INSIDE:
Women in Medicine. Prevention vs. Public Health. St. Mary’s Survives. Youth Health. Physician Wellness. SFMMS Gala. CMA House of Delegates. And more!
6 Meet Your New SFMMS President: Dennis Song, MD, DDS
Steve Heilig, MPH
7 Editorial: A New Era
Michael Schrader, MD, PhD
10
Adam Francis, CAE
14 Personal Responsibility or Public Health?
Robert Lustig, MD, MSL
17
Stephanie Hu
18
20
Kimberly Newell Green, MD
22
26
Remo
28
Cover Art by Cynthia Fletcher; http://www.cynthiafletcherart.com/
She will have a showing at Commonweal in Bolinas starting in April, with an April 7th opening: https://www.commonweal.org/news/cynthia-fletcher-lifes-force COVER ART
January/February/March
2 Membership Matters
5 President's Message: We Are About You
Dennis Song, MD, DDS
8 Executive Memo: Mind Matters: Prioritizing Physician Well-Being in Mental Health Awareness Month
Conrad Amenta
9 CMA House of Delegates Report
Michael Schrader, MD, PhD
29 Kaiser Permanente Monica Kendrick, MD
12 SFMMS Annual Gala Highlights
26
In advance of the March election, SFMMS leaders joined California Governor Gavin Newsom in support of Proposition 1. The state ballot measure includes $6.38 billion in bonds aimed at expanding mental health treatment and addiction services and turning hotels and motels into housing for people experiencing homelessness in the state. It would also change how the state spends money it receives as part of the Mental Health Services Act. State programs currently receive 5% of MHSA funds or less and counties receive 95% or more. Newsom said the bond would fund 11,150 new treatment beds and 26,000 outpatient beds.
The SFMMS Community Service Foundation (CSF), a charitable 501c3 organization, was founded decades ago to collaborate with and support community health organizations in San Francisco and Marin.
One of the CSF roles is to provide small but significant unrestricted cash grants to worthy local health-oriented nonprofits, from a long-standing CSF fund. Previous grantees include: NovatoSpirit, GirlVentures, SF Marin Food Bank, Homeward Bound, American Clinicians Academy on Medical Aid in Dying, Glide Church, Planned Parenthood of Northern California, Brady Center to Prevent Gun Violence, SFGH Foundation for reproduc-
San Francisco General Hospital/UCSF, the San Francisco Free Clinic, Operation Access, the Marin Canal Alliance,
the Palestinian Children’s Relief
To discuss nomination of an organization, contact Steve Heilig: Heilig@sfmms.org
The California Medical Association (CMA) is honored to announce that Senate President pro Tempore Mike McGuire will be our featured speaker at CMA's 50th Legislative Advocacy Day, happening on April 10, 2024, in Sacramento! Contact Adam Francis at The SFMMS: AFrancis@sfmms.org to receive hands-on experience and learn the essentials of advocating for your patients and profession.
The Medical Board of California will review best practices for physician health programs, a move advocated by CMA to better support physicians facing mental health challenges, burnout and substance abuse. CMA President-Elect Shannon Udovic-Constant, M.D., recently testified before the medical board, emphasizing the critical need to maintain a healthy and resilient physician workforce and the limitations under current law for the board to create a program that aligns with those best practices.
On Feb. 21, 2024, Change Healthcare, a subsidiary of the UnitedHealth Group Optum unit, experienced a cyber-attack that resulted in nationwide outages affecting payors, physician practices and other providers and pharmacies. CMA, AMA and other health care organizations have urged HHS to use all available authorities to ensure that physician practices can continue to function, and patients can continue to receive the care that they need.
As Congress prepares to pass legislation that reverses only half of the Medicare physician payment cut implemented on January 1, 2024, the California Medical Association (CMA) is exasperated that for the fourth straight year physicians will face a payment cut. Coupled with medical inflation, physicians will experience a devastating 6% cut in 2024.
“While CMA appreciates the support from many lawmakers in Congress, this legislation will continue the staggering ‘death by a thousand cuts’ that Congress has allowed for the last two decades,” said CMA president Tanya W. Spirtos, M.D. Adjusted for inflation, physicians have experienced a 30% decline in payment since 2001, while other Medicare providers received 60% increases during the same time period.
“Make no mistake: These difficult cuts will further jeopardize physician practices, forcing more physicians into consolidation with larger, more expensive health care systems or private equity, into limiting the number of Medicare patients or into earlier retirement,” Dr. Spirtos added. “This will further challenge seniors seeking to find timely care.”
According to a CMA physician survey, two-thirds of physicians said Medicare payments do not cover their costs to provide care, with the result that nearly half are planning to retire early, and 70% are limiting the number of Medicare patients they can treat. In many California communities, no primary care physicians can accept new Medicare patients. According to a recent Definitive Health care study, 117,000 physicians nationwide left the workforce in 2021. Because patients cannot access physicians, wait times in California emergency departments average eight hours.
"Physicians are the foundation of the health care system, and we can no longer weather these cuts without Congress enacting long-term, meaningful Medicare payment reform," said Dr. Spirtos. "CMA is urging Congress to immediately address Medicare’s woefully inadequate physician reimbursement rates and the growing access to care crisis it is causing. CMA stands ready to continue working with Congress to reform Medicare.”
CMA sponsors Physicians Making Decisions Act regulating AI in health care
CMADocs.org – Feb. 27
CMA is sponsoring the Physicians Make Decisions Act (SB 1120), which requires that physicians be the ones to make final decisions on what kind of treatments patients should receive, rather than artificial intelligence (AI). In recent years, health plans have increasingly relied on AI to streamline the processing of claims and prior authorization requests. SB 1120—authored by Senator Josh Becker (D-Menlo Park)—requires licensed physicians to supervise treatment and coverage decisions made by algorithms.
January/February/March 2024
Volume 97, Number 1
Editor Michael Schrader, MD, PhD
Managing Editor Steve Heilig, MPH
Production Maureen Erwin
SFMMS OFFICERS
President Dennis Song , MD, DDS
President-Elect Jason Nau, MD
Secretary Ian McLachlan, MD
Treasurer Sarita Satpathy, MD
Immediate Past President Heyman Oo, MD, MPH
SFMMS STAFF
Executive Director
Conrad Amenta
Associate Executive Director, Public Health and Education
Steve Heilig, MPH
Director of Operations and Governance
Ian Knox
Director of Engagement
Molly Baldridge, MPH
Senior Director, Advocacy and Policy
Adam Francis
2024 SFMMS BOARD OF DIRECTORS
Edward Alfrey, MD
Melinda Aquino, MD
Julie Bokser, MD
Kristina Casadei, MD
Clifford Chew, MD
Esme Cullen, MD
Manal Elkarra, MD
Mihal Emberton, MD
Cindy Greenberg, MD
Ian McLachlan, MD, Secretary
Jason Nau, MD, President-Elect
Heyman Oo, MD, Immediate Past-President
David Pating, MD
Sarita Satpathy, MD, Treasurer
Michael Schrader, MD, Editor
Yalda Shahram, MD
Neeru Singh, MD
Dennis Song, MD, DDS, President
Kristen Swann, MD
Ranna Tabrizi, MD
Kenneth Tai, MD
Melanie Thompson, DO
Kristin Wong, MD
Andrea Yeung, MD
Helen Yu, MD
For questions regarding journal, including possible submissions, contact Steve Heilig: Heilig@sfmms.org
Welcome to the new year! I am thankful to be part of history in the making as our members and leadership help shape the future of physicians and patients not just in San Francisco and Marin, but well beyond our geographic boundaries. We are not just another membership. We have the most passionate, diverse, well-versed leadership out of any Society.
I keep getting surprised when asked about SFMMS. What do we do? Why are we here? You would think that most physicians would know. Then again, I shouldn’t be surprised. Navigating from the medical school application process, getting through USMLE, applying for internships and residency, and ultimately finding the right path after completion of training, when did you have time to think about who actually made the decisions and rules for which you are allowed to practice? How and how much would you be paid? What rules govern the benefits of patients? What local and state licensing requirements would impact how you practice? Who gives expert testimony about patient care to influence a legislator’s decisions? Who meets with the county supervisors to make changes in our counties? We do. So who are we?
• The doctor who can’t retire because there is no one willing to care for patients the way he has for decades.
• The doctor fresh out of residency with half a million in debt wondering what the next step is.
• The doctor who is passionate about advocacy in sugar, tobacco, and violence.
• The doctor that works hard to elect legislators that align with our local needs of physicians and patients.
• The doctor who serves in public health departments providing guidance for public health initiatives.
• The doctor who is confused about contracting with multiple medical groups.
• The doctor who works in public health clinics caring for underserved populations.
• The doctor who is retired and looking to give back to the profession.
• The doctor who is starting out in solo private practice and requiring resources that a small business needs.
• The doctor who is concerned about the mental wellness of colleagues.
• The doctor wants to meet new people and expand their network.
• The doctor who teaches students and residents while conducting and publishing the latest research in their field.
• The doctor who is in medical staff leadership and concerned about the rights of the physician members to practice.
• The doctor who is a resident and represents the concerns of those in training.
We are in a place of tremendous resources and physicians who crossover so many areas of medicine beyond categorization of medical specialties. We have a network of over 40,000 physicians state wide supporting our common goal of supporting our medical profession.
To support our membership of 3,500 members, we need you and your voices. My goal this year is to expand our long-standing strength as an influential powerhouse developing future leaders and cultivating relationships that do more good for healthcare. We have governance changes that will allow us to streamline our activities and bring efficiency to the organization so we can do even more. In order to do so, we need YOU to volunteer your time and background to make us even better. Whether you are retired, new in practice, or in the many different phases of life and career, please consider providing your time and wisdom that will help shape the future of medicine. One simple way is to apply for service on a committee and there are several to choose from with many commitments that only take a few hours a year. I am happy to communicate with you about how you can make a difference.
Please contact me at dsong@sfmms.org with any questions, concerns, or points of information and I will endeavor to help you or direct you to the right resources within our organization or beyond.
Dennis Song, MD, DDS
Dennis Song, MD, DDS is an oral and maxillofacial surgeon in private practice and Chief of the Dental Division at Sutter California Pacific Medical Center. He also serves as an Associate Adjunct Professor at the University of the Pacific School of Dentistry. A graduate of the UCSF School of Dentistry, UC Davis School of Medicine, and UCSF Residency programs, he has been active in organized healthcare since his days as a student.
Whydidyouchooseacareerinmedicine?
My mother once told me that had she had the resources and the time, she would have studied to be a doctor. As many parents may aspire their children to enter the health professions, my mother was going to be happy with any job I could hold down. I wasn’t exactly the best academic student in high school and my aspirations were pretty limited. She jokingly said that if I were to become a doctor, she would proudly walk into my office and demand to see me as my mother. Interestingly, after I became a doctor and hung a shingle, she refused to step foot into my office until more than a decade later!
Strangely enough, my path to medical school was not the traditional route. With great mentors and support, I was considered academically promising in college and was pushed really hard to apply to medical school. Influenced by ER and Doogie Howser, I didn’t have the heart to deal with the death and dying nor the intensity of trauma surgery so I decided dental school would be a safe place where I could be a doctor, but keep me the furthest from dealing with such patients. Alas, while in dental school I ended up gravitating towards surgery and pathology. An attending surgeon talked to me after clinic one day and told me that I really should go to medical school. So much to the chagrin of my mother, he inspired me to turn a four year dental school goal to schooling and residency for 11 years after college.
Why did you choose your medical specialty?
Although I graduated dental school and continued into the specialty of oral and maxillofacial surgery, I was very tempted to select a different course. Ironically, some of the most enjoyable times I had was in palliative care, primary care, pediatrics, and psychiatry. I enjoyed the longer term patient doctor relationships which is something I miss the most, but my family practice attending was struggling financially while doing house calls to meet patient needs within a failing healthcare system that didn’t reimburse adequately. I also realized that I was becoming frustrated with patients who weren’t getting better and medications that didn’t seem to cure anything. I found relief in surgical treatment where there was immediate gratification. Caring for the patient whose face was broken from violence to the resection and reconstruction of tumors in the mouth to the unusual oral infections in a toddler to the adult who lost all their teeth due to periodontal disease, I realized I needed to be that compassionate well-rounded doctor to care for these surgical patients. Ultimately, I ended up in the right specialty because it required a little bit of every area of medicine, was coupled with an exciting lack of continuity between dentistry and medicine, and retained some control over the care of my patients. There is always a new puzzle to figure out in every patient.
Why are you a member of SFMMS?
Caring for patients in the clinical setting is the first step for every physician. Healthcare isn’t just about a patient being sick and making an appointment whether that is in a rural outpatient clinic or being rushed into a metropolitan emergency room. The factors that influence patients and physicians transcend a sole person or group of people. Government, society, culture, education, and business are all part of that dynamic that affects the doctor-patient relationship. These factors are influenced by passionate members like you who think about the
Interview by Steve Heilig, MPHbigger picture. Patient and physician advocacy is necessary to affect change and this change requires a team that SFMMS has had a long and esteemed history in making. Not to mention, where else will you meet physicians from so many different backgrounds working together towards a common goal? It’s great to see such enthusiasm outside the daily grind of anyone’s practice of medicine!
Can you tell us about any goals you hope to accomplish as SFMMS President?
SFMMS has grown in membership and geographic size over the last decade. The accomplishments are too numerous to mention. With this growth are growing pains as is to be expected of any organization. One of my goals is to strengthen our organization to meet any challenge that comes our way whether it's fighting legislation that is bad for patients and doctors or supporting our members in difficult economic times. By asking you to volunteer your time, resources, and debate, we can aggregate these resources to be efficient in accomplishing as much as we can for our members and patients. Your participation is an asset and we need to invest it to do even more. This involved improving the governance of the Society that the Immediate Past President embarked on to testing new ways to provide engagement and services to you. We also need to harness and educate our legislators on what the needs are. This doesn’t magically happen in the background. It takes a team of dedicated physicians and staff of SFMMS to make things happen!
What about you would surprise our members?
I love urban exploration and usually find the time to visit an abandoned building or two in every country I visit, much to the bewilderment of anyone who happens to be traveling with me. The problem is that I hate insects and am a germaphobe which is often not compatible with this kind of activity.
Any advice for new physicians transitioning into practice from residency?
Time passes quickly and only moves faster after residency. Decide where you want to live, the lifestyle you want, and the form of medicine you want to practice. Focus on how you can achieve that goal whether it's in the public health service, academia, military, consulting, group practice, or even solo! It’s all out there and possible because physicians are doing it every day. Some paths are harder than others, but as long as you set your goals, you will be able to achieve them. Don’t let anyone tell you that you cannot do it and channel you into what you think you are “supposed” to do. Chart your own path and use your education the way you see fit. And another shameless plug, join your local medical society!
If you weren’t a physician, what profession would you most like to try?
Food is culture. In my travels, I usually avoid the tourist areas and try the cuisine wherever the locals generally eat. I want to share that joy with others so I guess I would be a chef entrepreneur all over the world. If not, I would probably want to try urban planning and management because I am always complaining about how red and green lights could be timed better whether I am a pedestrian or a driver.
The month’s issue of the Journal showcases the advocacy of some of our members to influence the acquisition by UCSF of St Mary’s Medical Center and Saint Francis Memorial Hospital. UCSF is throwing the two hospitals a financial lifeline, but will it also recognize the heritage of these two hospitals, their role in providing community healthcare and the autonomy of their medical staffs?
The financial woes of St Mary’s and Saint Francis are a story shared by many hospitals today. Declining inpatient census coupled with increased costs of supplies and labor while facing static reimbursements have left many hospitals on the brink. And then there is the looming expense of California mandated earthquake retrofits.
In July 2023 it was announced that the UC Regents were going to vote on the acquisition of the two hospitals by UCSF. This acquisition would allow UCSF to decompress inpatient services by transferring or redirecting patients to the two community hospitals and free up beds for tertiary care referrals.
UCSF envisions that the two hospitals will continue to function as community hospitals but with increased bed census, improved payer mix, and increased access to specialty services. The hospitals will fall under the newly created UCSF Health Community Division.
The initial announcement of the acquisition also created uncertainty about the role of the hospitals and recognition of their value, heritage, and tradition of serving the community as well as the support for independent physicians in the community.
Physicians at St Mary’s formed the Save St Mary’s campaign immediately following the announcement of the acquisition. They publicized their concerns in the local media. They wanted to preserve St Mary’s as a community hospital, insure the rights of staff physicians in private practice, and preserve the heritage of St Mary’s, including its name, as a 150 year old Catholic hospital that has served generations of San Franciscans.
Michael Schrader, MD, PhDFrom the outset UCSF has issued assurances that the medical staffs would remain open, both St Mary’s and Saint Francis would continue as community hospitals, and there would be a separate governing board for the two hospitals within the UCSF system.
The name change argument was about brand recognition, historical pride, and community support. A small group of physicians from St Mary’s lobbied continuously for a voice in the largely opaque process of renaming.
And they ultimately prevailed. We may never know the machinations of the decision making or who even made the decision but ultimately the names of both hospitals are to be maintained as UCSF Health at St Mary’s and UCSF Health at Saint Francis.
Nationwide we are experiencing a raft of consolidations in the health care industry. Hospitals are being acquired by larger groups and physicians increasingly are employed by these groups. San Francisco is no exception. What remains to be seen is whether hospitals and medical staffs can be suzerainties within larger empires or whether they will be reduced to vassal states without their own governance.
The consolidation process is immense and probably unstoppable. What we as physicians can do is use our political capital to mold this into a system that preserves our voice as advocates for our profession and our patients. Our physician colleagues at St Mary’s have shown us the path.
Dr. Schrader, an internist at Dignity Health, is Chair of the SFMMS delegation to the CMA and a past-president of the SFMMS.
SFMMS Statement:
“The San Francisco Marin Medical Society and our 3,500 physician and medical student members applaud the University of California San Francisco and the community at St. Mary’s and St. Francis Hospital for the completion of their recently announced acquisition. SFMMS was pleased to see that both parties recognize the importance of physician autonomy and the need to preserve the facilities as community hospitals, ensuring needed services remain in the area. SFMMS looks forward to maintaining our strong relationship with the physicians and systems as they undergo this transition.”
As May marks Mental Health Awareness Month, it's an opportune time for the medical community in San Francisco and Marin to turn a keen eye towards an issue close to home: physician burnout. Traditionally, this month focuses on destigmatizing mental health issues and promoting resources and support. However, for physicians, who are often the frontline responders for mental health in others, the importance of assessing their own mental well-being becomes paramount.
Physician burnout is a growing concern, especially in highpressure medical environments. It's characterized by emotional exhaustion, depersonalization, and a diminished sense of personal accomplishment. The repercussions are far-reaching, impacting not just physicians but also the quality of care they provide, their personal lives, and the healthcare system at large.
This Mental Health Awareness Month, let’s recognize a few fundamental truths:
• Recognizing burnout as a systemic issue, not as an individual failing, can lead to more effective strategies. This includes implementing institutional changes like reduced administrative burdens, adequate staffing, and creating a more supportive work environment.
• The COVID-19 pandemic has added unprecedented strain on healthcare systems and providers. Many physicians are still dealing with the aftermath, including emotional trauma and increased workload.
• The Bay Area's medical professionals work in an environment where high standards, even perfection, are the norms.The demanding nature of healthcare leads to significant stress.
• There's often a stigma attached to mental health in the medical community, where physicians are expected to be resilient and emotionally invulnerable. Mental Health Awareness Month offers a platform to challenge these stereotypes and encourage physicians to seek support without fear of judgment.
Throughout the year, but especially during this Mental Health Awareness Month, SFMMS will share resources with our physician members, including opportunities to join workshops, seminars, and support groups focused on physician mental health. We encourage healthcare institutions in San Francisco and Marin to do the same.
Encouraging open conversations, providing resources for counseling and mental health, and fostering a community of support within the medical fraternity are crucial steps. The health of our physicians is integral to the health of our community. It's time to ensure that those who care for us are also cared for.
The long delayed CMA HoD finally took place virtually on February 10, 2024. The original meeting in October 2023 was canceled secondary to a labor dispute at the LA Live venue. The CMA was able to negotiate a full refund of more than $400,000 and county medical societies received reimbursements as well.
The required yearly organizational meeting, dubbed the Hybrid HoD, took place in November both in person and virtually with election of officers and approval of organizational actions. Dr. Shannon Udovic-Constant became President Elect and Dr. George Fouras was elected to Vice-Speaker. Dr. Lawrence Cheung was remembered for his service to the CMA.
The discussion of the three major issues was rescheduled to February 2024 by vote of the Council of Delegate Chairs and dubbed the Interim HoD. The major issues were Consumer Health Technology/Artificial Intelligence, Climate Change, and the Office of Health Care Affordability.
The Speaker, Dr. Jack Chou, and newly elected Vice-Speaker, Dr. George Fouras, opened with a humorous video of the intensive abbreviated training for George. George, dressed in camouflage yoga pants ran stairs and performed calisthenics in this rigorous preparation. He was instructed in the use of the gavel and was asked to perform tasks such as drawing the CMA logo.
Extractions for additions, deletions, and substitutions to the recommendations were submitted before the session electronically. Shorter extractions were submitted during the session. Polling of the delegates was done by an online voting platform and proceeded without major complications or delays. Dr. George Fouras was an able Vice-speaker and nimbly handled a parliamentary procedure challenge with the aplomb and good humor expected from an SFMMS-trained leader.
We established CMA policy on the three major issues creating a platform from which CMA can lobby to protect the interests of our community, our patients and our physicians. SFMMS started with an addition to an existing Recommendation that morphed into a new, separate Recommendation about creating educational resources for physicians and patients to implement the policy we had created about climate change. The Interim HoD stuck to a strict schedule and time ultimately ran out before our Recommendation could be voted on. The Recommendation then goes directly to the CMA Board of Trustees for consideration at its next meeting.
Other current activities of the SFMMS Delegation include
submission of Resolutions to the Year Round Resolution process. We currently have a Resolution about taxing alcoholic beverages to fund health care. California has one of the lowest taxation rates for alcoholic beverages. In addition, Dr. Michael Schrader submitted, as an individual, a Resolution opposing hate speech. Both resolutions are currently open for comment on the CMA website.
Dr. Schrader has announced that he will be stepping down as Chair of the SFMMS District VIII Delegation having served six years as Vice-Chair and Chair. There will be an upcoming election by the Delegation. Dr Ameena Ahmed has announced her candidacy for Chair.
Dr. Schrader, an internist at Dignity Health, is Chair of the SFMMS delegation to the CMA and a past-president of the SFMMS.
Ameena Ahmed, MD
Edward Alfrey, MD
Bryan Anker, MD
Mel Blaustein, MD
Andrew Calman, MD
Kristina Casadei, MD
Anne Cummings, MD
Mansi Desai, MD
Anthony Digiorgio, DO
Roger Eng, MD
Daniel Flis, MD
Gordon Fung, MD
Brian Grady, MD
Elizabeth Griffiths, MD
Opal Gupta, MD
Colin Hamblin, MD
Tracey Hessel, MD
John Huang, MD,MPH
Praneeth Janaswamy, MD
Kavon Javaherian, MD
Saman Kannangara, MD
Javaid Khan, DO
Michael Kwok, MD
Man-Kit Leung, MD
Jonathan Levin, MD
John Maa, MD
Robert Margolin, MD
Ian McLachlan, MD
Ben Meisel, MD
Cathlin Milligan, MD
John Nienow, MD
Nishita Nigam, MD
Heyman Oo, MD
Shilpen Patel, MD
Ellena Popova, MD
Sarita Satpathy, MD
Monique Schaulis, MD
Michael Schrader, MD
Emily Silverman, MD
Phillip So, MD
Dennis Song, MD,DDS
Peter Teng, MD
Melanie Thompson, DO
Christina Wang, MD
Elyse Weinstein, MD
Charles Windon, MD
Kristin Wong, MD
Andrea Yeung, MD
Haining Yu, MD
After confirming many elections experts’ fear that turnout would be low, the March 5, 2024, primary election saw mixed results on ballot measures, incumbents dominate their races, and razor thin margins that may lead to recounts. The Secretary of State has until April 12 to certify all results.
For the San Francisco Marin Medical Society, here are the main takeaways:
• Low turnout favored moderate/conservative candidates/causes.
• CMA/SFMMS-supported CA Proposition 1 (mental health facilities and funding) passed by roughly 20,000 votes out of more than seven million. While it was an extremely close call, the work now begins at the county level to secure newly available funds.
• SFMMS-supported Measure A (affordable housing bond) passed with just over the 66.6 percent needed (currently at 70 percent).
• SFMMS opposed Measure F (require addiction treatment for welfare recipients), which unfortunately, passed despite opposition from the medical community.
• Incumbents faced very little challenge to their seats.
Low voter turnout levels historically favor more conservative candidates and causes, as conservative voters have proven more reliable at turning out to vote. No greater example of this can be seen than in the statewide results for the U.S. Senate seat where the leading Democratic candidate Adam Schiff and Republican candidate Steve Garvey are in a statistical dead heat, despite the State’s overwhelming Democratic voter registration advantage. While most election experts believe Schiff will easily win over Garvey in the General election in November, the low turnout of the Primary election (and split democratic ticket) led to this currently close race. In San Francisco, the lean toward more moderate candidates/outcomes can be seen in the race for control of the Democratic County Central Committee (DCCC), the organization that decides party endorsements in superviso-
rial, mayoral, and ballot measures contests. The slate of moderates dominated, securing 18 of the 24 seats. This is a complete flip of four years ago, when progressives won all but two seats on the DCCC.
SFMMS took three positions during this election – supporting California Proposition 1 and San Francisco Measure A, while opposing San Francisco Measure F.
• Proposition 1 passed with a razor thin 50.2 percent to 49.8 percent margin. The ballot measure authorizes $6.38 billion in bonds to build housing and residential treatment facilities for people with mental illness; shift some county mental health dollars back to the State government; and increase the percentage counties must spend on housing for people with severe mental illness and addiction.
• Measure A, to sell $300 million in bonds to support affordable Housing, passed with 70 percent of voters saying ‘Yes’ and 30 percent saying ‘No’ (it required 66.7 percent support to pass).
• Measure F, to require drug screening and treatment to receive county welfare, passed, with 58 percent in support.
Other Election Results
• In Congressional races, incumbents Nancy Pelosi (San Francisco) and Jared Huffman (Marin) should easily cruise to reelection in the House of Representatives.
• In the open State Assembly race to replace San Francisco Assemblymember Phil Ting, Democratic Supervisor Catherine Stefani holds a commanding 57 percent to 29 percent lead over her nearest competitor, democrat David Lee, whom she will face in the November General Elections.
• In the other local State Assembly and State Senate races, the incumbents all cruised to easy victories, including Assemblymembers Matt Haney (SF) and Damon Connolly (Marin), and Senator Scott Wiener (SF).
• Two seats on Marin County’s Board of Supervisors are to be decided this year. The District 4 seat will continue to be held by incumbent Dennis Rodoni, who avoided a runoff by soundly beating Francis Drouillard, an engineer and former member of the Marin County Republican Central Committee. In the race to replace retiring supervisor Katie Rice in District 2, San Anselmo
City Councilman Brian Colbert and a former Kentfield School District trustee Heather McPhail Sridharan appear to be headed to a November runoff, with Colbert seven points shy of avoiding a runoff and Sridharan in second place with 26 percent of the vote.
• San Francisco Measure B, a police staffing initiative, looks very likely to fail with 72 percent of voters rejecting the measure.
• San Francisco Measure C, a tax cut on real estate transfers of commercial to residential properties, is winning but currently too close to call, 53 to 47 percent.
• San Francisco Measure D, which add further good government amendments to local ethics laws, is very likely to pass, currently sitting at 89 to 11 percent.
• San Francisco Measure E, to add flexibility to police policies and procedures (including additional surveillance abilities), is likely to pass, currently sitting at 54 to 46 percent.
• San Francisco Measure G, a nonbinding initiative encouraging the SF School Board to bring back Algebra 1 for eighth graders, is very likely to pass with more than 80 percent support.
Adam Francis is Senior Director of Policy and Advocacy for the SFMMS.
On February 9th, SFMMS hosted our Annual Gala at the California Academy of Sciences in San Francisco. The evening included the recognition of Heyman Oo, MD, SFMMS Outgoing President, for her dedication and leadership to the SFMMS membership and communities of San Francisco and Marin during her 2023 Presidency; the welcoming of Dennis Song MD, DDS, SFMMS 2024 President; speeches from local and national elected officials; and a talk by Robert Lustig, Professor of Pediatrics in the Division of Endocrinology at University of California, San Francisco.
We are thankful to our SFMMS members and leaders. We look forward to seeing everyone at next year’s SFMMS Gala!
Over the course of her decades-long service, Speaker Emeritus Pelosi has shown incredible foresight and bold leadership. She has stayed stalwart despite opposition, and she has fought for those who are often underserved and unheard – much like the San Francisco Marin Medical Society who convenes us today. Congratulations Speaker Pelosi and thank you to my longtime friends here at the medical society for recognizing her with this well-deserved award.
– Governor Gavin Newsom
Sid Borirak-Chanyavat, MD
Carlos Botas, MD
John Brown, MD
Nancy Carteron, MD
Kristoffer Chang , MD
Matthew Cushing, MD
Gina Gregory-Burns, MD
Alan Johnson, MD
Gregg Jossart, MD
Paul Katz, MD
Kevin Louie, MD
Robert Lowell, MD
William Montgomery, MD
Charles Moser, MD
Alison Niederer, MD
Maureen Park, MD
Michael Parnes, MD
Luke Perkocha, MD
Jacqueline Poggi, MD
Jordan Shlain, MD
Loren Stolle, MD
Mark Taylor, MD
Gamin Thomason, MD
Anna Webster, MD
Jerry Yang, MD
Stanley Yantis, MD
James Breivis, MD
Harold Ginsberg, MD
Stafford Grady, MD
Clement Jones, MD
Rose Louie, MD
Stephanie Lowe, MD
Craig Lubbock, MD
Helen Manber, MD
Marvin Quan, MD
Steven Snyder, MD
Avghi Thunstrom, MD
Ronald Ward, MD
William Berger, MD
Roger Boles, MD
Anthony Eason, MD
William Hoffman, MD
Russell Leong, MD
Leslie Lopato, MD
Robert Mithun, MD E.Myers, MD
Janice Patterson, MD Emanuele Rapicavoli, MD
James Reed, MD
Robert Riner, MD
Marc Schwartz, MD
Elisabeth Widman, MD
Kim Wu, MD
Mark Yanover, MD
Woodfin Norris, MD
Stuart Pickel, MD
C. Sciaroni, MD
Kathleen Unger, MD
Lola Van Compernolle, MD
Richard Welch, MD
David Werdegar, MD
Harold Brownstein, MD
Robert Bush, MD
Leo Cheng, MD
John Gartland, MD
Milton Louie, MD
Lawrence Margolis, MD
Eugene Mironoff, MD
Paul Carlat, MD
John Fletcher, MD
Morton Friedman, MD
Wayne Fung, MD
Bernard Gordon, MD
The Bay Area has the best healthcare in the country. We are home to two Top-10 medical centers, a doctor-to-patient ratio double the median for the U.S., and the sixthlowest mortality rate, resulting in the second longest life expectancy for any U.S. city. For acute medical care and trauma, you can’t do better than SF General. If you’re dying, this is the place to be. Yet despite our vaunted medical prowess, the medical profession hasn’t solved our biggest problem — not that anyone else has solved it for that matter.
The global crisis of chronic non-communicable diseases (NCD’s) continues to chew through lives and money in the U.S. and around the world. Despite clear knowledge of the diseases, their causes, and their consequences, virtually no headway has been made in stemming the tide of the NCD tsunami. For instance, the global burden of diabetes was estimated at 151 million individuals in 2000, 285 million in 2010, 422 million in 2014, 539 million in 2021, and is now expected to reach 563 million in 2030 and a whopping 785 million by 2050. Likewise, the burden of cancer and dementia continue at an unabashed rate, with no prospects of slowing down. Not only are the frequency and prevalence of these diseases increasing, but the age at which they tend to occur is getting earlier as well, thus increasing the cost of delivering healthcare to the affected populations, yet with fewer people able to pay into socialized health care delivery systems (e.g. Medicaid). The cost is bankrupting healthcare budgets worldwide, and placing untoward burdens on its delivery. It’s very clear, you can’t fix healthcare until you fix health. And we haven’t fixed health.
Once upon a time, people got sick, and they either recovered or they died. Then, in 1940, Albert Alexander, a London constable, was the first human to receive a dose of penicillin for an acute facial infection that had spread to multiple abscesses and claimed his eye, and which left untreated would have been fatal. The response was “remarkable,” but it didn’t last — the infection relapsed within six months, and death ensued a year later. Nonetheless, the “Golden Age of Modern Medicine” was born. Therapy targeted to the pathology. The right antibiotic killed the right bacteria, and people got better. Now, you could achieve cure. There’s a pill for that.
We still believe we’re in the Golden Age of Medicine, as we now use high-throughput screening of drugs, Big Data informatics, and genetic editing like CRISPR-Cas9 to target sickle cell disease, which will likely result in “cure.” We’re
programming an individual’s own immune cells to kill cancers in that same individual (CAR-T therapy). We are using robotics and cyberknives to reach surgical outcomes previously unimagined. All here in the Bay Area.
But these targeted therapies are not remotely addressing what is reducing lifespan and healthspan nationwide. Because today, for the chronic diseases that affect society — the cluster of diseases folded in under the umbrella term “metabolic syndrome” — that cost 75% of health care dollars in the U.S. and half of health care dollars around the world — are diseases of the environment. While NCD’s existed before 1980, individually and as a group they have skyrocketed in prevalence and severity, and all for the same reason — changes in the environment.
Furthermore, we thought health insurance would fix NCDs by providing easy access and mitigate catastrophic costs for healthcare. Instead, health insurance provides patients with carte blanche to exercise poor judgment, thinking “well, I’m covered,” known as “moral hazard.” Good health is an illusion in a population that smokes. But is that the failure of the individual, the failure of the society, or the malfeasance of the cigarette industry? More perniciously, food and pharma markets have been co-opted by dark forces specifically to drive poor judgment. This is “immoral hazard.” Well, the same thing is going on with metabolic syndrome and ultra-processed food.
Our current explosion of adult and childhood obesity came to public attention approximately 50 years ago, when it was noted that a stable childhood obesity prevalence curve morphed into a parabolic one. Currently, 19.7% of American children and 5.7% of European children are obese. The prevalence of adult obesity in the U.S. increased from 30.5% in 2000 to 42.4% in 2018.
The common wisdom — calories. Calories In, Calories Out. The standard interpretation of the First Law of Thermodynamics can be stated, “If you eat it, you had better burn it, or you’re going to store it.” That is, to maintain energy balance and body weight one calorie eaten must be offset by one calorie burned. In this interpretation, the behaviors of increased energy intake and decreased energy expenditure are primary, and therefore the weight gain is secondary. A corollary to this interpretation is that what you eat is your own choice; and whether you exercise or not, and how much you exercise, is also your own choice. Thus, we derive our standard societal mantras around obesity as gluttony and sloth, diet and exercise, and “personal responsibility.”
However, the above interpretation of the First Law does not explain many aspects of the obesity pandemic. 1) Why has body temperature declined over the last 150 years in the U.S.? This suggests a metabolic defect in mitochondrial function, and an involuntary reduction in energy expenditure. 2) Why are animals bred in captivity gaining weight over the last 25 years? This Suggests the presence of environmental obesogens (chemicals which cause weight gain) to which animals, as well as humans, are exposed. 3) Why is there an epidemic of 6-month-old obesity? Why do babies weigh 200 grams more than 25 years ago, and it’s all fat? This suggests epigenetic alterations in utero
Our group at UCSF and others have since documented the central role of high insulin levels, unrelated to calories, as a primary driver of weight gain. Children who became obese following therapy for brain tumors did so because their brains signaled their pancreases to release more insulin, and when we suppressed insulin release using the drug octreotide, both their food intake decreased and their physical activity increased, resulting in weight loss. Subsequently, we identified a subcohort of obese adults who exhibited increased insulin release in response to glucose administration, and who lost weight and increased activity in response to pharmacologic insulin reduction. More recently, the NIH showed that the same number of calories consumed as ultraprocessed foods would lead to weight gain, versus whole unprocessed foods which led to weight loss. Thus, the quality of the food is more important than the quantity of the food as it relates to weight gain and adiposity. The Standard American Diet, replete with ultraprocessed foods, acts as an endocrine disruptor to alter mitochondrial ATP production and drive both adiposity and fatigue.
Thus, the alternate interpretation of the First Law can be stated, “If you’re going to store it (i.e. an obligate weight gain driven by biochemical factors out of your control, such as high insulin), and you expect to burn it (i.e. normal energy expenditure for normal quality of life), then you’ll have to eat it.”
In this interpretation, the gluttony and sloth are secondary to the biochemistry, which is itself secondary to changes in the environment.
“Personal responsibility” infers that you take the risk, and that you suffer the consequences. After all, one’s body is one’s own property, and individuals are in charge of their own property. While this premise at first appears to be very “American,” it is not supported by either the Declaration of Independence nor the U.S. Constitution; and recent U.S. Supreme Court rulings (e.g. Dobbs v. Jackson Women’s Health Organization) cast doubt on this premise as well, which is really based on transactional history, not on legal or moral precepts. The table below is a compendium of global health crises that originally fell under the rubric of “personal responsibility.” However, each of these has since been reclassified as a “disease” and/or as a public health target.
It’s very easy, even for doctors, to view an individual with obesity or metabolic syndrome as “having made their own bed.” I would argue that “personal responsibility” is an ideological rubric for discounting or ignoring the misfortune of others. Nonetheless, societal neglect of the suffering of its most vulnerable citizens is pervasive in current Western societies. Numerous studies show that compassion for the obese goes right out the window. The question is, why? And why is it so prevalent now? A review of the tobacco industry literature reveals its origins.
The association between smoking and lung cancer was first made in 1950. In 1964 the U.S. Surgeon General issued his report on smoking and lung cancer. The tobacco industry initially responded with denial and rejection of culpability. With the passage of the Federal Cigarette Labeling and Advertising Act in 1966, individual lawsuits started to accrue. This spurred the tobacco industry in 1972 to develop a coordinated marketing strategy that focused on “assumption of risk;” implying that people now had the knowledge and the right to make their own
contnued on page 16
Table. Types of chronic diseases that require both individual and societal interventions for mitigation.
choices. It was not until 1982, and the onset of class-action lawsuits (e.g. Cippolone v. Liggett ) that the industry began to market the concept of “personal responsibility” as a reason to keep smoking, in which not only were people responsible for their own choices, but that they were also responsible for their own consequences.
To qualify under the rubric of “personal responsibility” for NCD’s like obesity, diabetes, and metabolic syndrome, four prerequisites must first be met.
1. Knowledge. One must be aware of the problem, the causes, and the consequences in order to be able to make a conscious choice. But what if the public is kept in the dark about the pernicious role of sugar and ultraprocessed food in causing obesity and chronic metabolic disease, and the industry’s role in fomenting it?
2. Access. One must be able to pursue either choice freely. However, in the U.S., many poor communities don’t have immediate access to healthy foods and products, termed “food deserts;” but actually they are “food swamps.”
3. Affordability. You have to be able to afford your choice, and society has to be able to afford your choice. Currently the Consumer Price Index is 50% lower for ultraprocessed products due to federal subsidies for corn, wheat, soy, and sugar. Conversely the CPI is 100% higher for fresh produce. However, the cost of obesity to the individual is much higher. Many poor people simply cannot afford to eat healthfully, and are coerced into the poor choice. The problem is that Medicare will be broke by the year 2026 due to the chronic disease burden associated with that poor choice.
4. Externalities. Your choice can’t hurt anyone else. Smoking morphed from a “personal responsibility” issue to a public health issue once the harms of second-hand smoke became known. Alcohol morphed from a “personal responsibility” issue to a public health issue due to drunk driving. So what are the externalities of obesity and diabetes? How about Social Security and Medicare bankruptcies, and lack of health care access with clogged emergency rooms with younger people having heart attacks, being diagnosed with cancer, on dialysis, and in nursing homes suffering from dementia.
“Personal responsibility” is perceived as a consequence of our inherent “freedom to choose” — which is predicated on choice being synonymous with liberty . However, in the courtroom, “personal responsibility” becomes “freedom to blame” as poor choice is synonymous with fault . Thus, by
reassigning liability to the consumer, corporations can invoke “personal responsibility” to skirt its own culpability. Insurance companies can jack up rates on obesity care delivery. It also makes it harder for the medical establishment to empathize with the victim; for instance, an analysis of orthopedic nurses demonstrates reduced motivation to care for patients they consider opioid addicts. By reassigning liability to the patient, doctors can invoke “personal responsibility” to skirt their own responsibility to educate and care.
Doctors need to be aware of their conflicted interests. Our job is health Healthcare subserves health , not the other way around. And in the case of NCD’s, health means public health, which means fixing the environment. It also means fixing our current insurance reimbursement paradigm, which is way broken. Medical, dental, and dietetic societies need to band together to demand that Washington fix the food. Doctors need to learn nutrition, which is not even taught in 72% of medical schools. Doctors need to learn some public health. It’s time for doctors to stop thinking about prescriptions and procedures, and start thinking about prevention
Robert H. Lustig, M.D., M.S.L. is Emeritus Professor of Pediatrics in the Division of Endocrinology, and Member of the Institute for Health Policy Studies at UCSF. Dr. Lustig is a neuroendocrinologist, with expertise in obesity, diabetes, metabolism, and nutrition. He is one of the leaders of the current “anti-sugar” movement that is changing the food industry. He has dedicated his retirement from clinical medicine to help to fix the food supply any way he can, to reduce human suffering and to salvage the environment, by interacting with all stakeholders to bring them together around a common vision of metabolic health: protect the liver, feed the gut, support the brain. Dr. Lustig graduated from MIT in 1976, and received his M.D. from Cornell University Medical College in 1980. He also received his Masters of Studies in Law (MSL) degree at University of California, Hastings College of the Law in 2013. He is the author of the popular books Fat Chance (2012), The Hacking of the American Mind (2017), and Metabolical (2021). He is the Chief Science Officer of the non-profit Eat REAL, he is on the Advisory Boards of the UC Davis Innovation Institute for Food and Health, the Center for Humane Technology, Simplex Health, Levels Health, Journeys Metabolic, and Myka Labs. He is also the Chief Medical Officer of BioLumen Technologies, Perfact, and Kalin Health.
Insurers, brokers, hospital administrators—for years, organizations have been playing a game of secret discounts that obscures the true cost of healthcare and drives up prices with no concomitant increase in quality. In an attempt to increase price transparency, the Centers for Medicare and Medicaid Services (CMS) began mandating in 2021 for hospitals to post standard charges on a publicly available website. The policy specifically requires (a) a single machine-readable file containing standard charges for all items/services provided by the hospital and (b) a consumerfriendly display or cost estimator tool with 300+ “shoppable services,” such as elective surgeries and X-rays.
Curious about this data, I went onto the websites of a dozen top hospitals on USNWR to take a look, and quickly found that there’s a new game being played: if hospitals are being forced to publish pricing information, how can they make it as difficult as possible for patients to find it? On most websites, CMSmandated items are buried behind layers of menus or within long paragraphs of text, requiring consumers to click through or scroll down multiple pages to locate what they're looking for (or give up). It’s actually faster to Google “<hospital name> price transparency” instead of starting from the website’s main page.
There’s also a second part to the game: how can hospitals meet CMS’s mandate requirements while making it as uninformative as possible? One particularly egregious case is an entity that uploaded their “consumer-friendly” shoppable services list as a CSV file with over 1,000 columns (which is more than Excel can display). Even when hospitals do better than a CSV file, there are still challenges with using their pricing data to make financially-informed healthcare decisions due to the high variation in shoppable services that they choose to post. Some hospitals publish cost data on X-rays, others do not; some include major surgical procedures, others only report biopsies. Even when similar services are posted, they use different coding
systems that prevent direct cost comparisons. Machine-readable files providing details on all hospital services may solve this inconsistency problem, but these files are just that: machine-readable. They’re often too large to open using standard software like Excel, let alone read through.
The issue is clear: healthcare prices may be available, but they're hardly transparent, and the result of CMS’s policy has done very little to foster market competition and drive down costs. Instead, it’s created a new game for insurance companies and hospital systems to play at the continued expense of patients. To improve this, CMS should set stronger mandates calling for standardized reporting and display of shoppable services, support for under-resourced hospitals in reaching this goal, and stricter penalties for entities that don’t comply. Price transparency will not be the only solution to the healthcare cost crisis, but it will be one step in the right direction by empowering patients to make financially-informed choices and making it that much harder for insurers and hospitals to play the game that they’ve been winning at for so long.
Stephanie is a first-year medical student at UCSF with broad interests in health policy and machine learning in medicine who hopes to work towards making healthcare more affordable and accessible.
From the dawn of civilization, women have been central to the healing arts. By tracing the arc of history, we can finally realize the indispensable contributions of women in medicine. History has always been written by men about men, but even so we find records from Egypt, dating to 1500 B.C. that attest to women receiving medical education at the prestigious Heliopolis Royal Medical School. The works of Metrodora, a Greek physician between 200-400 C.E., are the earliest known medical text authored by a woman and she pioneered surgical treatments for breast and uterine cancers.
In the sanctuaries of ancient Greece, with over 300 temples honoring Hygeia and Panacea with statues, both men and women in the roles of priests dispensed medical advice and treatments. Similarly, during the Roman era, women physicians were common. They ran practices and were considered peers to their male counterparts. This parity is echoed in the numerous memorial inscriptions for these women healers found on tombstones.
Wealthy aristocratic women were also instrumental in developing hospitals. A notable example from the fifth century is the hospital founded by Empress Eudoxia in Jerusalem. However, by the seventh century, the advent of male physician guilds marked a shift, systematically marginalizing women from the field. This exclusion reached a tragic zenith during the 15th century inquisition with skilled female herbalists and community leaders persecuted as witches. The message was clear—it was not wise to challenge the prevailing male power structure in the Middle Ages, regardless of your knowledge, if you were a female. The last witch burned in Germany in 1775 stands as a grim marker of this era.
It’s no surprise that it took almost another hundred years for women to emerge again in traditional medicine. It was not until Elizabeth Blackwell graduated from the Geneva Medical College of New York in 1849 that the presence of women physicians in the United State began to reemerge. Coinciding with the California gold rush of 1849 and the burgeoning suffrage movement, the first woman to practice medicine in California was Elizer Pfeifer Stone, in San Francisco in 1863. The specifics of her credentials are in doubt, but she was likely Germanborn and trained and had practiced in New York before settling in California. In 1864 the first black woman to graduate from medical school was Rebecca Lee Crumpler (1831-1896).
Toni Brayer, MDShe battled deep-seated prejudice against women and African Americans. After the Civil War, she cared for freed slaves who had no access to medical care.
The first Native American woman, Susan La Flesche Picotte (1865-1915) practiced medicine in 1889, 35 years before Native Americans were recognized as US citizens. As a child she witnessed a sick Indian woman die after a white doctor refused to treat her and she was inspired to do something. Do something she did; campaigning for public health and the treatment of TB for people of the Omaha tribe, caring for thousands of indigenous people on the reservation and in government schools, while being paid a salary of $500 a year.
Dr. Charlotte Blake Brown, an 1874 graduate of what is now known as the Medical College of Pennsylvania, was a California resident who traveled east for an education. With two other women physicians, she founded the Pacific Dispensary for Women and Children in San Francisco, which became Children’s Hospital and was the first hospital to offer internships and residency training to women in the West. I did my Internal Medicine Residency at Children’s Hospital before it merged with Pacific Presbyterian to become California Pacific Medical Center. The IPA physicians group took Dr. Brown’s name to form the Brown and Toland Medical Group.
Lucy M. Field Wanzer raised money to attend medical school by learning telegraphy and opening a telegraph office. She became the first woman to graduate from the University of California, San Francisco School of Medicine after being rejected in 1873. She was told that any woman who wanted to study medicine should have their ovaries removed to which she replied that male students should have their testicles removed. Doctor R. Beverly Cole, (the male president of SFMS) had opposed her persistent efforts to gain entry to the medical college.Finally, apparently intrigued by the spunk with which she withstood all attempts at hazing, he offered her a preceptorship in his office. That same year, five women physicians were admitted to the California State Medical Society at its San Francisco convention. Dr. Lucy Wanzer became a member of the San Francisco Medical Society the next year.
The remarkable opening of the practice of medicine to women in the second half of the 19th century was followed by an equally remarkable slamming shut of the doors in the early 20th century. Women in medical school classes after the 1910
Flexner report were a rarity. In 1971, Dr. Roberta Fenton must have looked out in the great hall at the CMA convention and seen only men staring back at her, as there were almost no women office holders throughout organized medicine in those years, and hardly any women doctors in practice. Dr. Roberta Fenton became the first woman president of the CMA.
The number of women entering the medical field started to pick up again in the 1970s—during the second wave of feminism in the U.S. Only five percent of practicing physicians were women in 1970. Female medical students faced internal challenges over role conflict, stress, anxiety, isolation, resentment and harassment. Many hospitals did not have changing rooms for women surgical residents. They were not allowed to wear scrubs and had to wear nurses’ dresses and stockings. Although the Civil Rights Act was passed in 1964, female applicants were asked illegal and inappropriate questions during interviews, including about personal relationships and plans for pregnancy. Even so, by 1990 women represented 29 percent of doctors. The numbers in the education pipeline really tell the tale. By the 2004 academic year, women represented 50% of all med school acceptances.
Now that there is a critical mass of women physicians in practice, academia and research, we are seeing the fruits of these open doors. Women leaders have been at the forefront in policies that address gender disparities, promote women’s health issues and workforce diversity. We have spearheaded maternity leave policies (which benefit men also to be home with new families), domestic violence education and legislation, basic research into women’s health, prison medicine and renewed focus on public health and rights of children. Women physicians have won Nobel prizes, discovered enzyme telomerase, developed a rapid test for HIV/AIDS, pioneered mRNA vaccine technology and identified the genetic mutation responsible for Rett syndrome. Women have discovered cell cycle regulatory proteins and their implications for cancer treatment. They pioneered research on neural stem cells to treat neurodegenerative diseases and Alzheimer’s. The list goes on and on, contributing greatly to improved healthcare outcomes and quality of life for people around the world.
Despite these recent strides, however, women assuming leadership in medicine is far from complete. We have a long way to go before we are recognized as equals to men in this healing profession. The demands of practice and research that coincide with a woman’s childbearing years make it difficult for women to advance in academic medicine and in a position of leadership. The traditional work hours, lack of mentoring, advancement protocols and committee structure are not conducive to women assuming leadership positions or advanced faculty status. Even after multivariable adjustment there is a large and statistically significant earning difference between women physicians and men to the tune of $2 million in their respective lifetime careers. The glass ceiling is still intact.
As a wife, mother, physician, former chief of staff and CEO, I felt it was essential to get involved and to make the effort to have a greater impact on the issues I feel passionate about. That’s why, back in 1985, I made the decision to become active in organized medicine. At The San Francisco Medical Society, I broadened my world view and learned leadership by becoming a CMA delegate and then in 1996 becoming the 3rd woman President of SFMS. I realized both then and now, how difficult it is for women physicians to achieve balance in their lives, as well as try to take leadership positions in our profession. But it is worth it. The history of women in medicine shows us just how far we have come and gives us the long view of how much more there is to do.
We can have great impact upon our patients, our colleagues and our communities by holding the door to medicine open with one foot—allowing our sisters to follow—with the other foot stretching upward to kick at the glass ceiling until the cracks begin to appear.
Dr. Toni Brayer practices Internal Medicine at CPMC. She is a former President of SFMS and Editor of SF Medicine. She and her husband are currently ranked #3 in the country for their age group in husband-wife tennis.
"Youth mental health is the defining public health crisis of our time."
– Vivek Murthy, US Surgeon General
I’m a doctor. A doctor’s toolbox includes medical education and training, a license to diagnose, and the ability to recognize ailments and prescribe treatment. So, when a colleague suggested that unlicensed folks with lived experience might be as good or even better at meeting the needs of people who are struggling with their mental health, you might think that I’d be skeptical. What tools would untrained individuals have in their toolboxes?
To be sure, there is a crucial need for more mental health care support in our country. Today, 157 million Americans (48%) live in areas with a shortage of mental health providers. Limited provider capacity means that of the 46% of young adults who have diagnoses of substance abuse or mental illness, 55% of them receive no care.
We have all encountered, personally or professionally, the staggering wait times for mental health support. The average wait time to see any mental health provider is one to three months and up to six or even 12 months in some cases in the Bay Area and elsewhere. And for historically underserved communities, including BIPOC and LGBTQ+ populations, finding a culturally sensitive provider can be even more challenging.
As a pediatrician, I have always told my patients and their parents that they need to build a village of support around them. And as a physician, I know I need a team around me to take care of patients. As I looked at the literature on peer support, I realized that the model of connecting folks who have lived through the same struggles has been helping people for decades outside of clinical settings. Communities for people who are mutually struggling with grief and addiction, for example, are trusted and commonplace. No one can better understand what it is like to lose a loved one or to hit rock bottom than someone who has been there, too.
It’s why groups of people continue to gather week after week, year after year, in church basements and rec centers, to support each other in ways that friends or doctors never could. It’s why people living with mental illness connect online to support and empower each other.
Lived experience is a tool only a peer has in their toolbox—and it can be as valuable as a doctor's handbook or prescription regarding mental health. I began to wonder: what kinds of mental health outcomes could be unlocked if peer support was available at scale for folks living with other types of mental health struggles, such as eating disorders, depression, or anxiety?
Peer support is powerful. Research has proven peer support to be an evidence-based practice that can significantly improve mental health outcomes, especially among college-age students and individuals from historically underserved communities, including Black, Transgender, and firstgeneration college students. Research from Mental Health America shows peer support leads to:
• Increased hopefulness and sense of well-being
• Increased activation
• Increased ongoing engagement with care
• Improved self-care
• Increased social functioning
• Decreased substance use and depression
• Decreased hospitalization, use of in-patient services, and costs to the mental health system
Peer support is the gift of sharing life experiences with someone who has lived the same truth. Peer supporters model wellness, personal responsibility, self-advocacy, and hopefulness by sharing their stories and embodying recovery.
Realizing the value of peer support put me on the path to cofounding Flourish Labs and creating Peers.net. We are a mental health company growing the workforce by hiring people with experience of mental health challenges and training them to become certified peer supporters.We are proud to be a CalMHSAapproved training provider for Medi-Cal Peer Support Specialists.
On our telemental health platform Peers.net, people seeking support can choose from a diverse group of supporters. Through our matching platform, they can choose not only a supporter who shares lived experience of mental health issues but also var-
ious life identities, from ethnicity or gender and sexual identity to experience of childhood trauma or with the foster or juvenile justice system.
As we work towards insurance reimbursement, sessions are available on a self-pay basis at a rate far below therapy rates, and we have a scholarship program for adolescents and young adults who cannot pay. Because we want our services to reach vulnerable youth who are unlikely to have the ability to pay, we also have a GiveBack program and deliver free peer support sessions in partnership with both national organizations like Active Minds and local organizations like Compass Family Services and the Boys and Girls Club of San Mateo.
But does it work? And is it safe? We aspire to create the most robust supervision and quality program among peer support organizations. We use a combination of human supervision and AI to ensure that the support we deliver is safe and that our peer supporters are continually learning. We do warm handoffs to licensed crisis experts when needed, and have escalation pathways in place to ensure that, alongside peer support, our clients are plugged into a care team when necessary. We follow quality measures like access, engagement, and patient-reported outcomes, including therapeutic alliance, perceived session effectiveness, and patient experience. We are inviting external investigators to independently evaluate the efficacy of our care, starting with a randomized control trial to assess the clinical effectiveness of our care that began enrolling in early February out of UC Berkeley.
We support youth and young adults from ages 13 to 30. We train our peer supporters to support the entire continuum of mental health needs. They can be utilized as a front door to healthcare, starting with low acuity care like support around stress at school, friendship or relationship difficulties, or difficulties with transitioning to higher education or a job. Peer support at this stage can prevent the development of more serious mental health struggles. Peer support is often a low barrier, more accessible entry point to mental health care for communities in which mental health support carries a great deal of stigma.
We also support mild to moderate issues like depression or anxiety. And peer support is effective as an adjunct to a broader care team for severe mental illnesses from bipolar disease to
schizophrenia. In California, one in three hospitalizations and one in five ED visits are due to mental health. HCAI.ca.gov
In partnership with care teams, we can deploy our peer supporters to support patients discharged from an inpatient setting or the emergency department or as step-down or follow-up care after intensive outpatient or partial hospitalization programs. These patients are often discharged into a void, and peer support can keep them on track and engaged until they receive definite care and can continue as an effective lower-cost “maintenance” treatment to prevent remission or relapse. Only 31% of youth receive follow-up within seven days of ED discharge, and 27% return to the ED within six months.1
One of the most potent aspects of peer support is the potential to address gaps for particular patient groups, like youth, and provide culturally sensitive care for underrepresented groups like BIPOC and LGBTQ+ folks. Our telehealth peer support also helps reach people in rural areas and other mental health deserts. In order to meet the needs of these vulnerable youth, we designed Peers.net with extensive youth and young adult participation. Peers.net represents a powerful example of co-creation in action, demonstrating how young people's voices can lead to innovative and impactful solutions for their mental health needs.
Approximately 75% of mental health issues present before the age of 24. With early and effective treatments, we can prevent years of suffering, difficulties holding a job or supporting a family, and deaths by suicide. We believe that by building a diverse workforce of trained young people who support each other, we can help build a future where all young people have access to the support they need to thrive.
Kim Newell Green, MD is a pediatrician, Chief Medical Officer and Cofounder of Flourish Labs, Board Member of California Medical Association and Past President of San Francisco Marin Medical Society, and humbled mom of two gorgeous but challenging tween and teen girls from whom she learns a lot about mental health.
For decades, Marin Health Medical Center (MHMC) has been the primary hospital treating cyclists injured across Marin County. Research from the Marin Health Trauma Center has contributed to important aspects of safe bicycle riding. In 2022, a new public health hazard was recognized with electric bikes–also known as e-bikes. Over the four years of the pandemic, the MHMC emergency room and trauma service witnessed a dramatic increase in trauma activations for e-bike accidents resulting in serious injuries and fatalities. This emerging hazard motivated MHMC healthcare professionals and the Marin Healthcare District Board (MHDB) to work proactively to raise awareness about the hazards of e-bikes to protect both youth and adult riders.
elected officials with the intent to catalyze new legislation to address the special dangers, particularly among kids. Class 1 and 2 e-bikes are often being ridden improperly by children under 16 without a helmet, and on inappropriate surfaces like park pathways where they are forbidden. In March of 2023, SFMMS President Heyman Oo testified before the Mill Valley Town Council in support of new regulations to curb risky behaviors by youth e-bike riders (actions like moving against traffic or riding without a helmet), and require them to attend a safety course if cited.
A review of the MHMC Trauma Registry1 revealed that riders in an e-bike accident were more likely to require hospital admission than those injured from a regular bicycle (despite a similar injury severity score), with an order of magnitude higher risk of death (head injuries were the most common mechanism of death). More than 10% of patients that presented to our Trauma Center after an e-bike crash expired from their injuries, as compared to less than 0.3% of those riding a pedal bicycle. The injury pattern includes pelvic fractures, which are more commonly seen in motorcycle riders. And while the deaths have all been in our older population, younger adults and kids have suffered severe disabling injuries. Data from the National Electronic Injury Surveillance System confirms this local observation, and demonstrated that e-bike riders have a materially different risk and injury profile from riders of pedal bicycles.2
In December of 2022, the Marin Healthcare District Board passed Resolution MHD 2022-08, which urged state and local agencies to 1) study current e-bike safety risks and how they might be effectively mitigated by best practices regulation, and 2) develop and deploy coordinated educational resources for riders of e-bikes. The resolution was distributed widely to
By September of 2023, the ongoing injuries and disability witnessed at MHMC prompted a meeting with Marin Health and Human Services and local elected officials (including Marin County Supervisor Mary Sackett and Marin Assemblyman Damon Connolly).
The poignant story of a young Marin child injured after being thrown from a Class 2 e-bike was an inspiration for Assemblyman Connolly to introduce AB 1778 to restrict kids under the age of 16 from operating a Class 2 e-bike, which can reach a top speed of 20 mph with a throttle alone. Caution would advise that young kids should not operate a motorized bicycle that can travel at moped speeds, and that new regulations should match existing laws prohibiting youth under 16 from operating Class 3 e-bikes. In December 2023, SFMMS Immediate-Past President Dr. Heyman Oo spoke at a Marin Civic Center press conference where AB 1778 was first announced, and shared the rising accounts of disability and serious injury resulting from e-bikes.3,4 The Marin County Bicycle Coalition and American Academy of Pediatrics joined in support.
SFMMS surgeons in both Marin and SF have worked with American College of Surgeons members across California and nationally to gather the existing data and raise awareness among policymakers of the emerging trends. The popularity of e-bikes has clearly led to a significant increase in riders involved in crashes over the last three years, and the serious injuries and
deaths continue. There has also been a dramatic increase in the alarms raised through news media outlets regarding the safety of e-bikes, and the need for regulation.
The central intent of evaluating the MHMC trauma database was to understand the impact of e-bike crashes in our community, and to elevate awareness of e-bike safety as a priority in Marin and California. This enabled SFMMS to champion statewide legislative efforts to address this emerging public health danger, and five bills have now been introduced in the Spring of 2024 to promote e-bike safety. Our hope is that rather than taking a passive response using distracting narratives, that California can lead the way with national legislation to protect our vulnerable children and aging adults from the inherent dangers associated with e-bikes.
Dr. John Maa is a staff surgeon at Marin Health Medical Center, and was the 2018 President of the San Francisco Marin Medical Society. He Co-Chairs the American College of Surgeons Joint Advocacy Committee for California.
Dr. Ed Alfrey is the Chair of Surgery and Trauma Medical Director at Marin Health Medical Center and a Member of the SFMMS Board of Directors.
1) Maa J, Alfrey EJ. Marin Voice: Trauma surgeons make plea for more e-bike safety. Marin IJ December 6, 2023.
2) Fernandez AM, Li KD, Patel HV, et al. Electric Bicycle Injuries and Hospitalizations. JAMA Surg. Published online February 21, 2024. doi:10.1001/jamasurg.2023.7860
3) Sackett M, Oo H. Marin Voice: Supervisor teams up to put focus on safe e-bike behaviors. Marin IJ December 14, 2023.
4) ABC 7 News. Bay Area lawmaker proposing restrictions on electric bikes for minors. December 23, 2023. Accessible online at https://abc7news.com/electric-scooters-bikes-proposalage-limit-kids/14219009/
San Francisco budgeted $597 million for behavioral health in the past fiscal year. Of that, $75 million went toward substance use treatment programs. So, did this government spending work?
By one key measure, the drug epidemic is getting worse. In the first seven months of 2023, 473 people died from drug overdose, and the city appears on pace for another year of record deaths. But this measure proves too crude. Absent our millions in taxpayer spending, it’s possible the impact of the drug epidemic could be even greater. We know these dollars help fund 595 substance use treatment beds, divided into 78 for withdrawal management, 246 for residential short-term stays and 271 for residential step-down. The city contracts with nonprofits such as HealthRight 360, the Salvation Army and the Latino Commission to operate these beds and programs. We also know bed demand remains high. The city deserves credit for substantially expanding treatment beds amid the challenges of the past few years. Nonetheless, only a handful of residential treatment and step-down beds are available on any given day, and patients frequently wait days to secure one. Withdrawal beds have better availability but are intended only for acute detoxification, not long-term recovery.
prise because the audit was never meant to measure quality but rather to conduct fiscal monitoring.
The absence of quality measurement, analysis and improvement is precisely what should change. At a public hearing last year on city-funded nonprofits, Supervisor Catherine Stefani declared, “At a bare minimum, we need to know the impacts of the services the city funds.” Earlier, Stefani made good on that statement by introducing legislation to audit the $1.7 billion in city funding to all community-based organizations, including substance use treatment providers. This follows revelations that the city paid over $25 million to organizations with revoked, suspended or delinquent nonprofit statuses and that HealthRight 360 temporarily suspended intake for substance use treatment due to short staffing.
Still, the question remains. Is our government spending working? As a health care provider in multiple San Francisco hospitals, I’ve treated a spectrum of patients at the center of San Francisco’s overdose crisis: The patient with debilitating addiction who quit after completing a program and even became a counselor to others, the patient who went through multiple programs only to relapse each time and even the patient who swears to never go into a program again and chooses to take their chances on the street. It’s the latter who made me wonder — when I discharge a patient from the hospital to a residential treatment program, what are their chances of overcoming addiction? What is their experience going to be like? Are some programs better than others and for whom?
The Department of Public Health does intermittently conduct audits. Last year, its audit on HealthRight 360, the city’s largest substance use treatment nonprofit, said: “We are pleased to report that there were no findings identified in our fiscal and compliance monitoring.” This is hardly the kind of scrutiny on process and outcomes we need. But this comes as no sur-
Stefani’s legislation would subject nonprofits receiving contracts of $750,000 or more to annual audits and for city contracts to include “measurable objectives.” Mandating “measurable objectives” is an important step toward accountability but may lack the specificity to ensure accountability in practice — especially in regard to substance use disorder outcomes. That’s why, as a researcher who studies how the health care system can deliver better care at a sustainable cost, I propose amending the Mental Health SF law to require specific quality reporting and annual review for effectiveness. This change has the potential to bring transparency, facilitate accountability and provide insights for future policy.
Consider that in almost all other realms of health care, such as when patients are admitted to the hospital, numerous qualityof-care measures are recorded. Recent Medicare reimbursement overhauls require certain measures to be reported. Adjustments to some reimbursements are then made based on performance. Shouldn’t San Francisco and its leaders want similar accountability for the nonprofits it sends millions to annually and entrusts with holding the front lines of the drug addiction epidemic? Some work is underway. The Department of Public Health’s 2023 mental health implementation plan focuses its residential treatment evaluations on bed optimization and wait times. However, the plan fails to mention measuring the quality of individual programs.
I propose four broad areas for measuring the quality and effectiveness of city-funded substance use treatment programs: process, outcome, experience and equity.
Process refers to what services a program provides and whether a program actually performs the functions the city wants. Examples might include providing program residents with one-on-one social work consultation or offering appropriate medication-assisted treatment (e.g., buprenorphine for opioid use disorder). These measurements could help identify which nonprofits are pursuing best practice innovative services that differentiate programs.
Outcome refers to how patients fare during and after a program and how the program performs. Examples might include the percentage of participants who complete the program and the percentage of participants whose substance use disorder is in remission at a six-month follow-up. Or it could mean the housing status of participants upon their discharge from a program or dollars spent per client day.
Experience refers to participants’ subjective experiences, which could be compiled by quantitative ratings and/or qualitative reports. The importance of participant experience cannot be understated because the path to remission commonly involves relapse. When a patient has a positive experience, it can facilitate openness and desire to pursue treatment in the future.
Equity refers to whether disparities exist in outcomes among different sociodemographic subgroups and what actions are taken to mitigate inequities if they exist.
Developing and conducting these measurements appropriately can be difficult. Nonprofit providers should be involved in the process because they bring expertise on feasibility and utility. The amendment to Mental Health SF could further direct the law’s implementation working group, which was created to advise city leaders on the design, outcomes and effectiveness, among other functions, as well as the development of specific metrics and monitor performance. Expanding the group to include people with relevant expertise may be necessary.
Just as with hospitals, the purpose is not to penalize but to ensure accountability, identify best practices and facilitate continuous improvement. Measuring processes and outcomes could even help illuminate areas where additional public investment is needed, such as housing for individuals completing treatment. To be sure, implementing these changes would add costs and regulatory burdens. Resources would be needed to measure and improve quality. San Francisco may need to provide upfront support to help nonprofits scale up their expertise and information technology infrastructure. The consequences of not pursuing accountability include continued spending with little certainty of effect, missed opportunities for improvement and further public mistrust in government. Looming large are the recent taxpayer bailouts of Baker Places and the Positive Resource Center and the possible takeover by HealthRight 360 to sustain operations.
San Francisco residents deserve assurance that their public dollars are being spent judiciously. People suffering from substance use disorder need treatment programs that work. Our leaders ought to want the same. What do we get for our $75 million in substance use treatment spending? I say, let’s find out, and let’s bring accountability.
Brandon Yan, MD, MPH is a resident physician in San Francisco and a public health researcher trained at the UCSF School of Medicine and the Harvard T.H. Chan School of Public Health. Born and raised in San Francisco, he has published widely on health policy and public health issues. A previous version of this piece appeared in the San Francisco Chronicle. The author’s views are his own.
It gives us great pleasure to voice our support for the acquisition of Saint Francis Memorial Hospital and St. Mary’s Hospital and Medical Center by the University of California, San Francisco. We are pleased that UCSF is committed to working closely with the medical staffs of both hospitals to assure a successful union, retain existing services, maintain the community hospital concept to ensure patients have convenient and ready local access for their primary and specialty care needs, while curbing the ever-escalating cost of medical care.
A group of dedicated physician leaders at St. Mary’s Hospital and Medical Center have been working long and tirelessly in collaboration with our UCSF colleagues to this end. At a time when communities are losing health care options, this deal preserves local care by ensuring that two of San Francisco’s longest-serving community hospitals, and the unique services they provide, will remain accessible to San Franciscans, while preserving the names assures that their legacy is not forgotten.
St. Mary’s Hospital has served San Francisco for more than 166 years. It is the oldest continuously operating hospital in San Francisco and probably the state of California. At the present time, the patients and the healers of this community are not predominantly Catholic. They are represented by a vast array of religions and spiritual beliefs, reflecting the demographics of San Francisco, and well beyond the Bay Area. The physicians, nurses, and supporting staff understand the need to shed our Catholic label, and embrace a more open, secular tone. However, the historic dedication of the Sisters of Mercy, and their contribution to the health of San Franciscans past and present should be recognized, and not forgotten.
Also not to be forgotten is St. Mary’s contribution and advances to the field of medicine over the years. From the beginning of St. Mary’s Hospital on Stockton Street in 1857, the cofounders Dr.. Beverly Cole and Dr. Levy Cooper went onto to be the founders of UCSF School of Medicine and Stanford Medical School, respectively. St. Mary’s contributions to health care did not end in 1857. Dr. Richard Welch’s advances in hip surgery remain the standard today; Drs. Ken Hsu and James Zuckerman’s
invention of the “X-Stop” gave rise to the idea of minimally invasive spine surgery; Dr. Elias Hanna’s use of the internal mammary artery for aortocoronary bypass graft surgery is today common practice; the first angioplasty for the treatment of coronary artery disease in 1979 by Dr. Richard Myler revolutionized the treatment of heart disease. These examples are but a few of the many contributions by St. Mary’s doctors under the auspices of the Sisters of Mercy. By keeping the name “St. Mary’s” UCSF acknowledges the importance of this legacy.
Moreover, UCSF Health is committed to the retention of the employees of both hospitals and the open medical staff model. Ensuring local doctors can continue to practice at each location preserves critical long standing patient-provider relationships and supports San Francisco’s diverse medical community. We believe the melding of these institutions will make care better for patients and meet our community’s health needs in an integrated and equitable way.
Ranked as one of the top hospitals in the United States and a world-leader in innovative research, and one of the highestranked medical schools in the country from where many of our colleagues at St. Mary’s graduated, UCSF also brings to Saint Francis and St. Mary’s increased access to life-changing clinical trials, and access to specialized services which may not be available in some community hospitals. Combined with St. Mary’s medical residency training program, this union will assure a plentiful next generation of health care providers.
As providers at St. Mary’s and St. Francis hospital, we look forward to continuing to meet the health care needs of San Franciscans in an integrated way, in partnership with UCSF. We support this deal to advance the health of San Franciscans, and far into the future.
Furthermore, we especially would like to thank the San Francisco Marin Medical Society for their advocacy and support in our endeavor to preserve the legacy of St. Mary’s Hospital.
Remo L. Morelli, MD, FACC is President and Eugene Groeger, MD, FACS is Vice-President, Medical Staff, St. Mary’s Hospital and Medical Center.
The Honor, Love & Respect our Seniors program was announced on February 12, 2024 at the Chinatown Media & Arts Collaborative. This is a joint project sponsored jointly by On Lok, Self-Help for the Elderly, Chinatown Community Development Center, the All American Medical Group (AAMG), and the SFMMS. This is a new program to address the growing problem of violence directed toward seniors in our Asian American Community.
Speakers were Supervisor Connie Chan, San Francisco Board of Supervisors, District 1; Anni Chung, President and CEO, Self-Help for the Elderly; Grace Li, CEO, On Lok; Malcolm Yeung, Executive Director, Chinatown Community Development Center; Dr. Joseph Woo, President AAMG; and Dr. Michael Schrader, Past President, SFMMS.
The speakers addressed the random and gratuitous violence and harassment inflicted on Asian American seniors. But they also described the value, influence and experience of the senior community.
Anti-Asian American violence has been connected to the geographic origins of the Covid virus, but the history of antiAsian racism in California goes back to the Gold Rush.
This campaign grew out of discussion forums organized by Anni Chung and Dr. Joe Woo. The fundamental question was what can we do about hatred, racism and violence directed at Asian Americans? Stand up to it, speak out against it, bear witness, and offer solace to victims.
The victims of racism suffer isolation, fear and depression. We can reach out to them as a group and as individuals. Comfort them, reaffirm their value, let them know they are not alone, and let them know they are welcome. And honored. And cherished.
The Honor, Love & Respect our Seniors campaign aims to reach out to seniors and affirm their value to our community. It will begin with Chinese radio interviews with seniors extolling their experience and wisdom. The next phase is a youth writing forum to express reverence dubbed Senior Love Letters. There is a spring Banquet Celebration for seniors in Chinatown in late March.
– Michael Schrader, MD, PhD
In 1963, my dad, then a 20-year-old chemistry student at UC Berkeley and oldest brother of eight, drove his motorcycle cross-country from San Francisco to Florida to visit family. However, tragedy struck when he was involved in a head-on collision with a truck, leaving him in a monthslong coma with multiple fractures including both femurs, pelvis, wrist... My grandmother immediately went to Florida and once my dad was stable, drove him, casts and all, back to San Francisco where he received further surgical treatment of his extensive injuries at UCSF hospital. Sometime during his hospitalization Ron Whyte became his roommate and one of my uncles recounts that Ron was very important to my dad and really helped him through his long hospitalization.
I was born a decade after my dad’s accident and for as long as I can remember, this phenomenal gift by and from Ron Whyte hung over my dad’s desk in his study. My dad never spoke about his accident because, I believe, the experience was so painful, however, after my dad’s premature death from renal cancer at age 69, I learned (from Wikipedia) that Ron Whyte (1941-1989) made quite a name for himself as an American playwright, critic, and disability rights activist. I further learned that Ron was also at UCSF to undergo then-experimental bilateral-leg amputations for congenital and traumatic injuries to his legs. My father cherished Ron Whyte’s gift and, I believe, Ron Whyte’s pivotal
friendship during what was likely the most traumatic time in my dad’s life.
These fundamental truths depicted in Ron Whyte’s timeless gift, when Ron was merely 22 or 23 years old, are a testament to Ron’s remarkable knowledge and insight into social justice; Ron understood that human-connection is essential, that health-and-wellness is a human right, that environmental justice and conservation are necessary for our sustainability, and that gun violence and police brutality sabotage our humanity. I believe that my dad, at age 21, vehemently agreed with Ron and that is why this gift was forever at the center of my dad’s “study.” I also believe that Ron’s gift is part of the reason why I have spent nearly three decades unraveling the science of democracy and social justice; I only wish that my dad and Ron were here to engage in more intellectual collaboration regarding our shared purpose and passion to right the wrongs of society and to achieve widespread humanity.
Mihal is a practicing family medicine physician and UCSF volunteer clinical faculty with copyrights and publications describing the science of social justice and democratic public policy, which she uses to advocate for social justice reform and civil rights protections
Patients are increasingly seeking an integrated approach to their health, complementing a doctor’s appointment with an ongoing focus on a healthy lifestyle. This whole-body approach is effective for achieving positive results for both patients and health care providers.
This emphasis on prevention and wellness is not new to Kaiser Permanente; it’s been a primary focus since our inception almost 80 years ago. Today, we offer these services to our patients through a robust program of Lifestyle Medicine. Using evidence-based therapeutic approaches to prevent, treat, and even reverse chronic disease, Lifestyle Medicine addresses the root causes of many conditions and empowers patients to have more control over their health.
Lifestyle Medicine is organized according to six pillars: nutrition; physical activity; stress reduction; restorative sleep; social connection; and avoidance of risky substances.
First-line targets are typically nutrition and physical activity, along with guiding patients towards avoiding or decreasing their use of tobacco, drugs, and alcohol. We offer an extensive menu of classes and provide guidance on the value of eating
Note: The SFMMS has advocated strongly for saving Laguna Honda Hospital, and was very pleased to see this essential institution recertified. More of course remains to be done, but we happily thank and congratulate our local leaders in the San Francisco Department of Public Health, city government, and everyone involved in this effort. This message from San Francisco City Attorney and longtime SFMMS friend David Chiu conveys the good news. – Editors
I’m writing with great news about Laguna Honda Hospital. This week, our City received a key recertification that will help preserve this critical institution relied upon by so many of our most vulnerable San Franciscans.
For over a century, Laguna Honda has been the last safety net for our seniors, our family members with severe disabilities, and low-income San Franciscans who can no longer care for themselves. Every time I’ve visited, I’ve witnessed incredible acts of care and compassion. So a year ago this month, when the hospital was under threat of closure after losing its certification, our office filed a lawsuit to continue funding, pause resident transfers, and keep Laguna Honda open.
a predominantly plant-based diet. Our Thrive Kitchen hosts a monthly virtual cooking class which is free to members and available for a nominal charge to non-members. Our virtual 12-session Plant Strong Program helps patients improve their health through lifestyle medicine to gain energy, stabilize— or even reverse chronic conditions such as diabetes, high cholesterol, and hypertension.
Instead of focusing solely on formal exercise, many practitioners emphasize movement to help patients understand that walking, housework, gardening, and other daily activities count as physical activity. We also offer free handouts and streaming videos teaching strength training, yoga poses, stretches, and fitness routines.
We help patients manage stress and improve sleep through coaching, handouts and classes on breathwork, mindfulness, sleep hygiene, and more. Kaiser Permanente members can also take advantage of free access to the popular apps Calm and myStrength.
Kaiser Permanente also offers a wide range of counseling services, classes, support groups, and other programs for tobacco cessation, alcohol overuse and abuse, and addiction. We aim to remove barriers when our members are ready to improve lifestyle and they may self-refer to our Patient Health Education department to get started.
I heard from many residents’ families and staff as they faced tremendous uncertainty, worrying about whether more residents would be transferred and the toll those transfers could have on fragile patients. Fortunately, through litigation, we reached a settlement agreement with state and federal regulators to temporarily continue funding and pause the transfers of residents, giving Laguna Honda the breathing room it needed to successfully apply for recertification. This week, the state announced the hospital’s recertification into California’s Medi-Cal program, whose funding is relied upon by 95% of Laguna Honda patients.
By coming together as a community, we have preserved this critical institution and restored an essential part of San Francisco’s safety net. I want to thank our Department of Public Health and Laguna Honda staff, who worked so hard over the past year to earn recertification. I also want to thank the amazing legal professionals in my office whose work led to this announcement. Our City Attorney’s Office is one of the very best municipal law offices in the country, in no small part because of those in my office who were part of saving Laguna Honda.
For over 150 years, Laguna Honda has cared for our most vulnerable. With this week’s announcement, I’m hopeful it will do so for another 150 years.
Gratefully yours,
DavidYour brain may tell you that you have to understand to accept something. That if you only “understood,” you could accept how another person is behaving. It's possible, and often healthy, to accept without understanding. It’s very likely other people don’t understand you and why you do and say what you do. Very often we also don’t and/or can’t understand what others do and say.
Non contingent acceptance is not caring less — it is caring more. It is putting the integrity of a relationship first whether that is with a human or the practice of medicine.
Listen to the Mindful Healers Podcast:
Mindful Negotiating Tips with Mark Mahoney, Esq.
Do you think you aren’t good at negotiating? Do you worry about offending people or disappointing them? Do you want to learn some mindset strategies for effective negotiating? Listen to learn why doctors and women often struggle to negotiate. Learn the basics of effective negotiating. Leave with mindfulness and coaching tools to help you negotiate better.
Have you ever had an unexpected outcome and been unable to stop thinking about it? This episode will empower you with tools to respond with more grace and ease in the face of adversity. We hope you will leave with a better understanding of how shame, blame, guilt, and rumination make hard things harder.
Jessie Mahoney, MD
Mindful Yoga for Healers in Old Mill Park Sponsored by SFMMS: NEW DATES!
SFMMS members are invited to attend yoga and community building at the Old Mill Park Amphitheatre in Mill Valley on Sunday, May 12th and Sunday, October 6th. Special thanks to Dr. Jessie Mahoney for hosting this beautiful event. Visit the SFMMS Events Page for event information and to register: https://www.sfmms.org/news-events/events
Want to practice Mindful Yoga for Healers with Jessie before this event?
Join Dr. Mahoney on Zoom most Saturdays at 9am or anytime on YouTube.
For more information visit: https://mindfulyoga.jessiemahoneymd.com/ or https://youtube.com/c/JessieMahoney.
Jessie Mahoney is a pediatrician, a certified life coach for physicians, and a yoga instructor. She is the Chair of the SFMMS Physician Wellness Task Force. She practiced pediatrics and was a Physician Wellness leader at Kaiser Permanente for 17 years. She is the founder of Pause and Presence Coaching where she supports and empowers her physician colleagues using mindfulness tools and mindset coaching.
The SFMMS Membership Engagement Committee (MEC) was established by the SFMMS Board of Directors. Delegated to and directed by the SFMMS Board of Directors, the MEC plans, facilitates, and reviews proposed SFMMS membership engagement opportunities, including but not limited to: in-person, virtual, or hybrid convenings of members and non-member physicians; communications campaigns; educational and practice support opportunities; wellness activities; the Annual Gala; Annual General Meeting; socials and mixers; networking opportunities; and raffles and other promotional initiatives.
This opportunity is right for you if you want to foster a sense of community among physicians in San Francisco and Marin Counties and believe that physician engagement is key to improving the conditions of medical practice and outcomes for patients.
To learn more and apply, visit https://www.surveymonkey.com/r/P8RRGJT or scan the QR code with your smartphone
Honoring Diastole at Pie Ranch in Pescadero, CA Mindful Coaching, Yoga and Culinary Medicine. CME available. October 5th, 2024
Connect in Nature at Green Gulch, Muir Beach, CA Mindful Coaching, Yoga and Culinary Medicine. CME available. September 6-8th, 2024
Mindful Coaching, Yoga and Culinary Medicine CME Wellness
Retreats for Women Physicians: 4-5 night intimate physician wellness retreat opportunity for women physicians in Santa Margarita CA. April 14-18th and May 5-9th, 2024.
Each month, as part of the Physician Wellness leaders' work, they curate wellness resources around a common theme for our monthly wellness blog. Read, listen, and attend the monthly resources the committee has curated for SFMMS members by visiting: https://www.sfmms.org/news-events/sfmms-blog.aspx? Category=physician-wellness.
Have you missed a recent Wellness Event?
You can learn more about upcoming wellness events or view recordings of past events on the SFMMS Wellness Page at www. sfmms.org/get-help/physician-wellness
Physicians find it challenging to supervise practice managers as they often fail to adequately assess their abilities during the initial hiring process. As a result, many physicians engage the help of consultants when recruiting and hiring for this position.
“Managing is like holding a dove in your hand. Squeeze too hard and you kill it, not hard enough and it flies away.”
– Tommy Lasorda
An effective manager is a leader; someone who has the capacity to monitor the various facets of managing a practice. This person:
• Should possess a sound understanding of practice operations,
• Must be driven to accomplish practice goals and
• Must have a vision.
In addition to these attributes, an effective manager is an excellent relationship builder and communicator: one who can facilitate information exchange and partnerships throughout all facets of the practice.
While managers cannot be expected to be adept in all the areas they manage (such as tech workups), they should be able to lead the team to perform optimally, while creating a cohesive work environment.
Hence the most important attribute of a good manager is being a good leader: someone who inspires the team to perform to their fullest.
Good managers must have managerial talent, mutually respectful staff relationships and the ability to “manage up” effectively with their physicians. A skilled and effective manager can pay for their salary many times over, so invest wisely.
Often, practice managers start in other areas of a practice, such as in the clinic, in billing or at the front desk. Some practices have successfully promoted individuals from within the organization into management positions, while others have not. For this reason, careful consideration and evaluation of the potential candidate and their skills must be made.
Furthermore, reevaluation of practice needs must be made periodically, as growth occurs. In some instances, a practice manager will be successful when the practice is small but will fail to grow or increase skill levels with the practice.
Don’t be pound-foolish. Survey local practices of similar size for salary ranges, and access industry-specific salary survey comparables that break down administrator/manager salary ranges by size of practice, revenues and other factors.
Before hiring a candidate, set specific expectations and boundaries.
Determine the areas of the practice that you want to be involved with and the areas completely delegated to the manager. For example, many physicians completely delegate human resources and operational issues to the administrator but remain involved in other areas such as strategic planning, considering a new provider, opening/closing offices, marketing, website content, equipment purchases, EHR, and other IT decisions.
Expectations for work hours, demeanor, behavior and dress should be clearly defined in writing. They should include such requests as
• Greeting staff members each morning,
• Team huddles to build relationships with staff.
• Meetings to proactively manage the day.
Frequently managers perceive a lack of realization or attention to their accomplishments.
It is imperative that physician owners set time-defined objectives, which meet owner needs and challenge the manager and track progress. Both the physician and the administrator must agree on ideally quarterly goals/objectives for the practice or the manager’s professional growth in writing. This document will become the outline of goals for their annual performance review.
Most managers cannot directly supervise more than eight staff members effectively. Therefore, a front office, clinical or billing supervisor may be necessary to support the practice manager and avoid burnout. It is important that the owner/physician provide this support and encourage the manager’s professional development as well.
Continuing education courses keep the manager’s skills sharp, just as CME helps increase a physician’s knowledge. Encourage your administrator to join Medical Group Management Association, (MGMA) or your medical specialty society administrator organization and attend the joint meetings. Encourage the manager to seek out other professional opportunities that may become available locally, regionally or nationally.
Managers should be treated like non-owner partners in the organization and should fully participate in all owner meetings, including annual strategic planning meetings.
All projects should have target dates, checkpoints to monitor progress and periodic updates in between. Utilize tools such as Microsoft Outlook, which has a task feature to track tasks, deadlines and requests for updates.
Remember, as physicians, you set the culture of the practice. Don’t let actions speak louder than words.
If you want your manager to build a cohesive team, look to build a cohesive team with your manager and other staff members.
Reward your manager with sincere thanks, praise and creative perks such as:
• Spa day
• Sports tickets
• Extra time off
• A monetary bonus
• Gift that you know the manager will appreciate.
A personally planned, thoughtful way of expressing appreciation often means more to your manager than just a bonus. Even a note of thanks is appreciated.
It’s important to remember, a manager is not just a task master. He or she is also a team builder and a leader.
Set goals for quarterly team building/morale events or hold periodic contests with various themes such as the “best idea” that increases revenue or reduces expenses.
If you have clearly outlined your goals in written form, it is simple to transition this document into a performance review checklist and ascertain progress in terms of how goals are being accomplished and if timelines are in order.
It is important to assess relationship and team building efforts as part of the evaluation process. Acquiring feedback from employees is one way to assess these attributes. This is called a 360-degree review.
This is accomplished by asking staff to evaluate management abilities anonymously via a Web site–based survey such aswww. surveymonkey.com or www.formsite.com. Such a survey will provide the physician(s) with information regarding strengths and improvement areas from the staff’s perspective. However, keep in mind that poor performers may use this as a method to get even, so watch for ratings that are out of line with the norm and eliminate them. The survey should be structured to measure both strengths and weakness in a constructive manner.
The annual performance review should start with positive performance areas first, then “sandwich” in constructive feedback to avoid defensiveness. End with positive praise for tasks/ projects well done.
The manager should leave the discussion feeling positive and ready to tackle areas where improvements are needed.
Too many physicians will not discipline or fire managers because they are the only person trained to accomplish most administrative tasks. This is holding the practice hostage and not recommended.
Insist that the manager train another staff person to perform most tasks. This will minimize embezzlement exposure and enable the organization to function in the absence of the manager if necessary.
Anticipatory budgets should be prepared by the third quarter of each year by the manager. Financial reports to be shared with owners should be ready no later than one week after the close of the month. These reports should include the following:
• Dashboard report with key highlights
• Profit/Loss report and MD productivity report
• Your medical specialty benchmarks:
> A/R Aging, Turnover, Gross and Adjusted Collection percentage
> Staffing Ratios, Staff wage percentage to collections and Full Time Equivalents
> Recommendations for overhead expense ratios
When purchases or contracts are involved, managers should prepare cost-benefit analysis for physician meetings and give three ranked recommendations.
If the manager is not able to function or perform on the level communicated clearly during the interview process after numerous discussions and attempts to correct the situation, it may be time to consider cutting your losses.
If a decision is made to terminate employment, documentation of performance deficiencies via performance reviews and written warnings is essential to protect the practice.
Obtain legal advice if there has been little or poor documentation of substandard performance to avoid legal difficulties.
An attorney can suggest severance pay amounts based on length of service. These are usually conditional upon waiving the right to sue.
Debra Phairas is the president of Practice & Liability Consultants and has over 38 years of healthcare administration and consulting experience. www.practiceconsultants.net
Turnkey 2000 sq. ft. medical office in Mill Valley. All furniture and equipment are new and modern design. Ample parking. Perfect for primary care or medi-spa or specialty clinic. Please contact: marindoc415@gmail.com.
