen. "You cannot change what you cannot see."

When you slow down and refill and nourish yourself, you are able to notice and own your unhelpful thought patterns and old habits, and consider whether you want to make changes.

True wellness comes when you have agency and feel empowered.

It comes when you know what works for you.

When you value and trust yourself.

And when you give yourself permission to act accordingly.

There are solutions but they don't likely look like what you have tried already. That hasn't worked. If you continue to feel stuck, unwell, and exhausted, why not try something new?

Physician coaching has led many physicians to meaningful change. It is experiential and active. Small immersive experiential wellness retreats work similarly.

These are the two interventions, that in my 20 years of wellness leadership experience, provide sustained relief, change, and hope, as we wait for the healthcare system to change.

It is always nice when studies back your experience up. A new study released in JAMA in May 2022 last week demonstrated a significant positive impact of coaching for residents. Previous studies published in JAMA in 2019 and 2020 have also shown an impact on burnout, and quality of life for attendings after just 6 weeks.

As an FYI, you don't have to be burnt out or "broken" to benefit greatly from coaching. Everyone needs effective coping skills to perform at their highest level and live their best life.

Professional athletes know this well. They regularly engage in mindfulness and coaching, and even yoga.

True wellness is experiential. It should be done in a way that is in and of itself well. It works much better that way.

It doesn't have to, and probably shouldn't be, done at work.

It doesn't have to paid for by work. It doesn't have to be done inside - or on zoom. It doesn't have to be done with those you work with.

Effective wellness programming can be done in spectacular, healing locations with amazing interesting people from all over the country- without a windowless ballroom or conference center in sight.

Effective wellness interventions can be done from home, even from bed. They can be a way to build new communities and make new connections. They can be done in groups and spaces where you feel like you belong and they can be done 1:1.

You can even cry, laugh, smile, and breathe deeply while you learn and grow and begin to feel "Well" again.

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When CME and wellness are shared in ways that are "well" the impact is far greater.

The Value of a “Retreat” Being the best possible parent, spouse, friend, doctor, colleague, and contributor to a better world are not possible from a place of depletion.

"Even a short period of retreat is a benevolent rest, a stepping outside of busy daily routines and our ordinary identity. Released from the tyranny of time, we are invited into the reality of the present. They are food for the heart. Take a long retreats, short retreats and mini retreats....breathe with compassion for your busy self, and then put down all your plans. Open yourself to wonder. Let your heart be fed and your spirit renewed. So that you can tend your family, your community, the world, you can do so with a stronger, more peaceful heart.”

– Jack Kornfield

TO NOURISH Kto provide food and other substances necessary for growth, health, and good condition.

K to cherish, to cultivate, to tend, to sustain K to nurture, to support, to supply

Living your “one wild and precious life” WELL is about nourishing your mind, body, soul, and spirit fully.

Retreats, even short ones, offer a chance for full mind, body, soul, spirit, heart, lungs, nervous system, and belly nourishment.

When we are fully nourished is where the hard-to-find solutions become clear.

Dr. 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. She specializes in helping ease career transitions and burnout, parenting struggles, and relationship challenges. She is a leader of the Mindful Healthcare Collective and is co-host of the Mindful Healers Podcast. She teaches virtual weekly yoga to physicians and other healthcare providers and leads yoga, coaching, and wellness retreats in spectacular natural locations. You can read her blog at www.jessiemahoneymd. com. You can connect with her at jessie@jessiemahoneymd.com.

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SFMMS Physician Wellness Committee Update: April/May/June 2022 | Wellness Articles By Dr. Jessie Mahoney

SFMMS WELLNESS EVENT HIGHLIGHTS SFMMS Members Attend the Nocturnists’ Live Event in SF in June: TOGETHER AGAIN Since 2016, the Nocturnists have uplifted the voices of over 350 healthcare workers through sold-out live performances and their acclaimed podcast. Their live performances help clinicians develop their stories for the stage, enabling them to speak publicly about the fears, doubts, joys, and passions that shape their personal and professional lives.

With the generous support of the Nocturnists, SFMMS Wellness raffled tickets to our membership to "TOGETHER AGAIN," their live performance on the evening of Friday, June 10th at the Brava Theater in San Francisco. Attendees heard from 8 wonderful storytellers, each with a unique spin on the theme.

Mindful Yoga for Healers

A monthly weekend offering of free Mindful Yoga for Healers. This is specifically for SFMMS members to join their colleagues in order to heal, replenish, restore, and connect! Sign up at https://mindfulyoga.jessiemahoneymd.com/ to be notified of class dates and times.

Wellness Retreats Back by popular demand, SFMMS Wellness raffled sponsorship for our members to attend one of three one-day retreats at Pie Ranch on either Sunday, June 12th, Thursday, June 23rd or Saturday, September 24th. The Honoring Diastole Wellness Retreats are led by SFMMS Wellness Committee Chair, Dr. Jessie Mahoney and SCCMA Physician Wellness Leader, Dr. Gail Wright of SCVMC Pediatric Cardiology. You can sign up and learn more here: https://www.jessiemahoneymd.com/honoring-diastole

“I was initially skeptical about the value of a day-long retreat - but this day was deeply therapeutic.”

– Chief Infectious Disease, TPMG

“Thank you for the most soul (and belly) nourishing program. It was just what I needed.

The location was incredibly special. Truly a magical day.”

– Marin Endocrinologist

45-minute Intro Physician Coaching Session What is physician coaching? Physician coaching is an evidence based intervention to decrease burnout and improve quality of life. (JAMA 2019) It is a safe space to explore your career and life frustrations, resentments, dreams and desires. It is preventive care for a sustainable and enjoyable career in medicine. It provides you with a toolbox of strategies to help you optimize you potential, productivity, and joy. It helps minimize stress and ease struggle. Professional athletes have coaches; physicians need them too.

SFMMS Wellness raffled 45 minute intro coaching sessions with local, certified physician coach to our membership in June.

We plan on raffling more opportunities like this to our membership in Fall 2022. If you are interested in learning more, please email Molly Baldridge, SFMMS Director of Engagement at mbaldridge@sfmms.org.

To view recordings of past events or to register for upcoming events, visit the SFMMS Wellness Page at www.sfmms.org/gethelp/physician-wellness.

SUMMER READS

Our Physician Wellness Committee curated an SFMMS Summer Reads list of books for Summer 2022. In lieu of an SFMMS book club meeting this summer, members were randomly selected to receive the Summer Reads book of their choice.

You can still enjoy the following curated list this summer: "Can't We Talk about Something More Pleasant?: A Memoir" by Roz Chast "The Conscious Parent: Transforming Ourselves, Empowering Our Children" by Dr. Shefali Tsabary "The Menopause Manifesto: Own Your Health with Facts and Feminism" by Dr. Jen Gunter "Things That Matter: Overcoming Distraction to Pursue a More Meaningful Life" by Joshua Becker "An Invitation to Pause... again: musings from a mindfulness coach about life and dementia" by Janet Archer "Life's Messy, Live Happy: Things Don't Have to Be Perfect for You to Be Content" by Cy Wakeman 32

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COMMUNITY MEDICAL NEWS Kaiser Permanente

Kaiser Permanente San Rafael

Maria Ansari, MD

Naveen Kumar, MD

The past two years have been among the most difficult we’ve experienced in the history of modern health care, and our challenges have been intensified by the separation brought about by social distancing and remote work. Kaiser Permanente has been exploring ways to see each other in person, while maintaining safety protocols for social distancing. Just as we’ve missed those connections, our communities have missed the annual events that bring us together to celebrate what makes the Bay Area such a vibrant place to live and work.

That’s why we are excited to be participating in some of the community events that we’ve traditionally sponsored in the past.

After a two-year hiatus, the renowned SF LGBTQ+ Pride Parade and celebration will take place on June 25 and 26, commemorating the Bay Area’s LGBTQ+ communities and allies.

KPSF has a long history of involvement with the Pride Parade, the largest celebration of its kind in the country, which typically draws more than a million people from around the world. We’re proud to say that 2019 was our 25th consecutive year as one of the parade’s top sponsors, and equally proud that so many of our physicians and employees from Northern California participate and show their support.

At events such as these, we will be taking care of ourselves and our communities by making safety a top priority. All events sponsored by Kaiser Permanente will abide by city, county, and state COVID-19 guidelines. We will also take into consideration risk factors published by the CDC such as the number of COVID-19 cases in the community and whether the event is held outdoors.

Kaiser Permanente will also be sponsoring Carnaval, the two-day festival celebrating the diverse Latin American, Caribbean, and African Diasporic roots of the Mission District and the San Francisco Bay Area. Now in its 44th year, Carnaval has grown to be the largest multicultural celebration on the West Coast. This year’s theme, Colores de Amor: Inclusivity, Family, & Community, reminds us why its’s important for our communities to resume holding the events that strengthen our connections.

With so many Marin County residents entrusting Kaiser Permanente with their care, we were pleased to open the new San Rafael Park Medical Offices in July.

For more than 60 years, Kaiser Permanente San Rafael has been a part of Marin County, caring for our patients and promoting the health and well-being of our community. The new offices were designed with the community in mind, guided by our commitment to high-quality care, high levels of customer service, and convenience. San Rafael Park Medical Offices offer comprehensive primary care and onsite access to pharmacy, lab, rehabilitation therapies, imaging, endocrinology, and eye services—all under one roof.

The departments and services available at San Rafael Park Medical Offices: Adult and Family Medicine; Endocrinology; Health Education; Imaging; Lab; Ob-gyn; Ophthalmology; Optometry; Outpatient Eye Surgery Suite; Pediatrics; Pharmacy; Physical/Occupational Therapy; and Vision Essentials (includes Optical Sales).

“At this new technologically advanced building, our members can expect to receive the same high-quality, integrated, and industry-leading care they’ve come to depend on,” says Naveen Kumar, MD, Physician in Chief, San Rafael Medical Center. “I have tremendous gratitude for our care teams, whose clinical excellence is reflected in this beautiful new space.”

The project represents years of hard work and thoughtful collaboration with environmental stewardship top of mind. One example was the decision to repurpose an existing building instead of constructing one from the ground up. The three-story, 145,000 square-foot building has features like all LED lighting, electric vehicle charging stations, reclaimed water in the plumbing fixtures, and solar panels, which provide 100 percent of the building’s electrical needs. There are also bike racks and commuter showers to make it easy to leave the car at home.

The San Rafael Park Medical Offices was years in the making and is a testament to the San Rafael leadership team’s long and deep commitment to our community. We welcome the opportunity to serve the broader Marin County and surrounding communities in our spacious new building.!

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For over 50 years thesecondopinion has been providing free, comprehensive second opinions to adults in California diagnosed with cancer.

We rely on the expertise of over 60 volunteer cancer specialists to provide our service and give cancer patients a better understanding of their cancer diagnosis and treatment plan, so they can make informed medical decisions.

Are you a physician looking for an opportunity to use your knowledge and experience? Help cancer patients by volunteering with thesecondopinion.

Our multidisciplinary second opinion panels are conducted via Zoom telemedicine once a week and consist of a medical oncologist, radiation oncologist, pathologist, radiologist, surgeon, the cancer patient and family members. Medical malpractice insurance is provided.

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San Francisco Marin Medical Society 312 Sutter, Suite 608 San Francisco, CA 94108

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