San Francisco Marin Medicine, Vol. 94, No. 2, April/May/June 2021

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

CONFRONTING CHALLENGES Combatting Racism and Discrimination Physician Wellness: A New Wealth of Resources COVID Turns the Corner Addiction in the Covid Era – SFMMS Webinar SFMMS Annual Report

Plus Adverse Childhood Experiences, Fires, Smoking, and (Still) Closed Schools

Volume 94, Number 2 | APRIL/MAY/JUNE 2021

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IN THIS ISSUE

SAN FRANCISCO MARIN MEDICINE

FEATURE ARTICLES

MONTHLY COLUMNS

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Membership Matters

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President's Message: Monique Schaulis, MD, MPH, FAAHPM

We're All in This Together Sandra R. Hernández, MD

10 Acknowledging Our History and Moving Toward Equity and Justice in Medical Education

Denise M. Connor, MD 12 Confronting Anti-Asian Hate and Violence

Michelle Leung, MS3 and Joseph Woo, MD

14 Combating Medical Racism: The Case for Compulsory Physician Training

Jeffrey B. Ritterman, MD 16 ACEs Screening: Not Just for Pediatricians

Heyman Oo, MD 20 How "Buoyancy" Can Help You

Jessie Mahoney, MD

26 The COVID Endgame: Predictions on the future of vaccines, schools, media, science, and more

Vinay Prasad, MD, MPH

28 Do Good and Avoid Harm: Why Health Care Providers Should Get a COVID Vaccination

Charles E. Binkley, MD 30 COVID-19 Vaccination Update for Employers

Jamie M. Bossuat, Esq

31 Smoking and COVID: The Primacy of Prevention

John Maa, MD

32 Whose Habitat Is it? Musings Upon Seeing the Effects of Wildfire Mitigation in a High-Risk Area

Linda Hawes Clever, MD

April/May/June 2021 Volume 94, Number 2

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Executive Memo: Pursuing Physician Wellness in All Things Conrad Amenta CMA House of Delegates Report Michael Schrader, MD, PhD

COMMUNITY NEWS 41 Kaiser News Maria Ansari, MD

41 Chinese Hospital Sam Kao, MD

OF INTEREST 24 Lasting Impact: Patient Stories 36 Highlights from the 2020/21 SFMMS Annual Report 40 Book Review: Together – the Healing Power of Human Connection in a Sometimes Lonely World by Dr. Vivek Murthy

John Maa, MD 44 Advertiser Index

33 Science-Based School Reopening: A Letter to the Governor and State Health Director

Monica Ghandi, MD, and others 34 Telemedicine Webside Manner: Putting Your Best Face Forward

Amy McLain, BSN, RN

SAN FRANCISCO

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MARIN MEDICAL SOCIETY

Editorial and Advertising Offices: San Francisco Marin Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133 Phone: (415) 561-0850 Web: www.sfmms.org

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MEMBERSHIP MATTERS

The 2021 SFMMS / David E. Smith Addiction Medicine Conference: Addiction Medicine and Recovery in the Covid Era June 18, 2021, 8:45am- 1:30pm, Via Zoom The past year has been not only a vast challenge in terms of the pandemic, but with respect to substance abuse issues as well. Drug abuse rates, relapses, overdoses and trends have all worsened significantly. We thus are bringing back a streamlined webinar version of this once-annual conference, which for years has brought hundreds of attendees to learn about leading edge treatment, prevention, and recovery issues from a skilled faculty of addiction specialists and researchers. With loosening of restrictions on medication-assisted-treatment and hopefully expansion of treatment resources now underway, the morning should be filled with useful and stimulating information.

Join us. For information: Steve Heilig/heilig@sfmms.org or visit www.sfmms.org/news-events/events.

CMA president statement in response to continued threats against public health officers "One of the unfortunate side effects of this pandemic has been the demonization of public health officers from fringe voices and anti-vaccination activists. Public health should not be a political issue and the public must also speak out when public servants like Dr. Luu come under attack. The death threats she has received are unacceptable and must not be tolerated. While we have seen an uptick in targeting of public health officers around the state and across the country, the most vitriolic seems to be reserved for women and those of Asian-Pacific Islander descent. Enough is enough. We cannot tolerate the efforts to intimidate public servants like Dr. Luu, and must ensure we have public protections in place for public health officers. As we work together to bring this pandemic to an end, we must also work to address the increase in racial hatred and the increased threats against those who are working overtime to keep the public safe.”

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SFMMS Applauds Federal Ban On Menthol Tobacco SFMMS President, Dr. Monique Schaulis, published an op-ed in the San Francisco Chronicle this week expressing SFMMS' support for the Biden administration's move to ban menthol cigarettes within the coming year. This pro-health/ anti-tobacco policy has been a long time coming, as it became obvious that such flavorings are a primary factor in Big Tobacco’s marketing to youth and specifically to Black Americans.

California Medical Association President Peter N. Bretan, Jr., M.D., issued the following statement in response to recent violence and hate crimes against the Asian American and Pacific Islander (AAPI) community.

“The California Medical Association (CMA) is one of many groups standing in solidarity with the Asian American and Pacific Islander (AAPI) community, especially at this time. Over the last year, we have seen an appalling rise in anti-AAPI hate crimes, two of the latest including a fatal mass shooting in the state of Georgia and a vicious attack on an elderly woman in New York.

These events are just two of many that have occurred at staggering and increasing rates in the last year in what appears to be a culmination of hate left to fester and propagate amidst a year filled with misinformation, xenophobia and outright racism. Too many of these incidents are in our own communities. Stop AAPI Hate, an organization that tracks and responds to incidents of hate, violence, harassment, discrimination, shunning, and child bullying against Asian Americans and Pacific Islanders in the United States, issued a report documenting the incidents reported to it between March 19, 2020 to February 28, 2021. California had the highest number of reported cases, over 1,500. CMA condemns all of these heinous and intolerable acts.

CMA has been clear in calling out racism that is endemic to the United States and called on ourselves and each other to do more to address the cultural cancers that foment racial violence. The work of eradicating this hate begins with examining and challenging the state of our own environments and profession.”

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Help Promote Health Care Access, Health Equity, and Workforce Diversity Our state has a growing shortage of physicians and COVID-19 has exposed deep inequities in health care. UCSF PRIME is a medical school program that prepares future doctors to care for underserved communities, such as the homeless in urban communities. Please join us in asking lawmakers to fund this critical program and send an email using this customizable template https://www. universityofcalifornia.edu/support. State funding will support existing programs and the creation of two new programs focused on caring for Native American and Black/African American communities in California.

Working Together to Safely Reopen Schools Now After a year of school closures, there is excitement and hope mixed with understandable fear and uncertainty. Parents, teachers, and community members are wondering what it will look like to go back to in-person learning. They are reasonably asking if it will be safe for everyone. A group led by doctors (including SFMMS past-president Kimberly Newell Green, MD), parents, teachers and community leaders are launching this effort to answer those questions. For information, see: https://www.safelyopenschoolsnow.org/

April/May/June 2021 Volume 94, Number 2 Editor Gordon L. Fung, MD, PhD, FACC, FACP Managing Editor Steve Heilig, MPH Production Maureen Erwin EDITORIAL BOARD Editor Gordon L. Fung, MD, PhD, FACC, FACP Tonie Brayer, MD Linda Clever, MD Anne Cummings, MD Irina DeFischer, MD Shieva Khayam-Bashi, MD John Maa, MD David Pating, MD SFMMS OFFICERS President Monique Schaulis, MD, MPH President-elect Michael C. Schrader, MD, PhD, FACP Secretary Dennis Song, MD, DDS Treasurer Heyman Oo, MD, MPH Immediate Past President Brian Grady, MD 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

FREE PPE from CA Office of Emergency Services and CMA The Office of Emergency Services has partnered with the California Medical Association (CMA) to distribute millions of units of PPE to medical practices who are encountering challenges securing adequate supply, and those experiencing financial hardship due to the pandemic. As part of CMA’s continued PPE Relief efforts, the Association has developed a new online ordering portal where practices can easily order the specific PPE they need, in the quantities that best suit their practice size. The PPE Relief portal will streamline the access, supply, process and payment to those organizations seeking to augment their PPE inventory. Go to ppereliefdirect.org and learn more.

PPE available from SFMMS

SFMMS has an inventory of KN95 masks available for FREE to SFMMS members. Please contact Steve Heilig at heilig@sfmms.org to coordinate.

2021 SFMMS BOARD OF DIRECTORS Edward Alfrey, MD Ayanna Bennett, MD Julie Bokser, MD Keith Chamberlin, MD Anne Cummings, MD Nida F. Degesys, MD Manal Elkarra, MD Beth Griffiths, MD Robert A. Harvey, MD Harrison Hines, MD Zarah Iqbal, MD Michael K. Kwok, MD Jason R. Nau, MD Sarita Satpathy, MD Kristen Swann, MD Kenneth Tai, MD Melanie Thompson, DO Winnie Tong, MD Matthew D. Willis, MD, MPH Joseph W. Woo, MD Andrea Yeung, MD

Read hightlights from the SFMMS 2020/21Annual Report on page 36

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PRESIDENT’S MESSAGE Monique Schaulis, MD, MPH, FAAHPM

"As thousands of people file through, I feel proud walking under the giant boards that give instructions in many languages. I have had the privilege of experiencing the joy of first vaccines many times over. We crossed over 300,000 total shots in arms."

Each time I sit down to reflect and write the President's message, I am astonished at how much has transpired since the last column. The furious pace of change is ongoing in 2021.

Last week, our ICU was without Covid patients for the first time in recent memory. My critical care colleagues have exhaled just a little bit. The ED feels more relaxed in tenor.

Our children are heading back to school! San Francisco feels closer to normal.

Working at the Moscone mass vaccine site, I have a new perspective on what can be accomplished when leaders have the will to take action. As thousands of people file through, I feel proud walking under the giant boards that give instructions in many languages. I have had the privilege of experiencing the joy of first vaccines many times over. On my last shift, we crossed over 300,000 total shots in arms.

I capture in my heart the stories that people share with me at Moscone. Collective vulnerability allows for profound conversations between strangers. The mother of a UCLA Emergency Medicine resident told me her story just after the LA surge subsided. She knew the trauma that her daughter was experiencing as a young doctor and literally ached to embrace her—not being able to do so was excruciating. The vaccine would provide her with the freedom to mother again. We both cried as she shared the power of that moment of liberation. A very elderly couple told me that they were so happy to finally get their injections.

I wondered aloud why it had taken them so long to get in?

They shared that they had been trapped in their apartment building for the last eight weeks, unable to get out due to a

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broken elevator. Their more able neighbors had been bringing them food and supplies for the duration.

These moments of optimism, beauty and relief are tempered, however, by the pain of so many horrific incidents of racially motivated violence. Our collective nerves are frayed from the Derek Chauvin trial and from watching the senseless acts of brutality a ga in st t h e A A P I c o m m unity. Despite the fatigue of the pandemic, we cannot rest; we must continue to press forward together to address gun violence, racism and inequities.

Let’s take the energy and leadership we’ve marshalled against Covid and apply it to these other pressing problems. As John Lewis noted, “Nothing can stop the power of a committed and determined people to make a difference in our society.”

– Monique

Dr. Monique Schaulis, MD, MPH, FAAHPM, is a graduate of the University of Chicago Pritzker School of Medicine. She practices Emergency and Palliative Medicine with The Permanente Medical Group in San Francisco. She is President of SFMMS and serves as faculty for Vital Talk, a non-profit that teaches communication skills for serious illness. Dr. Schaulis chairs the Medical Aid in Dying special interest group for the American Academy of Hospice and Palliative Medicine.

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EXECUTIVE MEMO Conrad Amenta, SFMMS Executive Director

PURSUING PHYSICIAN WELLNESS IN ALL THINGS The profession of medicine has faced daunting challenges during the COVID-19 pandemic. At the San Francisco Marin Medical Society, we have heard from primary care physicians navigating complex public health guidance, personal protective equipment shortages, and vaccine shortages. From critical care physicians providing exceptional care in ICUs as surges constrain hospital resources; to independent physician practices who shifted overnight to provide the bulk of their care via telemedicine; in every care setting—and across medical specialties—physicians have put their own health and wellness on the back burner to care for their communities.

"We think about how to position the profession to thrive post-COVID-19.

SFMMS is applying physician wellness as a ‘lens’ through which we view everything we do."

Across every segment of our membership, we have heard you loud and clear: the San Francisco Marin Medical Society needs to help the profession to come together to heal.

In collaboration with the California Medical Association and fellow county medical societies, SFMMS will continue to provide timely interventions to those in crisis. But there is another project underway, one that broadly defines and guides SFMMS

as we think about how to position the profession to thrive post-COVID-19. SFMMS is applying physician wellness as a ‘lens’ through which we view everything we do.

When we convene and connect our members, bringing them together to build authentic relationships, it is because we know that nobody understands the experience of a physician like another physician.

When we develop advocacy and media training, helping physicians to tell their story to inform the decisions of policymakers, it is because we want our physicians to feel empowered and influential.

When we share opportunities to volunteer with community benefit organizations, it is because we know that “work after clinic” can make one feel disconnected from their community, their profession, and their mission.

Across everything we do, we know that we have done our job well when our physicians indicate that, because they engaged with SFMMS, they feel nourished and sustained.

In this issue of San Francisco Marin Medicine, you will find highlights from the SFMMS Annual Report. It summarizes our accomplishments over the previous year and our strategic priorities going forward. I encourage you to view each and every one of our activities through the lens of physician wellness… because that’s what we do.

Conrad Amenta

One of the Bay Area's biggest hospitals has hit a huge milestone: Zero COVID patients!

SAN FRANCISCO CHRONICLE – MAY 20: For the first time since March 2020, San Francisco General Hospital has reported zero COVID-19 patients. The development Thursday marked a major pandemic progress point for San Francisco and one of its biggest and best known hospitals.

Officials said COVID-19 vaccinations were largely to thank. For the past few weeks, the hospital recorded one or two COVID-19 patients who had recovered but remained at the facility awaiting placement because they were experiencing homelessness or otherwise vulnerable.

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CMA HOUSE OF DELEGATES (HOD) REPORT:

CMA DELEGATION POLICYMAKING UPDATE Michael Schrader, MD, PhD Every year the CMA House of Delegates (HOD) meets to discuss major issues that are meant to be broad platforms for policy. These major issues are meant to be apropos to the current concerns of the CMA members. Past major issues have been homelessness, Covid-19 preparedness, mental health, and cannabis use to name just a few. Every year the delegation chairs propose topics for major issues which are then discussed and selected at the yearly meeting of the Committee of Delegate Chairs (CDC) which meets in April. This year it met virtually via Zoom.

The Committee of Delegate Chairs opened with the announcement of a change in the rules that there would be only a single major issue. In the past we have had two to three. There was grumbling in the chat. Each Chair was supposed to introduce only a single major issue topic. Of course, as physicians, we exercised our prerogative not to follow explicit directions. Our District VIII had proposed health equity and structural racism in medicine as a major issue. I advocated for this and then stated that I would not mention that we had chosen climate change as our second choice. This further opened the door to second, third, and fourth choices from the other Chairs.

In this horse race, health equity and structural racism did well but corporatization of medicine was also an early favorite.

Scope of practice was also well advocated for. Climate change lost momentum early on. The CMA staff recommended health equity. Dustin Corcoran, CMA CEO, argued that health equity could be all encompassing and include Covid testing, vaccination, work force issues, provider compensation, corporatization, and scope of practice. Dustin argued that health equity could incorporate many issues without appearing self serving. To me it seemed a little cynical. But the push from the staff added impetus to health equity.

The also-rans for major issues included post-Covid medicine, CMA governance, scope of practice, delivery and payment,

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and GME coordination/optimization. These topics were slow out of the gate and were voted from the competition, except for scope of practice which made a surprise surge. Health equity was leading, followed closely by corporatization, with climate change, and scope rounding out the lead.

Scope was folded into corporatization still strongly in second place. Climate change started to flag: maybe it was too big, outside the scope of the HOD, or better addressed by a TAC. The two front runners had broken free and were galloping toward the finish line.

The question was then raised: Would there be only one winner or two? The chat lit up with calls for two major issues and support was strong for the two remaining contenders that were racing down the stretch. The speaker acquiesced to the demands of the delegation chairs and a vote was held. The call for two major issues was adopted and two winners were declared.

Climate change was still a favored topic and its proponents pushed for a TAC to address climate change. This proposal had previously been made at the Climate Change Town Hall meeting in February.

Will the HOD be in person or virtual or a hybrid? The voting for the President-Elect with probable run-off makes a hybrid meeting more complicated. Expect the final decision at the end of May. Dr. Schrader chairs the SFMMS delegation (with Dr. Ameena Ahmed, newly-elected vicechair) and is president-elect of the SFMMS.

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WE’RE ALL IN THIS TOGETHER Sandra R. Hernández, MD

As much as we all want to move beyond the pandemic, we must never forget the biggest lesson it has taught us. When it comes to our health, we’re all in this together.

A protective mask won’t work to its full potential if it is riddled with holes.

Neither will a health care system that covers some people and leaves others behind. The system can only work for everyone if it includes everyone. There has never been a better time — or a stronger case — for covering all Californians than there is right now. We should start by extending Medi-Cal to all Californians with low incomes, regardless of immigration status.

About three million people in California lack health insurance today. Undocumented immigrant adults compose the largest group among them. Our undocumented neighbors, friends, coworkers, and family members make enormous contributions to our economy and our communities. Many risked their lives during the pandemic to perform essential jobs — including many caregiving jobs. Yet California continues to exclude undocumented adults 26 and older from Medi-Cal. Undocumented immigrants have deep roots in California communities and make major contributions to our economy, the nation’s largest and most successful state economy. Nearly 2.5 million US citizens in California live with undocumented family members. Our exclusionary approach to health care coverage creates significant problems for these mixed-status families.

When some family members have coverage and others do not, the whole family suffers. There is no peace of mind — only the anxiety of knowing someone you love is vulnerable. Parents who lack health insurance are less likely to take care of health problems when — or even before — they arise. The resulting financial instability affects the entire household, including kids and grandparents. This stress and turmoil are entirely preventable.

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A Crucial Step

Every Californian ought to have access t o c o m p re h e n s ive care through a medical home they trust.

People with a medical home are more likely t o g e t va c c i n a t e d , manage their diabetes, get screened for depression, or receive myriad other essential health care services. Expanding Medi-Cal to all Californians with low incomes does not necessarily mean that everyone will have a medical home and access to all the care they need overnight, but it is a crucial step toward that eventual goal.

Two positive trends should make it easier than ever to expand Medi-Cal to undocumented adults with low incomes.

First, a strong and growing majority of Californians (66%) now favor providing health care to undocumented Californians, up from 54% in 2015. Second, California officials expect a $15 billion budget surplus in the next fiscal year, according to the most recent forecast.

In 2016, California extended Medi-Cal eligibility to kids from low-income households, regardless of their immigration status.

State leaders were right at the time, and they were right to do the same for young adults starting last year. Now the state has a golden opportunity to finish the job.

Sandra R. Hernández, MD, is president and CEO of the California Health Care Foundation.

Prior to joining CHCF, Sandra was CEO of The San Francisco Foundation, which she led for 16 years. She previously served as director of public health for the City and County of San Francisco.

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Confronting Racism Special Section

Combating Oppression:

ACKNOWLEDGING OUR HISTORY AND MOVING TOWARD EQUITY AND JUSTICE IN MEDICAL EDUCATION Denise M. Connor, MD Oppression is deeply and painfully woven into the fabric of U.S. society; experiences with racism, homophobia, transphobia, and sexism (to name just a few instruments of oppression) profoundly impact countless individuals in our culture. Throughout its history and into the present day, medical education has been complicit with these and other forms of oppression, supporting and sustaining them in both seen and unseen ways. Alarming data about the beliefs and practices of modern-day medical students provides evidence for the ways in which medical education is, at best, failing to interrupt, and at worst, perpetuating the harmful impact of these destructive forces on individuals and communities.

For example, we are graduating medical students in the modern era who believe that the skin of Black persons is thicker and has fewer nerve endings than that of white people 1— dangerous beliefs rooted in a false notion of race as biology that leads directly to harmful decisions to provide less pain medication to Black patients, including Black children suffering with appendicitis.2 We are graduating medical students in the modern era who, when seeing standardized patients with an identical set of symptoms meant to depict angina, are significantly more likely to diagnose angina in a white man than in a Black woman, and at the same time are more likely to rate the Black woman’s general health status as lower than the white man’s.3 These findings are deeply disturbing and relate directly to the hidden curriculum that exists in medical education that quietly supports and operationalizes racism in medicine, often in ways that are unintentional yet extremely impactful.4 Similarly problematic and harmful messages, both implicit and explicit, related to individuals from many other communities that have been historically marginalized abound in our system of medical education.

Because medical education propagates harmful beliefs and practices and sustains them over time, it is one of the key 10

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levers we must use to move toward equity and justice within our healthcare system. With this goal in mind, many medical schools have begun to consider how to become forces for anti-oppression and anti-racism.

At the University of California, San Francisco (UCSF), we are launching a new Anti-Oppression Curriculum (AOC) that will build upon prior work focused on diversity, equity, and inclusion at UCSF, including the recent Differences Matter campaign.5 Through intentional, longitudinal changes across our entire fouryear curriculum, we hope to impact learners, clinicians, and ultimately patients and their communities.

This effort aims both to shape the next generation of physicians’ views on how racism and other forms of oppression harm individuals and communities, and to offer opportunities for students to learn how to engage with strategies to disrupt those harms in partnership with patients and their communities. In parallel, we hope to expand the understanding of practicing clinicians and trainees who work with UCSF medical students in the clinical setting in ways that will ultimately have a positive impact on individuals seeking healthcare. Students engaging in a curriculum focused on anti-oppression will be encouraged to raise questions when they arrive in the clinical setting—for example, our learners will be equipped with a critical lens that will promote inquiry into how race is being used in clinical risk scores and algorithms and whether that use is appropriate or harmful. In a positive and respectful learning climate, these queries will have the power to raise awareness of issues that have been previously normalized and unquestioned in the way we practice medicine. To support these discussions, our AOC will focus on providing faculty development opportunities for clinicians to expand their understanding of these critical domains, to enable faculty to engage effectively with students on these topics.

The arc of how race has been incorporated (or not) into clinical teaching cases can provide us with helpful insights WWW.SFMMS.ORG

into where we have been and where we need to go in a key area of our curriculum: the representations of patients. When educational leaders recognized that stereotypes and racism were being unintentionally reinforced by cases used in medical school curricula (e.g. Black patients being disproportionately represented as experiencing homelessness or struggling with substance use disorder), many schools made a well-intentioned decision to remove racial identity from clinical teaching cases unless race was deemed ‘clinically relevant.’6 This well-meaning but ultimately misguided ‘colorblind approach’ approach leads to at least two problematic outcomes. First, it serves to center white patients—because the assumptions embedded in white supremacy unfortunately still influence our educational communities, when race is not mentioned, white race is often assumed as the default. Second, the approach to only mention race when it is felt to be ‘clinically relevant’ silently reinforces false notions of race as biology and buttresses ideas about fundamental differences between individuals of different races—a subset of diseases tend to be learned inappropriately as diseases of Black persons (e.g. Sickle Cell Anemia, which in fact is related to genetic ancestry across many regions of the world, as opposed to Black race), while others which affect a diverse array of patients are implicitly taught as diseases of the default white patient.

Given how much pattern recognition ultimately forms the basis of diagnostic thinking, these distorted views of diseases baked into early medical education can have long-lasting implications for students’ future reasoning. Additionally, this approach prevents us from recognizing and teaching about the impact of racism as a critical structural determinant of health, and strips patients of their social context, communities, and personhood in ways that prevents exploration and discussion of the experiences, strengths, and resiliency of individuals seeking healthcare. Looking back at this issue demonstrates its complexity, and the nuance that is needed when considering how to be anti-racist and anti-oppressive in medical education—there are no quick fixes.

As a starting point in this work, transparency, engagement, and partnership with students and communities around these complex topics will be essential. Encouraging a critical eye and creating opportunities for reflection within medical education in ways that encourage question-asking and problem-posing will be key to uncovering the hidden biases and false assumptions that underlie traditional views of health and disease.7,8 In fact, many of our students are well ahead of faculty in their understanding of the myriad forms and impacts of oppression.

This differential knowledge between learners and teachers is a particular challenge for medical educators who have been acculturated to the notion of expertise and ‘seniority’ going hand-in-hand. Moving toward anti-oppression in medical education will require us to become comfortable co-learning with our students and giving students opportunities to share their own expertise—a shift in perspective and in approach that will require us to let go of some of the traditionally rigid hierarchy of medical education. Paulo Freire, a pioneer in the field of antioppressive pedagogy, has described learners and teachers as “co-investigators,” a paradigm that can help us re-think our WWW.SFMMS.ORG

approach to teaching.7 While this shift will be a challenge for many, it has the potential to be a transformative, positive force for anti-oppression in healthcare. If students can come to expect this kind of co-learning and partnership in their medical education, they will be much more equipped to bring the same spirit of partnership to their clinical teams and patients in the future.

Kevin Kumashiro, a scholar whose work focuses on anti-oppression in education, has wisely noted: “an anti-oppressive teacher is not something that someone is. Rather, it is something that someone is always becoming.”8 This view is equally valid for a curriculum that aims to be anti-oppressive. As we continue to work towards anti-oppression and equity in medical education, we do so with great humility, with a keen awareness of the work of so many in the generations before our own, and with an understanding that this effort has no endpoint. Rather, our work toward anti-oppression in medical education will be valid only if we understand that constant striving, learning, and growth are intrinsic to the process. By keeping our goal of health equity at the forefront of the AOC, we hope to center patients and communities, and to move our institution closer to the promise and potential of truly equitable, compassionate, and humanistic healthcare.

Denise M. Connor, MD, is an Associate Professor of Medicine, Director of the AntiOppression Curriculum, and Gold-Headed Cane Endowed Teaching Chair in Internal Medicine at UCSF; and member of the San Francisco VA Medical Center's Hospital Medicine Division.

References 1. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016;113(16):4296-4301. doi:10.1073/pnas.1516047113 2. Goyal MK, Kuppermann N, Cleary SD, Teach SJ, Chamberlain JM. Racial Disparities in Pain Management of Children With Appendicitis in Emergency Departments. JAMA Pediatr. 2015;169(11):996-1002. doi:10.1001/jamapediatrics.2015.1915 3. Rathore SS, Lenert LA, Weinfurt KP, et al. The effects of patient sex and race on medical students’ ratings of quality of life. Am J Med. 2000;108(7):561-566. doi:10.1016/s0002-9343(00)00352-1 4. Amutah C, Greenidge K, Mante A, et al. Misrepresenting Race - The Role of Medical Schools in Propagating Physician Bias. N Engl J Med. 2021;384(9):872-878. doi:10.1056/NEJMms2025768 5. Differences Matter | UCSF School of Medicine. Accessed April 21, 2021. https://medschool.ucsf.edu/differences-matter 6. Deng M, Kelly M, Garg M. Decoding Race: Assessing Racial Stereotypes and Bias in the UCSF Medical School Curriculum. Presented at the: American Medical Association Accelerating Change in Medical Education Consortium Meeting; 2017; Ann Arbor, MI. 7. Freire P. Pedagogy of the Oppressed. 50th Anniversary Edition.

Bloomsbury Publishing; 2018.

8. Kumashiro K. Against Common Sense: Teaching and Learning toward Social Justice. 3rd Edition. Routledge; 2015.

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Confronting Racism Special Section

CONFRONTING ANTI-ASIAN HATE AND VIOLENCE “Do the best you can until you know better. Then when you know better, do better.” – Maya Angelou

Michelle Leung, MS3 and Joseph Woo, MD

Dr. Woo and I are having a “bad day”. Not so much that we’d perpetrate a senseless, xenophobic, and misogynistic act of violence… but we’re still quite peeved. After all, the world has changed. Just a little over a year ago, there was no such thing as “Kung-Flu” and we weren’t attending rallies to “Stop AAPI Hate”. We were focused firmly on our hospitals, clinics or studies, largely unaware of the undercurrent of anti-Asian sentiment that’s now sweeping the nation. While racism against Asian American Pacific Islander populations has always existed, this year’s surge was provoked by rhetoric and fear of the pandemic in the setting of tremendous social turmoil, according to SF State Professor of Asian American studies Russell Jeung. Dr. Jeung said, “The seeming increase is a function of both awareness as well as incidence.”

Perhaps we were actually a part of the problem, placidly content to play the part of the “model minority”: silent, well behaved, hard working. Did you know that ¼ of all Asian American have experienced a hate incident? More curiously, greater than 2/3 have been asked “where are you really from?” (Survey Monkey/AAPI data poll). Different cultures experience different forms of racism and it seems that Asians have the misfortune of being perpetual foreigners. Perhaps this is a wake-up call for all of us as so many of our colleagues have asked us, what can doctors do to change the narrative?

Physicians play a critical role in identifying victims of hate crimes and connecting them to resources. These include organizations such as Stop AAPI Hate, which keeps track of data and serves as a place where incidents can be reported, especially when victims fear calling the police. Cynthia Choi, co-director of Chinese for Affirmative Action (CAA) — said that prior to the pandemic, incidents of assault reported through the site were relatively minor. Now, the kinds of events reported in the media are “traumatizing.” In San Francisco alone, there have been sexual assaults, beatings, hospitalizations and deaths. Her organization has logged record numbers of harassment and 12

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discriminatory acts. Moreover, from March 19 through Dec 2020, Stop AAPI Hate documented 3,795 incidents, largely discriminatory treatment, verbal harassment, physical assault, or civil rights violations.

Silence is complicity. We must continue to raise awareness and speak out against divisive rhetoric. Terms like “China virus” should not become part of our current vernacular. Further, let’s embrace and learn from our shared American history. The murder of Vincent Chin in Detroit, Japanese internment, and the Chinese Exclusion Act are just a few examples of times that rhetoric has led to the assignment of blame and encouraged misdirected anger. Recently, the many acts of violence and verbal abuse against all peoples of color reinforce this point. While we’re at it, let’s move away from stereotypes and improve cultural education. When we humanize and appreciate our common experiences, it becomes increasingly difficult to generalize and incite hatred.

And solidarity is our strength. Professor Jeung calls on physicians to stand together with their colleagues of color. He supports healing rallies like those already held in San Francisco and Oakland, to recognize communities of color who are traumatized by crimes, and that together need to be healed. There is good anecdotal evidence that racial solidarity is effective — but not vigilante patrols that can easily fall victim to racial profiling.

Rather, according to Jeung, he prefers multiracial community ambassadors who “walk around and just greet and welcome people”. Not only do these ambassadors lower crime peacefully, they reduce the animosity between groups which targets the foundations of tensions between communities. Members have included formerly incarcerated Asian Americans who are paid to walk around and give directions, help unhoused, organize street cleanups, and work towards a common goal of safety. This concept saves so much more money than paying for police to patrol the same streets. Let’s support their sponsoring groups like Asian Health Services in Oakland and the Community Youth Center in San Francisco.

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In addition to showing solidarity across communities, improving mental health is a key way for healthcare providers to acknowledge and combat racism. Pre-existing cultural stigma against mental health, now exacerbated by COVID and racism, results in worsening mental health outcomes — more anxiety, depression, and somatic symptoms.

“There's not a ton of infrastructure on the medical side and healthcare side,” said Choi. “And the mental health resources available are so short term, when in fact we know that when someone has gone through a traumatic incident, it takes years to recover and heal.”

Interpersonal attacks and violence are a public health issue, Choi continues. The impacts of racism, (what she calls “weathering”) and being mentally exhausted from the strain of fearing for safety or being subjected to racism, significantly affects the health of communities.

Disturbingly, in a population where mental health support has to be offered in a sensitive, indirect manner, and in the right language, we have few bilingual mental health providers. There are even fewer who specialize in supporting patients or families through a traumatic incident. At best, immediate responders might hand survivors a pamphlet they can’t read. Combined with the cultural stigma and distrust of police and the government, many events go unreported. Beyond individual care, what is needed on a national level is a mental health needs assessment.

In fact, Stop AAPI Hate respondents are already showing higher

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rates of anxiety and depression than the general population.

From his findings, Prof. Jeung suggests that targeted outreach is required. These measures could include a hotline, legal support, along with mental health resources. Currently, due to lack of structural support in the form of funding, organizations doing such work are mostly run by volunteers.

We hope this is a flashpoint. A time to come together. A chance to raise the tide for all ships. After all, racism can be unlearned. Maya Angelou, again, gets the last words, “Hate, it has caused a lot of problems in this world, but it has not solved one yet”. Have a nice day.

Michelle Leung is a third year medical student at the University of California, San Francisco.

Joseph Woo MD, an emergency physician, is on the Board of SFMMS, Director of Community Relations at the Chinese Community Healthcare Association, and President of the All American Medical Group.

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Confronting Racism Special Section

COMBATING MEDICAL RACISM: THE CASE FOR COMPULSORY PHYSICIAN TRAINING Jeffrey B. Ritterman, MD Re ce n t eve n t s h ave e n co u ra g e d m a ny o f us to challenge our personal racism and to uproot the racism within our institutions. This is a national project, long overdue.

Despite the rigors of medical school education and years of Continuing Medical Education, few of us know much about medical racism. We may know the bare outlines of the Tuskegee Syphilis Study and we may know about the origin of HeLa cells from Henrietta Lacks’ cervical cancer without her knowledge or approval. But we know little else.

Medical racism still permeates the ongoing practice of medicine. The American Heart Association called structural racism “a fundamental driver of health disparities.” The editors of Family Medicine Journals issued a statement “Systemic Racism and Health Disparities” in which they said that “racism is associated with poorer mental and physical health outcomes.” The American Academy of Pediatrics issued a similar statement.

The medical and lay communities were shocked when we viewed the video of Dr. Susan Moore struggling for breath and explaining how she had to beg for pain relief and for adequate treatment during her recent bout with COVID-19. Attended by a white physician she complained that “He made me feel like I was a drug addict…if I was white I wouldn’t have to go through that.” She died from COVID. The undertreatment of pain due to racial bias is also seen in children presenting to the emergency room with appendicitis, and with long bone fractures. Physician misperception of a patient’s pain is due in part to ignorance and stereotyping.

A recent study showed that half of the medical students and medical residents tested had the misbelief that Black patients are less sensitive to pain than white patients. They would have undertreated Black patients in a clinical situation.

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Perhaps no illness demonstrates the intersection race and health care more than sickle cell anemia. Undertreatment of pain is a major problem. Sickle cell patients, who are predominately Black, wait significantly longer during emergency room visits than other pain patients.

The authors of a study on this phenomenon concluded that: “The AfricanAmerican race of the SCD patients, and their status as having SCD itself, both appear to contribute to longer wait times for these patients.

These data confirm patient anecdotal reports.”

The anecdotal reports are striking: “Every time, it’s a battle,” one patient said about her ER experiences. She complained that staff members suspect her of faking her condition in order to score opiates and view her as a non-emergency because she only has pain. “I always dress professionally,” said a retired school administrator. “Nice shoes, interesting earrings, every hair in place, and Vogue-worthy makeup. It’s crazy that you, as an African-American, have to do this so you aren’t treated like a drug addict.”

The Institute of Medicine was asked by the federal government to do a comprehensive review addressing unequal medical treatment. Their findings confirmed unequal treatment and unequal health outcomes. This was true for cancer and cardiovascular and renal disease.

The algorithms used for calculating renal function are also biased against Black patients, making it more difficult for them to get dialysis and transplantation. Similar race-based algorithms are used in obstetrics to determine if a C-section is needed and in emergency medicine to help diagnose kidney stones. Each has been challenged as biased against Black patients. Significantly higher death rates have been noted among Blacks from hypertension, diabetes, septicemia, kidney disease, hypertensive renal disease, cardiovascular disease and infant mortality.

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COVID-19 also results in excess mortality among Blacks.

While this is explainable by the greater burden of disease in the Black population, the problems with inferior healthcare access, and the greater exposure to the social determinants of disease, concerns about bias in COVID-19 treatment have also been raised. This is particularly worrisome as the understandable Black mistrust of the medical system compromises vaccination efforts.

There is acceptance in medicine that medical racism exists and that it results in unequal treatment and unequal outcomes.

We cannot leave it up to individual physicians to commit to the self-education required to deepen their knowledge and understanding. When it became clear that physicians were undereducated and underperforming in pain management and end of life care, it became a requirement to get training in these areas in order to maintain a medical license.

Let’s take a big step toward uprooting racism from medicine by designing an added dimension to physician training—and a new requirement for maintaining a medical license. Lives are at stake.

Jeffrey B. Ritterman, M.D. is a retired cardiologist from Kaiser Richmond, and on the Board of Directors, San Francisco Physicians for Social Responsibility.

MEDICAL RACISM:

San Francisco Physicians for Responsibility Responds Jeff Ritterman, MD

We continue to learn about medical racism: ■ Pain is undertreated due to racism. Black children seen in

the ER with either a long bone fracture or appendicitis receive less pain medication compared to their white counter parts. Sickle cell anemia patients who come to the ER in painful crisis wait longer than other ER pain patients due to racism. They are viewed as drug addicts and mistreated.

■ The algorithms used for renal function are biased against

Black patients delaying their care and making it harder for them to get dialysis and transplantation.

■ The social determinants of health are politically biased

against Black patients. Black communities have more exposure to toxic chemicals, more food deserts, and suffer more over policing, all resulting in worse health outcomes.

■ COVID claims a disproportionate number of Black lives

because of poor health access, jobs that lead to more COVID exposure, crowded housing and racist medical treatment.

Racist treatment was painfully evident in the case of Dr. Susan Moore.

■ As we continue to learn more about medical racism or what

author Harriet Washington has called medical apartheid, we have started to act.

■ The SF Physicians for Social Responsibility is working with

the Bayview Hunters Point Community to help the vaccination effort. Medical racism has resulted in a loss of trust. Developing a culture of trustworthiness is needed to help with the vaccination effort. We are working to make the medical information of the vaccines relevant to the community.

■ SF PSR will be hosting a webinar on May 26, 7 PM about

Addiction Medicine and Recovery in the COVID Era Friday, June 18, 2021 | 8:45 a.m. - 1:30 p.m. via Zoom | Free of charge!

For more information visit www.sfmms.org/news-events/events For questions, contact Steve Heilig at heilig@sfmms.org

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“Policing as a Public Health Crisis.” We are partnering with the Ella Baker Center and Impact Justice. Zach Norris, the Executive Director of the Ella Baker Center, and the author of the amazing book “Defunding Fear” will speak along with Ashlee George, co-director of Impact Justice’s Restorative Justice Project.

■ Next year PSR will sponsor a speaking engagement with

Wesley Lowery, author of the New York Times bestseller, “They Can’t Kill Us All.”

■ The Kaiser Oakland Ally Book Club will be convening a task

force to discuss how we can improve health equity and promote physician education on health equity.

Comments/questions welcome: Jeffritterman@gmail.com

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ACES SCREENING: NOT JUST FOR PEDIATRICIANS Heyman Oo, MD “When I talk to parents about their child’s experiences and the relationship between ACEs and long-term physical health, they start telling me all sorts of stuff about their own childhood. It’s given me useful insights into their family, their own medical history and we can start to have a conversation that moves towards healing in a way that feels safe for them.”

– Dr. Elisa Pujals, Family Medicine Physician1

In the late 1990’s, in conjunction with the Centers for Disease Control and Kaiser Permanente San Diego, Dr. Vincent Felliti conducted the original Adverse Childhood Experiences (ACEs) Study.

It demonstrated a significant link between adverse events experienced by patients in their childhood and their risk for negative long-term health outcomes2 like stroke, COPD and cancer. This association was independent of traditional behavioral risk factors like smoking or drinking. Since then, much scientific research has gone into understanding more about the neuroendocrine and physiological pathways that underlie how toxic stress in childhood can have such profound and long-lasting effects into adulthood. In other words, early traumatic experiences can alter people’s brains3, organs4 and epigenetics,5 putting them at higher risk for cardiovascular disease, diabetes and other chronic conditions as adults.

This explosion of research is evidenced by a quick search of PubMed for the term “Adverse Childhood Experiences” yielding almost 4,000 articles, while “Toxic Stress Children” yields about 2,000 more.

As more and more scientific evidence points to the widespread health impacts of childhood adversity, the implications for public health become clear. That is why the California State Surgeon General’s office took the visionary step of committing state resources to better understand this public health crisis and to reduce the negative health impact of ACEs, making this effort a cornerstone of its Roadmap in December 20206.

“Being able to talk about stressful life experiences and trauma in a way that feels routine and destigmatized is so critical to helping families understand that they are not alone, these things are common and most importantly, that they can do something about it and we are here to support them. You cannot talk about trauma without talking about resilience and being able to help families focus and build on their strengths as a family is protective and preventative.”

– Dr. Reshem Agarwal, Pediatrician When people talk about trauma and toxic stress, there is a very normal feeling of despair, a “What can we possibly do about this?” sense of overwhelm, as ACEs are ubiquitous. The original Kaiser-CDC study showed at least 64% of people having at least 1 ACE. However, there is some early evidence to show that seemingly simple basic measures like high quality sleep, good nutrition, exercise and strong social supports can promote both psychological and physical resilience buffering against toxic stress7. These are “seemingly simple” interventions, however, as any physician who has tried to support their patient in lifestyle changes to improve their physical health knows, it is far from simple. Yet, when promoted in a trauma-informed way8, the impact of these interventions can be profound.

“I explained to the patient that this was a new screening we were doing for all pregnant women and the patient opened up about the things that had happened in her life. We had a nice conversation and even though she didn’t need any resources at that moment, I think ultimately she felt more cared for because we asked. I was surprised to be reminded that the act of screening and showing care was enough.”

– Erinn Lance, Certified Nurse Midwife

Many physicians, understandably, initially balk at the opportunity to screen for ACEs and toxic stress. There is real fear that we, as medical providers, are opening a can of worms which we do not feel equipped to handle or treat. However, with compassion and empathy, in conjunction with proper training, we ARE equipped and can make progress towards healing. If you invest in 16

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educating yourself and your staff in the science of ACEs and how to deliver trauma-informed care, you can be ready to help patients when they screen positive.

As our clinic moved towards universal screening for ACEs in children and pregnant women in line with the California State Surgeon General’s ACEsAware initiative9, we have learned that with careful planning and intentional training utilizing concepts like the California ACEs Learning and Quality Improvement Collaborative10TRIADS framework11, we are better equipped than we think to help our patients. Additionally, our patients are more open and receptive to these sensitive questions than we initially believed, particularly when the screen is administered in a routine, non-judgmental, trauma-informed, caring manner. Perhaps even more surprisingly to some, not every positive screen ends with a referral to behavioral health for therapy; on the contrary, very few of them do. When screening is done, not as a checkbox, but rather as a tool to start a conversation with a focus on resilience and healing, we have found that it really allows the doctorpatient relationship to reach a new level of mutual understanding.

To paraphrase Dr. Ken Epstein, a decades-long expert in traumainformed care from the San Francisco Department of Public Health and UCSF: “Trauma happens in the context of relationships and healing happens in the context of relationships.”12 If healing is not the core purpose of the doctor-patient relationship, then what is?

Dr. Heyman Oo, MD, MPH, FAAP is a primary care pediatrician, Associate Medical Director at Marin Community Clinics (MCC) in Novato, and an Associate Attending Physician at UCSF Zuckerberg San Francisco General Hospital.

She graduated from UC San Diego School of Medicine, earned her Master's in Public Health in Healthcare Policy and Administration from the Harvard TH Chan School of Public Health and completed her clinical training in general pediatrics in the Pediatric Leaders Advancing Health Equity (PLUS) residency program at UCSF. She has a passion for public health advocacy, immigrant and refugee health, and trauma-informed care and is the current clinician champion for implementation of ACEs screening at MCC. She is a clinical expert consultant for content and resource development with the California State ACEsAware initiative and the team lead for MCC in the Center for Care Innovations California ACEs Learning and Quality Improvement Collaborative.

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References 1. All quotes in this article are provided by providers from Marin Community Clinics who have been screening for ACEs in its pediatric and obstetric population this past last year.

2. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults.

The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998 May;14(4):245-58. doi: 10.1016/s0749-3797(98)00017-8.

PMID: 9635069.

3. Kalmakis KA, Meyer JS, Chiodo L, Leung K. Adverse childhood experiences and chronic hypothalamic-pituitary-adrenal activity. Stress.

2015;18(4):446-50. doi: 10.3109/10253890.2015.1023791. Epub 2015 Mar 18. PMID: 25783196.

4. Su S, Jimenez MP, Roberts CT, Loucks EB. The role of adverse childhood experiences in cardiovascular disease risk: a review with emphasis on plausible mechanisms. Curr Cardiol Rep. 2015 Oct;17(10):88. doi: 10.1007/s11886-015-0645-1. PMID: 26289252; PMCID: PMC4941633.

5. Tang R, Howe LD, Suderman M, Relton CL, Crawford AA, Houtepen LC. Adverse childhood experiences, DNA methylation age acceleration, and cortisol in UK children: a prospective population-based cohort study. Clin Epigenetics. 2020 Apr 7;12(1):55. doi: 10.1186/ s13148-020-00844-2. PMID: 32264940; PMCID: PMC7137290.

6. Bhushan D, Kotz K, McCall J, Wirtz S, Gilgoff R, Dube SR, Powers C, Olson-Morgan J, Galeste M, Patterson K, Harris L, Mills A, Bethell C, Burke Harris N, Office of the California Surgeon General. Roadmap for Resilience: The California Surgeon General’s Report on Adverse Childhood Experiences, Toxic Stress, and Health. Office of the California Surgeon General, 2020. DOI: 10.48019/PEAM8812.

7. Gilgoff R, Singh L, Koita K, Gentile B, Marques SS. Adverse Childhood Experiences, Outcomes, and Interventions. Pediatr Clin North Am. 2020 Apr;67(2):259-273. doi: 10.1016/j.pcl.2019.12.001. PMID: 32122559.

8. Oral R, Ramirez M, Coohey C, Nakada S, Walz A, Kuntz A, Benoit J, Peek-Asa C. Adverse childhood experiences and trauma informed care: the future of health care. Pediatr Res. 2016 Jan;79(1-2):22733. doi: 10.1038/pr.2015.197. Epub 2015 Oct 13. PMID: 26460523.

9. https://www.acesaware.org/screen/provider-training/ 10. https://www.careinnovations.org/programs/calqic/ 11. https://cthc.ucsf.edu/triads/wp-content/uploads/ sites/2/2020/11/TRIADS_Framework.pdf 12. https://www.gene.com/stories/screening-for-childhoodtrauma?utm_source=twitter&utm_medium=paid&utm_ content=metadata&utm_campaign=RBC+Editorial+Series+& utm_term=CR&sf113761322=1 13. https://socialworksynergy.files.wordpress.com/2013/12/blogpic_aces-infographic.jpg

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Physician Wellness

HOW “BUOYANCY” CAN HELP YOU Jessie Mahoney, MD Buoyancy is a word and a concept that you can use to change your life experience. Choosing to feel buoyant is a tool that can help physicians navigate the waves and choppy seas of practicing medicine in 2021.

Buoyancy is an example of how you can use words and language to change and/ or color your experiences i n way s t h a t s e r ve yo u , while staying true to your experience.

Buoyancy is different from “resilience” and different from “floating.” It is spacious, light and easeful. Buoyancy relies on inner strength, calm, and confidence. If you are buoyant, when you are pushed under you bounce back. Buoyant things stay afloat no matter the seas. When the seas are rough, buoyant things bob and toss and turn, but don't sink.

Buoyant objects and people don't have literal or figurative bricks weighing them down. They are balanced and in alignment. They are responsive and not reactive.

Why choose to feel buoyant?

Not because our systems don't need fixing. Not because the pandemic isn’t overwhelming and you aren't exhausted and burnt-out. Not because there isn't unfairness, suffering, racism, social injustice and much more wrong with the world. Buoyancy keeps you from sinking until the life rafts arrive. Showing up feeling buoyant provides relief and spaciousness and the ability to show up for your life, your loved ones, and your patients in a more present, whole and healed way.

How do you become buoyant?

Feeling buoyant is both a mindset and a neurological state.

Both take practice, attention, and intention. A buoyant neurologic state is one in which the parasympathetic nervous system is upregulated and the fight or fight or flight tendencies have been calmed. Practicing mindfulness, learning breathing techniques, yoga and spending time in nature can all help you.

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Mindset work is more foreign to many physicians.

C h a n g i n g yo u r m i n d s e t requires accepting that you have agency and ownership over your experience of practicing medicine in this moment. There is so much we don't have control over as physicians in our days and in our work, but we do always have “choice.” Choice to show up, choice to keep practicing medicine, and choice about the thoughts we have and the stories we tell about our lived experience as physicians in this moment. It's in these thoughts and stories where our power and control lie. When you choose thoughts, words, and stories about your experience you color your experience. If you see yourself as a victim, and tell a story to support that, you feel like a victim.

I wish you all much buoyancy in the days ahead. And if you want to explore this concept further take a listen to the Mindful Healers Podcast episode 12.

Dr. Jessie Mahoney is a Board-Certified Pediatrician, and the founder of Pause & Presence where she is a mindful coach for physicians.

She is co-host of The Mindful Healers Podcast and a leader of the Mindful Healthcare Collective. She is the Chair of the SFMMS Physician Wellness Task Force. She practiced Pediatrics and was a Physician Wellness leader at The Permanente Medical Group for 17 years. You can connect with her at jessie@jessiemahoneymd.com.

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As part of SFMMS' Physician Wellness efforts, we have been hosting a virtual Culinary Medicine series for our members!

We have hosted three events thus far.

Our first event, on March 9th, was facilitated by Dr. Marjorie Smith, SFMMS Member, Physician Wellness Leader, and the lead planner for our Culinary Medicine series! In her session, “A Primer for our Culinary Medicine Series,” Dr. Smith shared her story in coming to understand the importance of Culinary Medicine for physicians as a tool for wellness, she discussed introductory principles of Culinary Medicine, and provided a healthy snack cooking demonstration.

The second event, “The Mediterranean Diet” on March 18th, with Dr. Nisha Patel from Sutter Pacific Medical Group, focused on the Mediterranean Diet and included a Tabbouleh salad cooking demonstration with attainable tips for how to incorporate healthy food into participants' lives.

The third event in our series,”Soup: The Unrecipe” on April 13th, was facilitated by Dr. Anne Kennard, DO, a Board-Certified Obstetrician-Gynecologist, Integrative Medicine physician, herbalist, and yoga instructor. During her session, participants learned to create delicious, easy soups at home. Dr. Kennard shared that, “...by mastering the basics of soup making, or the ‘unrecipe’, the stress of meal planning turns to flexibility, practicality, and creativity.” SFMMS members who attended these events received a gift card and book to begin their culinary medicine journey.

To watch recordings of these events or to learn more about the recipes and books provided to attendees, please visit the SFMMS Wellness Page at

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Physician Wellness

SFMMS BOOK DISCUSSION GROUP Your SFMMS Physician Wellness Team is hosting quarterly physician book discussions. In February, over twenty SFMMS physician members gathered virtually via Zoom to discuss “Together: The Healing Power of Human Connection in a Sometimes Lonely World” by Dr. Vivek Murthy.

Participants shared the most interesting and impactful portions of the book for them as a physician. Read a review of this book from SFMMS Past President, Board Member, and Book Discussion Group participant, Dr. John Maa, on page 40.

Upcoming Book Discussion Group Tuesday, May 25th 6:30 - 8pm: “God’s Hotel” by Dr. Victoria Sweet We will be discussing “God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine.” The book focuses on “San Francisco’s Laguna Honda Hospital as the last almshouse in the country, a descendant of the Hôtel-Dieu (God’s hotel) that cared for the sick in the Middle Ages...Dr. Victoria Sweet, came for two months and stayed for twenty years. God’s Hotel, the story of the hospital itself, which, as efficiency experts, politicians, and architects descended, determined to turn it into a modern “health care facility,” revealed its own surprising truths about the essence, cost, and value of caring for the body and the soul. Dr. Victoria Sweet will be joining us for the evening, so don’t miss this opportunity to hear from and ask questions of the author! If you would like to join a future SFMMS Book Discussion, please contact Molly Baldridge, MPH, Director of Engagement at mbaldridge@sfmms.org or Dr. Jessie Mahoney, jessiemahoneymd@gmail.com.

“The Boy, the Mole, the Fox and the Horse” by Charlie Mackesy. “Charlie Mackesy offers inspiration and hope in uncertain times in this beautiful book, following the tale of a curious boy, a greedy mole, a wary fox and a wise horse who find themselves together in sometimes difficult terrain, sharing their greatest fears and biggest discoveries about vulnerability, kindness, hope, friendship and love. The shared adventures and important conversations between the four friends are full of life lessons that have connected with readers of all ages.” The date for the next Book Discussion Group is to be determined. For more information or for questions, please contact Molly Baldridge, MPH, Director of Engagement at mbaldridge@sfmms.org or Dr. Jessie Mahoney, jessiemahoneymd@gmail.com.

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RESOURCE CORNER: FREE WELLNESS RESOURCES FOR PHYSICIANS SFMMS Physician Wellness Webpage Physician wellness, physician well-being, professional fulfillment, resilience, and burnout are all terms used frequently these days. SFMMS has recently re-established a Physician Wellness Committee to identify and evaluate the many resources currently available, identify unmet needs in the local physician community, and recommend strategies for SFMMS to address those needs and support our local physicians. As part of our Physician Wellness leaders work, they have created a list of resources and events for the SFMMS membership. Visit the SFMMS Physician Wellness page at http://www.sfmms.org/get-help/physician-wellness to find curated resources for our SFMMS physician members.

Mindfulness for Healthcare: A Free Virtual Summit, May 20-23, 2021

In community with healthcare professionals, executives, therapists and scientists, mindfulness thought leaders will explore how mindfulness practice can support individual well-being, compassionate care-giving, and an inclusive, equitable healthcare system. SFMMS Physician Wellness Committee Chair, Dr. Jessie Mahoney, will be teaching several virtual yoga classes as part of this summit. To register for this free event or for more information visit: https://www.mindful.org/healthcaresummit/

SFMMS Physician Wellness Taskforce Update: April 2021 This quarter our SFMMS Physician Wellness Taskforce is continuing to grow our efforts to nourish and support physicians in Marin and San Francisco. We are continuing to build SFMMS wellness programming. Join us for an event soon.

Our team is now meeting every other month to continue to direct the SFMMS wellness efforts. We strongly support physician wellness being seen "as a value rather than an issue."

We are working to change perceptions around physician wellness and hoping to promote a culture physicians see taking care of their health and wellness as a nonnegotiable component of being a healthy and effective physician.

We are still working to increase engagement in wellness events, build community and strengthen collegiality, and find ways to support physicians in taking care of their own physical and mental health. We strongly encourage all physician leaders to consider physician wellness in all operational decisions and to join us in this important work.

Please continue to share your perspectives and suggestions for how SFMMS can help support your health and wellness so you can show up as the best version of yourself for you, your colleagues, your patients, and your loved ones.

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Wellness Events for SFMMS Members To register or to get more information about any of our upcoming wellness events, please visit the SFMMS Wellness Page at http://www.sfmms.org/get-help/physician-wellness.

Upcoming Physician Wellness Events: As part of SFMMS' commitment to Physician Wellness, our Physician Wellness Committee is offering a variety of virtual events to our members!

May 25, 6:30-8pm SFMMS Book Discussion Group, reading “God’s Hotel” by Dr. Victoria Sweet.

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MEMBER FORUM

LASTING IMPACT: PATIENT STORIES Our medical trainee writing contest, wherein respondents provide short answers to the question “What patient has had the biggest impact on you thus far?” has proven very popular. We decided to extend to everybody, from trainee to retiree. Our first batch is below. Hopefully this will become an ongoing series, so if you are interested, send your story to Heilig@sfmms.org.

VICTIMS OF INJUSTICE

CIRCLE OF JOY

David E. Smith, MD 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.

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.

Susan Shen, MD, PhD In the inpatient unit, O. lies motionless in bed, her hair tangled like an abandoned nest. Most days, she offers a fuming “f--you”! Sometimes, she yells, “Leave me alone!” and wanders the hallway, her eyes like dark orbs in another galaxy. When she sits at the dining table, she mechanically brings her fork to her pale lips. Her grieving mother always brings her food that rots away at the bedside.

I begin to despair. Medication after medication, her soul remains buried in an unmarked grave. Eventually, there are no more medications to try. Only one thing is left: electroconvulsive therapy. A life-saving treatment that requires a litany of paperwork despite the medical urgency. Paperwork I fill out before I go on maternity leave, leaving behind wisps of hope.

When I return to work foggy and sleep-deprived, my mind wanders in and out of baby-land. I come home and robotically bring my breast to my baby’s pink lips. I am desperately trying to take care of a helpless human being.

Over the coming weeks, I slowly emerge from my haze. I learn that O. received electroconvulsive therapy, to great effect.

She stopped screaming profanities, she started talking with her peers, and she even started to smile a little. She had already left the hospital.

Today, I watch as my baby giggles and coos. I remember O., whose depression robbed her of all joy. I remember that life begins with joy, and joy can return if we fight for it.

Susan Shen, MD, PhD is a psychiatry resident at UCSF.

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PATIENT UNKNOWN Natalie Neale, MD I was on my neuro ICU elective when I first encountered a patient’s name listed as “unknown” in the EMR. The patient had been “found down” on the street after suspected opioid overdose. In the neurologic ICU, he was essentially brain dead, save an intermittently reactive pupil which we treated as needed with mannitol. Any attempts at saving this man’s life or recovering brain function would be futile. He had no advance directive and no readily available contacts, but after detective work we were able to track down the names and contact information of two of this man’s close friends from his halfway house. We met with the friends and our ethics committee, and based on the collateral information came to the conclusion that this man would not want life-sustaining measures. He passed away with his two friends at bedside. Even though he was not conscious of anything, it still felt important to me that someone was there who knew him and cared about him.

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I suppose the reason this patient stuck with me so much is that he made me think about death in ways I never had before.

Maybe it sounds obvious, but I think that compassionate care should extend to the last breath of the patient, not just up to the point where the patient is conscious. In the end, I was proud that my team was able to give this patient a “compassionate death,” surrounded by people who cared about him.

Natalie Neale, MD is a resident in neurology at UCSF.

MURDERED SLEEP Michael Schrader, MD You might have seen this story on the evening news but I didn’t hear it until they called me at 2 am. I like to pretend that things that happen at work don’t bother me, but that isn’t true.

Most of the tragedies I just forget. I have taken care of patients for a quarter century at a San Francisco nursing home down the hill from St. Mary’s Cathedral where Ellis Street dead ends.

Annie was an elderly demented woman who had lived there several years. I started taking care of Annie three years before because her daughter was unhappy with the previous physician. There was a minor issue of tweaking thyroid replacement initially but then everything was stable for years.

She was confused but pleasantly conversant. She was cute.

Whenever I would go into her room to round she would look at me coquettishly and say, “You’re so handsome.” She always said it. And it always made me laugh.

One evening Annie’s daughter came to visit, paid the monthly bill and went to Annie’s room where she murdered her with a handgun and then killed herself. The staff were used to gunshots in the neighborhood and didn’t check the room for a couple of hours.

The police came. The TV news came. They cleaned the room.

They remembered to call me at 2 am.

I lay in bed that night for a couple hours after that thinking about poor Annie and that line from MacBeth about murdered sleep. No one ever knew why her daughter did it.

I talked to James the night nurse about this a couple months ago. James brought it up. He was on duty that night and found the bodies. It was he who had to clean the room. They gave him two weeks paid leave for his trouble.

I was in the room the other day. It’s a different color from the other rooms because they had to repaint. You might have forgotten this story, but James and I remember.

Internist Michael Schrader, MD, PhD, is president-elect of the SFMMS.

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AN EMERGING SOCIOECONOMIC CURIOSITY Anthony M DiGiorgio, DO, MHA I was a junior resident when Mr. X arrived at our ED. We operated on his traumatic brain injury. He survived that and a lengthy ICU stay. Four years later, he died in our hospital. It was the same admission.

There was nothing unique about the medical or surgical care of Mr. X. He was just another polytrauma patient with a subdural hematoma. Functionally, his recovery was slow but substantial, typical for TBI. The remarkable part of Mr. X’s story is that, for four years, he remained in the hospital. While he recovered significantly, he never regained functional independence. He couldn’t be discharged home. No post-acute care facility would take him. His family did not have the means to care for him.

My experience with Mr. X is just one of many which contributed to my interest in health care economics. I realized that, while medical school and residency taught me how to treat Mr. X’s disease, that was only part of the story. Unfortunately, there are more than a few patients like Mr. X, patients who are denied the care they need because of economics. In trying to understand these patients, I found myself learning about insurance, economics, policy making and administration. I realized how little the economists understand medicine and how little doctors, like myself, understand economics. To fully treat Mr. X, and the thousands like him, I needed to expand my focus to administration and advocacy.

Anthony M. DiGiorgio, DO, MHA is Assistant Professor, Department of Neurological Surgery, at UCSF and Zuckerberg San Francisco General Hospital.

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THE COVID ENDGAME: PREDICTIONS ON THE FUTURE OF VACCINES, SCHOOLS, MEDIA, SCIENCE, & MORE Vinay Prasad, MD, MPH Recently my Twitter feed filled with news about a boat lodged in the Suez canal. The New York Times Magazine ran a long story on whether artificial intelligence can help us ascertain if coffee is indeed good for us. I breathed a sigh of relief, perhaps COVID-19 is winding down. The media is returning to their favorite, hard hitting stories.

Of course, I am not a fortune-teller, but in this essay, I want to take an educated guess as to how the next year might play out. Like most predictions for this pandemic, don't be surprised if my estimates are wildly off, and don't hold it against me. After all, we didn't do that for anyone else.

Vaccines I have been amazed by the speed with which vaccines were developed and their efficacy. I am a long-standing critic of the pharmaceutical industry, but on this occasion, I give them credit.

Job well done. As I type this, 90 million Americans have received at least one dose of the vaccine. An additional 30 million Americans have had documented infections with COVID-19 and recovered. Some additional fraction have had undocumented infections and recovered. The fraction of people susceptible to COVID-19 is shrinking by the minute, and that's good news. I expect more stories in the media to be about green tea, blueberries, red wine, and dark chocolate to make up for the fall in COVID-19 coverage.

Schools In contrast with the brisk pace of vaccination, schools remain a struggle. Previously, Vladimir Kogan and I highlighted the urgent need to reopen in-person public schools. CDC guidance from just a few weeks ago recommended six feet of distance between students and reopening based on the community level of spread. Vlad Kogan and I investigated the data for both these claims, which would hamstring school opening. We found the recommendations to have no good support whatsoever. Amazingly, the CDC has agreed, and rescinded both of these policies, which pave the path to reopening schools.

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I don't know what the future will hold, but I suspect that the moment kids get even a foot in the classroom, the dialog will shift. Teachers will remember why they love teaching. Kids will remember why they love school, and parents will feel a weight lift from their shoulders. Once the dam is cracked, it will open wide. I hope that shortly, schools around this nation will return to normal.

The sooner the better, and once schools are open, we will have to survey the damage done to the kids, and work to mend it.

A Glorious Summer More and more vaccination, warmer weather, and a public that cannot sustain any more restrictions mean we will have a vibrant and joyous summer. Parties, dinners, parks, the beach — I suspect we will see an outpouring of socializing. A summer of revelry may help heal the wounds of the past year, and just might relax some folks.

COVID-19 Outbreaks I suspect that COVID-19 will never be gone. It will return in bursts in the fall and winter for years to come. I suspect it may concentrate in nursing homes and care facilities, despite high levels of vaccination. It will also spread in pockets of the country where folks are reluctant to be vaccinated. It will take a few winters before it loses the urgency and anxiety of 2020, and when a patient is admitted in the winter time, we may merely ask, "is it flu or COVID-19?"

The Pundits COVID-19 unleashed a broad swath of pundits. Many had never been in the limelight, a few have come to love it, and others (the wise ones) have started to hate it. I suspect that many COVID-19 pundits will pivot. Their expertise will shift to issues of nutritional epidemiology, exercise, gun violence, or other public health topics that retain national interest. Many others, particularly those with extremely specialized training, will be unable to pivot. I suspect we will hear less of them. I am OK with that.

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The Media The media will end the COVID epoch in a diminished position. In January and February of 2020, they repeatedly aired pundits who informed us that influenza was worse than COVID19. In March 2020, they realized the error of that messaging.

Instead, they erred in the other direction, showing us photos of Americans enjoying the beach, and shaming them for that choice. Ironically, a beach — even a crowded one — is amongst the safest places for Americans to go.

A media landscape whose first commitment is to attention — capturing as many views, eyeballs, and clicks as possible –has failed us. It cannot endure. Unless we reward thoughtful, nuanced, and informative work — even if it is slightly dull — we are going to continue to descend into sensationalism and distortion. Speaking of which: can artificial intelligence tell us if coffee is good for us?

Social Media Outrage is the drug of choice on social media, and we are all addicted. When I started using Twitter in 2014, it was once a year that a major scandal would occur. Pre-COVID-19, it was once a month, and now, it is twice a week. A lifetime of good deeds can be undone with a single tweet! The person who offends is not just placed in the stocks and publicly shamed; inevitably, their employer is cc'd and calls for them to be fired begin. It hardly matters that in the U.S., losing a job often means losing healthcare, and any semblance of identity; the crowd clamors for total annihilation. Anyone who has suffered real personal problems — problems that keep you up at night — will realize that social media concerns are often a distraction from the challenges most Americans face. Yet, the outrage cycle continues. My only advice here is if you see an outrage mob: walk away from it. Correction: run away.

Science As Politics Early in the pandemic, Jeff Flier and I wrote, "Society faces a risk even more toxic and deadly than COVID-19: that the conduct of science becomes indistinguishable from politics." That fear has been realized. Whether hydroxychloroquine or face masks or whether lockdowns provide net benefit, nearly every scientific issue has been sorted into political platforms and parties.

This problem is corrosive and will haunt us for years to come.

The more scientific disputes become tied to political identity, the more intractable and unscientific they will become.

I urge anyone who still considers themselves a scientist to do more to depoliticize disputes. That means the following: 1. If you use social media to present your scientific ideas, then do not use the same platform to advocate for political candidates. This back and forth merges the two sets of views in the minds of the readers.

2. Do not assume that folks who disagree with you on medical topics are from the opposing political party. They might be, or might not, but either way, it is irrelevant.

3. Understand that science is a method to ascertain how the world works, but does not prescribe policy. Policy is a choice based on values. Two folks can be equally committed to science, but have different values, and thus reach different policy conclusions.

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4. Focus on policies, not partisanship. Decide which policies are right — for instance, what are your feelings on conflict of interest — and having decided that, hold people from both political parties accountable. Recently, I noted a double standard. Both Scott Gottlieb and Vivek Murthy had glaring conflicts of interest, and many of the folks who skewered Gottlieb did not hold Murthy to the same standard. This hypocrisy is untenable.

The COVID-19 endgame COVID-19 will eventually end. Not with a bang, but with a whimper. The loss of lives is immense. The human suffering is massive. I mourn those we lost. Moreover, our institutions, our culture, our politics, our media are also diminished. We are weaker and more vulnerable than ever before. Not only to a future pandemic threat, but any calamity that requires humans to work together and take action in a setting of scientific uncertainty. Many of us are unmoored, and suffering. We are hollow and stuffed, and searching for a new effigy online. A new target for outrage. This summer, when cases fall, when vaccination grows, put down your iPads and phones, and meet real people in real life. Human contact alone may save us.

Vinay Prasad, MD, MPH, is a hematologistoncologist and associate professor of medicine at UCSF, and author of Malignant: How Bad Policy and Bad Evidence Harm People With Cancer. This commentary originally appeared on MedPage.

Introducing New SFMMS staff associate, Ashley Coskey!

Originally from the Bay Area, I moved to Portland, OR to attend Lewis & Clark College, where I received my B.A. in Political Science in 2020. Prior to joining SFMMS as an Associate, I held a fellowship at Upstream Public Health and worked for the Democratic Party of Oregon during the 2020 election. These positions combined with COVID-19 emphasized the dire need to invest in public health to reduce health disparities. I am honored to be a part of a group committed to driving progressive change in healthcare delivery.

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DO GOOD AND AVOID HARM:

Why Health Care Providers Should Get a COVID-19 Vaccination Charles E. Binkley, MD The COVID-19 pandemic has taken a substantial toll on health care providers. In the early days of the pandemic, when personal protective equipment (PPE) was scarce, providers were putting themselves, and their families, at risk for contracting the virus. Providers then suffered the emotional effects of caring for so many sick and dying patients as surge after surge ripped across the world. Despite the trauma that COVID-19 has inflicted on many in health care, some providers are declining vaccination.

The question that now arises is whether or not health care providers are ethically required to receive a vaccination.

The primary ethical obligation that every health care provider has is to do good and avoid harm to patients. For most people that manifests as making the correct diagnosis, administering the right treatment, and ensuring that benefit exceeds risk. However, in the setting of an infectious pandemic, an important part of that ethical commitment to patients is to not unintentionally infect them with COVID-19.

Providers often have to interact with patients in ways that do not always allow for implementation of contagion reduction strategies such as social distancing. This not only places the provider at risk of contracting the virus from a patient, it also places a patient at risk of contracting the virus from the provider. Because of the greater number of potentially infectious contacts that providers have, in many ways providers pose a greater risk to patients than do patients to providers. As well, patients may have medical conditions or comorbidities that make them more susceptible to infection and/or more likely to have a serious course should they be infected. Receiving a COVID-19 vaccine is the most medically and ethically sound way that providers can fulfill their commitment to do good and avoid harm to their patients.

Besides the ethical obligation that providers have to their patients, providers have an additional obligation to protect the safety of the entire health care team. Requiring that all team members be vaccinated is a direct way of meeting this obligation to the team, as well as to the patients they serve. In some ways it may not only be ethical to require that all members of the health care team be vaccinated, it could also be seen as unethical not to require vaccination. Members of the health care team who are unvaccinated pose an unnecessary risk of harm to patients and colleagues alike. This avoidable risk of harm is contrary to the duty that the health care team owes to patients, as well as the duty that members of the team owe to one another.

Some providers may object to being vaccinated, citing their right to make their own health care choices, including whether to get the vaccine. Patients reasonably expect that health care providers will respect their individual autonomy and right to self-governance, but there is no such reciprocal obligation owed to providers. In fact, providers already relinquish some of their 28

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autonomy over their own health as part of being in the profession.

Providers have an ethical obligation to care for patients, even if there is some personal risk to the provider’s health. Providers are also required to maintain certain health standards, such as annual tuberculosis testing and potential treatment as a means of not harming patients or other members of their team.

Some providers may seek medical exemptions. Indeed, there are legitimate medical exemptions, such as a history of severe allergic reaction to vaccines, medical comorbidities, and disabilities. Pregnant providers may be able to claim an exemption based on the limited data available in this population. However, the CDC is currently recommending that high risk pregnant people receive the vaccine since they are at greater risk of severe infection and are also likely to be at an increased risk of adverse pregnancy outcomes if they contract COVID-19.

Exemptions based on philosophical and/or religious grounds are another consideration. Since many religious leaders argue that receiving the vaccine to prevent infecting other people is a moral obligation based on charity and love for one’s neighbor, these exemptions should be carefully considered. In addition, framed through the religious lens of preserving life, one could imagine that certain faith traditions may encourage their followers to be vaccinated. Providers may also seek a consciencebased exemption since all the currently approved vaccines have some association with stem cells from aborted fetuses. However, in the carefully reasoned judgment of the Roman Catholic Church, one of the most strident institutions to oppose abortion, the vaccines are all morally permissible.

Health care providers should receive COVID-19 vaccinations not only for their own health, but also to protect their patients and other members of their teams. It is always preferable for ethical choices to be made based on individual agency. However, once vaccinations receive final Biologics License Approval, it could be ethical to require health care providers to receive a vaccine. The process would need to be transparent, and applied equitably and justly. Such a mandate would have to be guided by the obligation to do good and avoid harm. Mandating that health care providers receive a vaccine would also need to be a last resort. It’s time to end the collective trauma caused by COVID-19.

Charles Binkley, MD is Director of Bioethics, Markkula Center for Applied Ethics at Santa Clara University.

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COVID-19 VACCINATION UPDATE FOR EMPLOYERS Jamie M. Bossuat, Esq. Many employers are wondering whether they can require or incentivize their employees to receive the COVID-19 vaccine.

Below are a few answers to commonly asked questions.

Q: Can I require my employees to receive a COVID-19 vaccine?

A: Yes, with some limitations. First, you should evaluate whether the vaccine is job-related and consistent with business necessity. Second, you should ensure that your policies provide for employee accommodations. On December 16, 2020, the EEOC issued guidance which permits employers to require vaccinations but requires employers to provide reasonable accommodations to employees who are unable to receive the vaccine due to medical or religious reasons.

Q: How do I determine if I must accommodate a medical or religious concern?

A: This depends on the reason you are relying on for requiring the vaccine. For some jobs, such as healthcare, it may be the case that getting vaccinated is a standard qualification for performing the service. The decision must be based on objective medical information. For example, a strong factor supporting requiring the vaccine is if a government agency requires the vaccine as a condition of employing an individual in your industry. Accommodations for an employee who will not receive a vaccine must be evaluated in the interactive process with the employee. Some possible accommodations may include wearing a face mask while on-site even when no longer required for others, teleworking, or a leave of absence.

Denying an accommodation requires an “undue hardship” on the employer, which will vary based upon a business’s individual circumstances.

Q: Can I offer a monetary incentive for employees to receive a COVID-19 vaccine?

A: Yes, but with limitations. Employers should consider rules applicable to wellness programs and IRS requirements relating to taxability of such payments. (A payment for receiving a vaccination is likely to be treated by the IRS as an employer-sponsored wellness program.) Additionally, employers must decide how they will address employees who are not otherwise eligible for the incentive due to a medical or religious reason.

Q: Must I pay employees for the cost of the vaccine or the time spent receiving the vaccine?

A: If you are requiring the vaccine based upon business necessity, then it is likely in California that the employer would be required to cover the costs incurred by the employee in receiving the vaccine, including time spent.

Jamie Bossuat is an attorney with Kroloff, Belcher, Smart, Perry & Christopherson in Stockton. A graduate of Hastings College of the Law in San Francisco, her practice consists primarily of business and employment litigation. Ms. Bossuat has significant employment litigation experience and has represented both employees and employers in a wide range of employment matters. (Courtesy of the San Joaquin Medical Society).

Q: Can I exclude someone from the workplace because their failure to receive a vaccination is a “direct threat” to the employee or others?

A: In some circumstances, yes. This is another exception to the requirement that a vaccine-related concern be accommodated.

However, the standard is very high and must be based on objective medical evidence and an individualized assessment.

The fact that employees have been working with masks for several months may make this difficult to establish.

Q: Can I encourage vaccinations even if I do not require them?

A: Yes. Much like annual flu shots in some portions of the healthcare industry, an employer can encourage a vaccine and then put in place additional safety precautions for those who elect not to receive a vaccination.

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SMOKING AND COVID: THE PRIMACY OF PREVENTION John Maa, MD On February 22, the United States crossed the tragic milestone of 500,000 Covid-19 deaths, just one year and 16 days after the first US fatality was recorded in California. Our nation paused to honor this enormous loss of life, over twice the number seen in the nation that ranks second in global Covid mortality. At the peak, 5,427 daily US deaths were reported on Feb 12, 2021, exceeding the 4,414 confirmed Allied deaths at Normandy on D-Day. Over the span of three years and eight months during World War II, 407,316 US military servicemen and women were killed. The 407,000th US Covid-19 death came around January 22 - 11 months into the pandemic. Covid-19 claimed American lives at a rate nearly four times faster than World War II. However, there is one other cause of preventable death in the US that for years consistently surpassed the death rate witnessed in the first year of the Covid-19 pandemic. An estimated 480,000 US lives are lost from tobacco use each year, including more than 41,000 deaths annually from secondhand smoke exposure. Perhaps another important date to reflect upon was February 13, 2021 (nine days before the 500,000 death milestone), when the US crossed 480,000 Covid-19 deaths. Covid-19 claimed US lives at a pace slightly behind Big Tobacco, having taken one week longer to match Big Tobacco’s yearly toll. We have never shut down the economy, closed our schools, or sheltered in place to protect the public from the health hazards created by Big Tobacco. Social distancing from cigarette smoke remains an excellent idea, given the risks of secondhand smoke exposure (and possible spread of the virus).

Perhaps the most extreme example of the power of nicotine addiction is witnessed when a current smoker picks up a discarded cigarette butt from the sidewalk and places it into their mouth. This action ignores the warnings not to touch one’s mouth, or to share items with others who might have Covid, and is of special concern as the virus falls to the ground after being sneezed and coughed. This particularly high-risk activity illustrates that tobacco use and Covid-19 present twin threats to public health. A question that will be answered over time is the number of Covid deaths in 2020 that came in patients already suffering from serious tobacco related illnesses like coronary arterial disease, asthma or chronic obstructive pulmonary disease. A lifetime of health problems related to smoking may have predisposed some to have more severe Covid disease, resulting in death.

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An early premature conclusion based on incomplete data suggested that smoking somehow protected one from acquiring Covid-19, which has not been substantiated by further research. Instead, most studies demonstrate the opposite, that smoking is linked to transmission of Covid-19, and lead to worse outcomes including the need for intubation and death. It is for this reason that some states have chosen to vaccinate current smokers ahead of schoolteachers and others, which may create a perverse incentive for non-smokers to begin smoking. An early silver lining from the pandemic is that up to 300,000 UK smokers may have quit smoking due to COVID-19 fears. Unfortunately, the Wall Street Journal recently reported that current smoking rates in the US are on the rise (after decades of decline) in part due to the anxiety and stress induced by the pandemic. Encouraging more Americans to follow the lead of their UK counterparts may help slow the tragic arc of COVID-19 deaths in America.

Tough action was taken against the vaping industry during the pandemic to limit their harm to society. Many vape shops across America closed, having been defined as non-essential services. The Federal Trade Commission filed litigation in the Spring of 2020 to end the Juul-Altria partnership as a violation of the Sherman Act, and class action lawsuits went further to allege the Altria-Juul deal was a conspiracy to create an illegal monopoly. In April of 2020, Juul laid off one-third of their remaining workforce, and later exited five European markets including France and Spain (Austria, Belgium and Portugal), as well as South Korea. Similar direct action against Big Tobacco now could help curb the annual death toll from smoking.

The one-year anniversary of the COVID-19 pandemic presents an opportunity to reflect upon what we have witnessed over the past year. We should ask ourselves as a nation why do we continue to financially support the planting and harvesting of tobacco crops? Why are there not graphic warning labels on cigarette packs, as in other nations? We turned the country upside down to fight COVID-19 — if just half of our assets and energy were focused on reducing smoking’s deadly toll maybe we can finally defeat Big Tobacco? We can hope that someday a vaccine will arrive to prevent nicotine addiction, and end the health burden associated with tobacco use. It is essential for policymakers to take every effort to reduce the deadly toll of of tobacco use, and its role in worsening the COVID-19 pandemic.

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WHOSE HABITAT IS IT?

Musings Upon Seeing the Effects of Wildfire Mitigation in a High-Risk Area Linda Hawes Clever, MD

The context: We face many difficult choices these days. Consider COVID, for example. Do we shut down or open up? When and how much? Who knows the best and whose interest is being served?

Whom do we trust (if anyone)? Who is affected the most; who is most vulnerable? Health care workers? Elders? Minorities? How do we assure vaccine and health care equity? Similar tough decisions arise when questions, policies and practices arise about protecting neighborhoods, towns and cities from wildfires. Just like pandemics, wildfires will return, ferocious.

As millions more acres burn every year, more trees, animals, people and towns disappear. The skies turn orange at noon, and local AQI (Air Quality Index) and wind condition reports, never mind the temperature, are major topics of conversation. We wear masks, regardless of COVID. Work assignments and exercise locations shift; fear, anger, and sadness rise. Eyes, sinuses, and lungs suffer. Lives change forever. So we develop and undertake safeguards against these menacing infernos. Like COVID, however, it is not easy.

Good wildfire mitigation requires knowledge, experience, money, planning, permits, public education and (preferably) endorsement, care and caring, an eye to beauty and the sanctity of all life, selective clearing, thorough cleanup and even rehabilitation of our precious lands.

Not everyone has taken a walk in the woods lately, nor visited a meadow, a glen, a little lake brimming with frogs and birds and secret underwater dwellers. This bounty may be lost to well-meant, if over-bold, clearance measures, far ahead of fire.

Walks in “mitigated”, perhaps under-appreciated, areas led to these musings.

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The musings: The buckeye and the big-leafed maple were not majestic. The buckeye’s gifts—shiny, smooth, blonde-to-mahogany nuts— filled the palm of a delighted scavenger and folded with time into irregular, elegant sculptures. The big leaf maple graced the trail each autumn with, no surprise, REALLY BIG warm-brown leaves that were the size of your turkey platter.

Talking about turkeys…One could rave on about our dear departeds, so conversational among themselves and with us as they enforced their pecking order and displayed spectacular tails. Their rare flights featured awkward take-offs and gliding crash landings.

Talking about birds…the bright bluebirds’ swoops won’t vie with the sky for beauty, now that their sheltering tree is gone.

The quail might make it. They murmur over in the meadow across from the old corral with its loading chute—now collapsed, its sturdy posts painfully askew—that once entered onto the broad trail.

The bobcat probably didn’t bother with the turkeys and other birds and vice versa. No, bobcats prefer bunnies. The bunnies know that. They know when sitting very still won’t work and that they may escape in headlong hops. The bunnies might find new homes in the open spaces where cats and coyotes roam.

The moms and fawns, too, will have to go elsewhere, along with their proudly-antlered mates and papas.

The miners and other critters aren’t around anymore to munch the miners lettuce. It may not regrow anyway, having to push up through the heavy sawdust.

The ground squirrels and whatever else engineers those underground passageways with yawning or modest holes--some with entry and exit porches—will wonder what happened to their world when they poke out and see it, shaved.

The rattlesnakes and fellow reptiles…bonne chance and good riddance.

As for the humans, well, our brains understand fire danger and concur in our desire for safety. Our pocketbooks support the clearance. Our hearts and spirits break, you must know, at the effect our good intentions have on our wounded habitat.

Linda Hawes Clever, MD, Founder and President of RENEW, a not-for-profit aimed at helping devoted people maintain or regain effectiveness, enthusiasm and purpose so they can have a whole, healthy life, trained at Stanford and UCSF in Internal Medicine, Infectious Diseases, Community Medicine and Occupational Medicine. She lives in a lightly forested neighborhood that is a couple hundred steps from Open Space.

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SCIENCE-BASED SCHOOL REOPENING: A Letter to the Governor and State Health Director from dozens of concerned clinicians, researchers, and health leaders.

March 19, 2021 Dear Governor Gavin Newsom and Dr. Mark Ghaly, As physicians, nurses, and public health professionals, we write with deep concern on the state of school reopening in California. While we have been grateful for this state’s use of science-based decision-making in the early stages of the pandemic, we have not seen the same centering of science in our school reopening process. We write today to urge the California Department of Public Health to update its guidelines on reopening based on the latest science and data and do so no later than April 1. Urgent action is the only hope to reopen schools this year and prevent severe disruption of the academic year ahead.

Six million public school children in California have now been out of school for 12 months and counting with no opportunity for in-person education. While we recognize that some counties are proceeding with reopening plans in the coming weeks, these plans are extremely limited, fail to include the majority of students in California, and offer no dates for students who are not yet included. As a result, California ranks last among all 50 states for the proportion of K-12 students who attend school full-time in person. While the governors of Oregon and Washington have both issued mandates that all K-12 schools must reopen by April 19, our state has been left in limbo without a clear mandate.

California is now the only West Coast state where schools are not guaranteed to re-open.

In our hospitals and clinics, we are bearing witness to devastating health impacts from prolonged school closures in children. Our centers have seen an increase in mental health visits that aligns with trends noted by the CDC. These include increases in anxiety, depression, and suicidality. In our clinics, we are seeing higher rates of obesity, hypertension, and fatty liver disease which will have long-term impacts on children’s health. Children who used to love school are now completely disengaged while children with special needs are regressing in their development. While nearly all children are losing ground academically, the biggest negative impacts are on English language learners and children living in poverty, erasing years of effort towards reducing inequalities.

School reopening should be based on science and data. As such, we recommend the following: • Decouple reopening from the rate of community spread: the decision to tie reopening to the color tier process was made before we had evidence to guide our decision-making.

A year later, studies from Wisconsin and North Carolina provide clear data that schools can be reopened even in areas of high community spread. Continuing with the tier system widens inequities further by making it more difficult for schools with fewer resources to open while allowing well-resourced schools to continue in-person learning.

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This new project is a large collaboration spearheaded in part by SFMMS pastpresident Kim Newell Green, MD, with funding from SFMMS member Sandra Hernández, MD, CEO of the California Health Care Foundation. Their website has a wealth of information on all aspects of getting schools open again.

• Change physical distancing guidelines from a six feet requirement to a three feet recommendation: The CDC updated their guidelines to allow for three feet of distancing in most cases. California school reopening guidelines also specify a preference for six feet of distancing between students, allowing four feet only after all alternate approaches have been considered, including hybrid learning. The six foot distancing requirement is not evidence based and is now inconsistent with recommendations from the CDC, WHO and the American Academy of Pediatrics. Recent data from Massachusetts schools indicate that three feet of distancing is sufficient to maintain safety, a finding supported by the data from the Wisconsin study.

Public health is a balance of assessing harm and benefit. In this case the evidence is clear: keeping schools closed to inperson learning provides marginal benefit in terms of disease prevention while extracting an enormous cost on children’s physical and mental health. We urge the state of California to modify school reopening guidelines in accordance with the best scientific evidence. We know it can be done safely and we know the time to reopen our schools is long overdue.

Sincerely,

Dr. Monica Gandhi Professor of Medicine and Associate Division Chief of the Division of HIV, Infectious Diseases and Global Medicine, UCSF Dr. Kim Newell Green Associate Clinical Professor of Pediatrics, UCSF, Past President San Francisco Marin Medical Society Dr. Monique Schaulis President, San Francisco Marin Medical Society And many more….

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TELEMEDICINE WEBSIDE MANNER: PUTTING YOUR BEST FACE FORWARD Amy McLain, BSN, RN Last fall, Dr. Neel Naik, the Director of Emergency Medicine Simulation Education and an Assistant Professor of Clinical Emergency Medicine at Weill Cornell Medicine in New York City, spoke at the American Society for Health Care Risk Management’s (ASHRM) virtual annual conference. In his presentation on telemedicine, he made several interesting points: • Physicians do not understand how to engage with the patient • Physicians do not know how to present themselves to patients • Physicians do not know how to conduct a virtual physical exam

Dr. Naik went on to say that “physicians must alter their ‘bedside manner’ from traditional in-person care to better accommodate patient needs during video-based telehealth visits.” Yet, this important skill is often not taught.

If this is the case, then many physicians must be struggling to conduct a telemedicine visit with their patients and may be at increased risk for patient complaints to insurance companies and/or the medical board. It’s also important to know that telemedicine is a form of healthcare delivery and the standard of medical care provided to patients is the same whether you see them in person or not. Therefore, if an appropriate exam is not performed during a telemedicine visit, claims may arise from misdiagnosis and treatment errors.

To ensure your patients have an optimal virtual experience and best possible medical outcomes from their next telemedicine appointment with you, CAP recommends the following tips: ■ Prepare: You want your patient to have the utmost confidence in you. Know in advance why your patient is scheduled. Read the chart before your video encounter. Have a plan of action.

■ Time: Don’t be in a rush. Your patient will feel unimportant and you’re likely to miss important clinical details. Schedule the appropriate amount of time for each patient. Allow time for questions and be aware of “the doorknob phenomenon,” when a patient waits until the physician is leaving before asking a critical question.

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■ Location: Follow privacy and confidentiality rules.

Choose a quiet, private location with a neutral professional background. Remove distracting or inappropriate items. Encourage your patients to find areas in their homes to interact privately with you.

■ Technology: Ensure that your technology works correctly. You don’t want to delay or cancel your patient’s appointment because your system is not functioning properly. Check your camera, your computer, your microphone, your speakers, and your internet connection. Then, check it again. Use healthcare-specific or end-to-end encryption platforms. Have IT on speed dial.

■ Lighting: Poor lighting conditions have an enormous effect on video quality. You want to look your best and allow your patient to see your face clearly. Use natural lighting. Face the window—never sit with your back to a window. If you do not have a window, find a soft light to put in front of you.

■ Camera: Avoid unflattering and awkward angles by framing the camera correctly. Place the webcam at eye-level and position yourself so that you are in the center of the patient’s screen.

Avoid embarrassing situations. Remember, the camera may still be on.

■ Sound: Most microphones pick up background noises that can be annoying or distracting. Use quality headphones/earbuds to improve hearing. Mute yourself when your patient speaks. Recognize that there is generally a slight delay between the time words are spoken and when they are received. Avoid talking over your patient. Caution: hot mics!

■ Appearance: Present yourself as if you were in the office exam room with your patient. Introduce yourself and your role.

Wear your white coat and badge or medical professional attire.

Be mindful of your body language. Avoid distracting behaviors, such as excessive gesturing with your hands and distracting facial expressions.

■ Engage: Confirm your patient’s identity. Smile. Pay close attention to your patient and actively listen. Participate completely as if you were physically in the same room. Minimize distractions and avoid disruption, such as email/message notifications or phone calls. Look into the camera to maintain good WWW.SFMMS.ORG

eye contact. If you need to look away to take notes or consult a resource, tell them so they don’t think you are doing other work.

■ Collaborate: Guide your patient through the visit. Have the patient adjust lighting and camera, if needed, for closer inspection. Demonstrate and coach your patients to assist you with their physical examinations. Have them use their thermometers, blood pressure cuffs, and other medical tools to gather additional clinical data.

■ Close the Loop: Document the telemedicine visit in the medical record. Send a visit summary along with written next-step instructions to the patient.

CAP provides California physicians with superior medical malpractice coverage and a myriad of no-cost risk and practice management resources to help keep them safe and successful.

If you’d like to learn more about the benefits we offer to our physicians and how much you can save by switching your medical malpractice coverage to CAP, contact Dorine Leong at 650-543-2183 or via email at DLeong@CAPphysicians.com.

CAP is a proud supporter of the San Francisco Marin Medical Society.

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RESOURCES: For more in-depth information about telemedicine andwebside manner, please visit these websites: Cooperative of American Physicians (CAP) www.CAPphysicians.com California Medical Association (CMA) www.cmadocs.org American Medical Association (AMA) www.ama-assn.org Medical Group Management Association (MGMA) www.mgma.org

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Read the Full Report at www.SFMMS.org

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SFMMS BOOK REVIEW John Maa, MD

“I may be lonely but I’m never alone” – Alice Cooper from “I Never Cry”

the extent of the detriments Dr. Vivek Murthy has the disto our health and well-being tinct honor to serve as our caused by our current culture nation’s 19th and 21st Surgeon of independence. And then he General. His New York Times prescribes a program of connecbestselling book “Together – the Healing Power of Human Contivity, interaction, community, and friendships to treat this nection in a Sometimes Lonely largely hidden calamity of our World” was featured at the inausociety. Given that our current gural SFMMS Book Club on Feb Covid-imposed social isolation 2, 2021. This groundbreaking has only increased loneliness book focuses on the importance and isolation, this message is of human connectedness, the more important than ever.” Surconsequences of loneliness on health, and the healing power geon General Murthy highlights of community. The majority four key strategies to combat With US Surgeon General Vivek Murthy at the of the book was written before loneliness during the Covid White House in 2015 2020, and in the author’s note pandemic: 1) spend time each Dr. Murthy acknowledges the special significance the book day with those you love, 2) focus on each other, 3) embrace has now taken on during the Covid pandemic. He highlights solitude, and 4) help and be helped. that perhaps “social distancing” is a misnomer that would Echoing that sentiment, SFMMS Board member Dr. Sarita have been better phrased as “physical distancing”, as seeking Satpathy added “I relate to so many things that Vivek Murthy to disconnect human beings even further emotionally during wrote about — including the zoom calls we’ve been doing these difficult times may only exacerbate anxiety and fear and during Covid, which has helped make stronger connections underlying mental health conditions. with people in SFMMS and other colleagues.” Hopefully Dr. Dr. Murthy shares insights from his journey and conversations Murthy’s book will highlight paths forward to combat loneacross the country as US Surgeon General, where he discovered liness as we emerge from the Covid pandemic, and provide loneliness and isolation were recurring and rampant themes even new answers to bullying in schools, mass shootings, and an before the Covid-19 pandemic. Modern progress has brought improvement in race relations. technological advances that make it easier for us to connect, but Loneliness is a universal condition that impacts all of us and too “often these advances create unforeseen challenges that make those we love, now more than ever. One solution is to invest the us feel more alone and disconnected.” While social media platextra energy to reconnect with old friends we lost touch with before the pandemic, as there is now ample time to reach out. forms can bring people together, they can also amplify disagreeThe SFMMS book club is an excellent example of another posment and divide us even further. And this can accelerate the cycle of loneliness contributing to more loneliness. sible societal solution, highlighting what can be done virtually Dr. Murthy provides a deeper understanding of loneliness to bridge the gap, and widen our social circles. All SFMMS memover the ages and across cultures, highlighting how solitude can bers are welcome to join the quarterly Book Club events which be beneficial if it promotes self-reflection and personal growth, include a complimentary copy of the book to be read – see you unlike emotional isolation that can become a detriment to physat the next Book Club meeting! ical and mental health. Dr. Murthy shares deeply personal stories of loneliness — the bullying he experienced as a schoolchild, John Maa, MD, FACS was the 2018 President the devastating loss of his uncle from suicide, and invaluable of SFMMS and is Immediate-Past Chief of the lessons learned in caring for patients experiencing isolation.

Division of General and Acute Care Surgery His story caring for one of his own sick children after relocating at Marin Health Medical Center. to Washington D.C. to become Surgeon General highlights how professional success can ironically result in disconnectedness and the temporary disruption of close social networks.

SFMMS President-elect Dr. Michael Schrader reflected “Vivek Murthy has written a timely treatise on the growing public health crisis of isolation and loneliness. He documents 40

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COMMUNITY MEDICAL NEWS Kaiser Permanente

Chinese Hospital

Maria Ansari, MD

Sam Kao, MD

Workforce development is an important priority for health care organizations Was we seek to train and maintain the workforce necessary to meet current and future care demands.

A very successful effort in this area is our partnership with the University of San Francisco (USF) School of Nursing and Health Professions to host student nurses in Kaiser Permanente’s mass vaccination clinic located at the USF Koret Center.

The clinic, which opened Monday, Feb. 8, vaccinates approximately 1500 people per day. Supervised by the San Francisco Medical Center’s clinical staff, 72 USF nursing students assist with clinic operations, including preparing and injecting the vaccinations.

The students, who are working towards graduation and obtaining their nursing licenses, completed a rigorous COVID-19 educational program prior to deployment. Training included a course on immunization best practices, a course on the Moderna and Pfizer vaccines, and sessions on the impact of COVID-19 on public health.

The students will staff the clinic for a semester, giving them the opportunity to develop clinical skills and interact with patients. The program also allows Kaiser Permanente San Francisco to continue to provide care in our hospital and clinics, while also ensuring the safe, timely vaccination of our members.

Kaiser Permanente’s longstanding relationship with the USF School of Nursing and Health Professions also includes the regional Nurse Scholar Academy (NSA), which was honored by the American Association of Colleges of Nursing (AACN) with the organization’s AACN Exemplary Academic-Practice Partnership Award in 2018.

Workforce training programs like these have become even more important as the United States faces a national nursing shortage projected to worsen over the next two decades. Among many factors contributing to the shortage is the lack of clinical training opportunities for nursing students, as many hospitals have closed or scaled back such placements. At Kaiser Permanente, we are proud of our continued training programs and our strong partnership with USF.

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As we wrap up our celebrations of Chinese/Lunar New Years, we wish all much prosperity, health and happiness in the Year of the Ox. This time also marks the one year anniversary of our struggles with the novel coronavirus Covid-19. We thought this would also be a fitting moment to highlight how Chinese Hospital has helped shephard our community through this unprecedented healthcare crisis.

Chinese Hospital COVID-19 Highlights • SRO COVID-19 OUTBREAK PROGRAM: Since the beginning, Chinese Hospital has led the community through the pandemic crisis by implementing a comprehensive COVID-19 initiative consisting of bilingual community education and outreach, access to testing services, and linkage of clinical and social care. To mitigate outbreaks within the SRO resident community, Chinese Hospital has worked together with SFDPH and other community partners to deploy response teams to outreach to countless cases in SRO buildings. These efforts have largely been met with success, as the positivity rate in Chinatown has been one of the lowest in SF and Chinese Hospital boasts a zero employee (hospital-acquired) infection rate.

• TESTING PROGRAM: Chinese Hospital has offered accessible testing services to the community, performing over 4,600 tests to date. Chinese Hospital has also worked with the City of SF to coordinate and support weekly mobile pop-up testing events in front of the hospital, at Portsmouth Square, and onsite at SRO buildings.

• VACCINATION ROLL-OUT: Chinese Hospital was one of the first facilities to receive and administer the COVID-19 vaccine to its high-risk healthcare workers, patients, and other members of the community, as dictated by the state’s phased plan. Over 3,600 vaccines have been administered to date. Chinese Hospital continues to work diligently to offer vaccination its clinic facilities to its patients and members of the community.

• SF PUBLIC HEALTH FOUNDATION GRANT AWARD: Chinese Hospital was selected and awarded for grant funding from SF Public Health Foundation and SF Department of Public Health to continue its efforts and provide culturally competent COVID-19 education, outreach, and care in the Chinatown community.

• CITY AND MEDIA RECOGNITION: Chinese Hospital received national and local mainstream media coverage for its COVID-19 community leadership efforts and successes, including New York Times, San Francisco Chronicle, KQED, KPIX, and PBS, in addition to Chinese media outlets World Journal, SingTao, China Press, and KTSF26. This coverage provided valuable exposure for our community.

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From a San Francisco resident about receiving the COVID-19 Vaccine. A Poem for Moscone.

Crossing Market Street I thought do not get hit by a car before you get there and I don’t and walk into an enormous room where I am welcomed by cheerful helper after helper in matching t-shirts on the first day this massive site is open with its color-coded signs, its yellow arrows on the floor, its helpers waving me on and leading me to a waiting station with a seated woman in hospital blues, happy in her flesh, blue beads in her multi-braided hair, who says her name is Gayla, and she’s going to talk to me in order to distract me, saying she has been caring for a relative for six months in some other state, but I’m not sure who or where because is her mouth is covered by a mask, and now she’s taken this job in California for three months. And then she says, and soon we will be able to be with our loved ones again, and almost a year of tears begin to fill my eyes and Gayla says, Oh, baby! and grabs my hands, one in each of hers, and I am stunned, looking down to see my hands in hers, my hands that have not touched or been touched for almost a year, and I see her hands are beautiful, small and elegant, with tapered fingers and luminous black skin, so I squeeze both of them as hard as I can, and Gayla tells me I have made her day and the she says she thinks I am a sign from God that she was right to come here for this work, and I stare at her because I cannot speak, and she gives me a little square of gauze because there are no tissues for my eyes, and then she dabs my arm and puts the needle in my arm and plunges in the clear solution I have been waiting for so long, and she fills out my little card and says I should just sit there for a few more minutes and I do, until I can stand and walk a few steps off and turn and say, Thank you, Gayla, and she thanks me, too.

Now I go to sit on a distanced folding chair until my numbers show up on the big electronic screen and I walk past more lovely helpers who are saying, Congratulations! And Thank you for coming!

And Have a good day! And I walk out into the California sun, high buildings dazzling in the light, and the day is more than good, even though the restaurants are still empty and the art museum is closed in this world we’ve made and damaged, this shuddering world we be to keep on spinning for as long as it can.

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From The Murmur, Notes from the Physician-In-Chief’s Office at Kaiser Permanente

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