SAN FRANCISCO MARIN MEDICINE
Volume 95, Number 1 | JANUARY/FEBRUARY/MARCH 2022
J O U R NA L O F T H E S A N F R A N C I S C O M A R I N M E D I CA L S O C I E T Y
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IN THIS ISSUE
SAN FRANCISCO MARIN MEDICINE
FEATURE ARTICLES
MONTHLY COLUMNS
12 SFMMS Interview: Shannon Udovic-Constant, MD, Chair, CMA Board of Trustees Steve Heilig, MPH
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Membership Matters
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President's Message Michael Schrader, MD, PhD
SPECIAL SECTION: ETHICAL HEALTH POLICY
COMMUNITY NEWS
17 Fixing Our Dysfunctional Systems and Institutions is Critical to Improving Our Public Health Mihal Emberton, MD
32 Kaiser News Maria Ansari, MD
January/February/March Volume 95, Number 1
15 A 2022 Tobacco Control Update: Achieving the Tobacco and Nicotine Endgame in America John Maa, MD
20 Assigning Value to a Human Life During "Crisis Standards of Care" William S. Andereck, MD, FACP
22 Dying Well and Moral Formation: A Trainee Perspective on Ethics During the COVID-19 Pandemic Harrison Hines, MD 24 Axiom: Democracy is Necessary for Public Health to Thrive George Fouras, MD
26 Emergency Department Crowding in San Francisco: Increasing Effects on the EMS System and New Countermeasures to Improve Patient Flow John F. Brown, MD, MPA
SPECIAL SECTION: PSYCHEDELICS AND MEDICINE
28 From Underground to In The Lab: Therapeutic Use of Psilocybin in Psychiatry and Addiction in Medicine Andrew Penn, MS, PMHNP and Josh Woolley, MD, PhD
33 Feel Better by Opting Out of "Collective Suffering" Jessie Mahoney, MD
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Editorial and Advertising Offices: San Francisco Marin Medical Society 312 Sutter, Suite 608 SF, CA 94108 Phone: (415) 561-0850 Web: www.sfmms.org
Executive Memo Conrad Amenta
32 Kaiser Permanente San Rafael Naveen Kumar, MD
OF INTEREST 7
CMA Year in Review
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CMA Federal Wrap-Up
14 SFMMS Book Review Jeff Newman MD, MPH
25 Leave No Californian Behind Sandra R. Hernández, MD
30 How COVID-19 Opened the Door to a New Era in Psychedelic Medicine Shoshana Ungerleider, MD
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19 SFMMS Advocacy Case Study: Ending Smoking in Restaurants and Bars and More Steve Heilig, MPH 36 Advertiser Index
Greetings readers and colleagues: This edition starts the 95th year of this journal, and thus the cover image. Reflecting a bit on the stressful times we live in, it can be striking to look back at the span of time since the SFMS leaders launched their publication. The SFMS had already been in existence for over half a century, banding together for solidarity and education in still-young San Francisco, founding medical schools that would morph into UCSF and Stanford, and most local hospitals, and working on public health concerns. In 1928 World War I and the worldwide influenza pandemic were only a decade past, and looming were the Great Depression, the Holocaust and WWII, and then the ferment of the 1960s and all its social movements such as civil rights, feminism, environmental, anti-Vietnam war, and locally the counterculture and free clinic movements including healthcare for all. Through all this oft-jarring history, medical science, education, and advocacy have persevered, while holding to essential ethical principles and the conviction that “politics” should further the public’s health. We are now in another era of pandemics, war, and extreme political conflict. Let’s hope and work to ensure that our professions continue to not only minimize suffering but set an example of progress and cooperation across all borders of any kind. Thank you for being part of that goal. – The Editors
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MEMBERSHIP MATTERS Hundreds of organizations join together to oppose measure that would devastate health care delivery in CA The California Medical Association (CMA) and its local county medical societies have joined together with hundreds of organizations in opposing the so-called "Fairness for Injured Patients Act" (FIPA) because it will devastate our health care delivery system, hurt community health centers and raise health care costs for ALL Californians. FIPA will be on the ballot this November and, if passed, will effectively eliminate MICRA’s protections. Funded by a wealthy out-of-state trial attorney, this proposition would be a windfall for lawyers at the expense of California’s most vulnerable patients.
DMHC issues All Plan Letter to health plans implementing CMA-sponsored telehealth legislation
CMA publishes telehealth policy update During the COVID-19 pandemic, through CMA advocacy, both public and private health plans were pushed to expand their coverage and reimbursement for services provided via telehealth. Policymakers at the state and federal level are making decisions that will shape the future of telehealth for years to come. CMA has published a Telehealth Policy Update that summarizes what has already been done and provides some next steps that physicians can watch for throughout 2022.
Free N95 Masks Available for Clinicians from SFMMS
The SFMMS still has a supply of masks available for those in need, for pick up in central SanFrancisco. For information: Steve Heilig, heilig@sfmms.org
Friday, April 29, 6pm
The California Department of Managed Health Care (DMHC) issued an All Plan Letter (APL) to its regulated health plans, implementing a CMA-sponsored telehealth law (AB 457) that took effect on January 1, 2022. The APL clarifies plans’ responsibilities under the statute. AB 457 made major changes to California telehealth law.s.
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CMA recoups $33 million on behalf of physician members
In 2021, the California Medical Association (CMA) recovered nearly $3.2 million from payors on behalf of physician members. This is money that would have likely gone unrecouped if not for CMA’s direct intervention. That’s because California physicians have a powerful ally when it comes to dealing with problematic payors—CMA’s Center for Economic Services (CES).
48TH ANNUAL LEGISLATIVE ADVOCACY DAY
Tuesday, April 19, 2022 Sheraton Grand Hotel | Grand Nave Ballroom 1230 J St., Sacramento, CA 95814
For more information, visit cmadocs.org/events.
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Letter to Editor, San Francisco Chronicle, March 11:
Expand mental health Regarding “Heartbreaking cycle of mentally ill in ERs” (Bay Area & Business, March 9): Thank you for Heather Knight’s column on the mental health services crisis in San Francisco. Emergency physician Scott Tcheng is on the frontlines and relates all too accurately what many local health professionals see every day — the failure of our care for the most vulnerable in times of mass homelessness, addiction and mental health needs. We recently visited the new Tenderloin Linkage Center, where hundreds access various services in a place of respite. It is a good and needed start but doesn’t address a broken system. What is most needed is a large expansion of inpatient hospitals and other facilities for those who cannot, and likely will never, be able to function healthily and safely without supervision. There are much better medications and other approaches to helping such people than before, but far too many don’t have access to them. Gov. Gavin Newsom’s proposal to channel more such people into care is a good start, but sites and services must be expanded to house and treat them. The deinstitutionalization movement that shut down large care facilities decades ago has been a huge and inhumane failure. As Dr. Tcheng so aptly puts it, there is nothing compassionate about the neglect we now all see on the streets. Michael Schrader, president, Steve Heilig, associate executive director, San Francisco Marin Medical Society
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PHYSICIAN WELLNESS CORNER
January/February/March 2022 Volume 95, Number 1 Editor Gordon L. Fung, MD, PhD, FACC, FACP Managing Editor Steve Heilig, MPH Production Maureen Erwin
Free Wellness Resources for Physicians: Physician Support Line: 1-888-409-0141 or www.physiciansupportline.com Free confidential support line by volunteer Psychiatrists for US Physician colleagues during the COVID-19 pandemic. Available 7 days a week, 5am - 9pm PST.
SFMMS OFFICERS President Michael C. Schrader, MD, PhD, FACP President-elect Heyman Oo, MD, MPH Secretary Jason Nau, MD Treasurer Dennis Song, MD Immediate Past President Monique Schaulis, MD, MPH SFMMS STAFF Executive Director Conrad Amenta Associate Executive Director, Public Health and Education Steve Heilig, MPH Director of Operations and Governance Ian Knox Director of Engagement Molly Baldridge, MPH
SFMMS Physician Wellness Committee & Wellness Resources With the goal of nourishing and sustaining our physician members, SFMMS has gathered a physician workgroup to focus on physician health and wellness. We provide a variety of offerings focused on nourishing our members social, educational, and professional development. Building community and connection is critical to our mission. Over time we have been curating a list of local wellness resources for SFMMS members, http://www.sfmms.org/Portals/27/ Physician%20Wellness%20Resources.pdf.
SFMMS Physician Wellness Facebook Group: www.facebook.com/ groups/SFMMSPhysicianWellness/ SFMMS has a Facebook group where we share resources, events and coordinate local meetups for Bay Area physicians who are seeking connection and community with colleagues.
American Medical Association Physician Health (https://www.amaassn.org/practice-management/physician-health)
The AMA offers articles and practical resources for addressing physician health and reducing burnout, including a 'burnout management tip of the week.' You can subscribe to and receive in your email box each week.
MIEC Wellness (https://www.miec.com/wellness/)
Offering a toolbox of resources for physicians and their practice, whether it’s to improve the administrative efficiency of their office or access the appropriate wellness tools for themselves and other staff. The site also includes access to the Mayo Clinic's Well-Being Index and a confidential wellness tracking tool.
Staff Associate Ashley Coskey 2022 SFMMS BOARD OF DIRECTORS Edward Alfrey, MD Melinda Aquino, MD Ayanna Bennett, MD Julie Bokser, MD Anne Cummings, MD Manal Elkarra, MD Mihal Emberton, MD Beth Griffiths, MD Robert A. Harvey, MD Harrison Hines, MD Zarah Iqbal, MD Ian McLachlan, MD Jason R. Nau, MD Heyman Oo, MD Sarita Satpathy, MD Monique Schaulis, MD Michael C. Schrader, MD Yalda Shahram, MD Neeru Singh, MD Dennis Song, MD Kristen Swann, MD Kenneth Tai, MD Melanie Thompson, DO Matthew D. Willis, MD, MPH Joseph W. Woo, MD Andrea Yeung, MD
Free Wellness Resources for Physicians: SFMMS Physician Wellness Webpage Visit the SFMMS Physician Wellness page at http://www.sfmms.org/get-help/physician-wellness to find curated resources for our SFMMS physician members.
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PRESIDENT’S MESSAGE Michael Schrader, MD, PhD
COLLEGIALITY, PARTICIPATION, POLICY, MENTORSHIP, AND LEADERSHIP Greetings to all in this new year. Please allow me to introduce myself. I was an MD/PhD student at University of Pittsburgh/Carnegie Mellon University. I came to San Francisco because I wanted to study and treat HIV/AIDS, and did my internal medicine residency at UCSF/ Mt Zion. When I finished I had to choose between continuing with research or practicing medicine. I chose clinical medicine because I enjoyed it most. I was in private practice for 25 years. I have taught UCSF students for 25 years and am in the volunteer Clinical Professors. A couple years ago my private practice failed, pushed over the edge by Covid, and I became an employed physician with Dignity Foundation Medical Group (DFMG). I am currently the SF Medical Director for DFMG. It is now my honor and privilege to serve as President of SFMMS. We are 154 years old, have nearly 3,000 members, and are fiscally sound. We are respected in the community and have influence at the CMA and AMA. I came to organized medicine late in my career. I had been a member of my specialty society my entire career and had become a fellow but wasn’t particularly active. I can’t remember exactly why I joined the medical society but once I did I enjoyed the get-togethers—seeing old friends, meeting new ones. I had only been a member for a couple years when James Chen nominated me for the Board of Directors. It was something I had never really considered. And I thought: Here’s how I could make some changes, have a voice. I recently asked James what made him nominate me. His answer was that I had helped him out when he was starting his practice and he saw value in the medical society and wanted to share it. In a word: collegiality. What I found when I became a board member was a forum of ideas put forth by members who cared about the profession, the well-being of patients, and health policy. I found mentorship. And I found a voice larger than my own. I started out as a Board member with the idea that I would show up to every event. I didn’t join any committees early on—a mistake. But I showed up to every event that I could fit into my schedule. That’s participation. In my third year as a board member Man-Kit Leung showed me how to write resolutions to the CMA. And I wrote three resolutions: Support for the ACA, support for NIH funding, and support for Title IX funding for women’s health. This quickly got
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me into the Delegation as an alternate. The Delegation is a great place to influence policy. SFMMS has been influential outsized to our numbers, and has proposed important policy about mental health, firearm safety, drug abuse, and human rights. Among others. That’s policy. About five years ago I joined the SFMMS PAC. As I remember they had some positions to fill and I just thought I could help out. The PAC is a great place to be involved with politics. We support candidates and meet with candidates. Politicians need and welcome input from the medical community. Three years ago John Maa got me involved in the No on C campaign to reject the JUUL sponsored city initiative that would preempt San Francisco laws restricting vaping and electronic cigarettes. We were able to garner CMA support for opposition to this initiative that would jeopardize public health. That’s public health advocacy. I have had a number of mentors at SFMMS who have helped me greatly over the years. SFMMS members are more than happy to share expertise. Mentoring is its own reward. That’s mentorship. SFMMS needs leaders and SFMMS trains leaders. We need a new President every year. Also Board members, delegates and people to serve on committees. Leaders, Board members, and delegates from SFMMS go on to leadership roles on boards of directors, boards of trustees, and chiefs of staff. We are a training ground. That’s leadership. Where does SFMMS go from here, the next year and into the future? We need to prove the value of membership. We need to increase engagement of the Board and the membership. We need to protect our profession from the challenge to MICRA, corporatization of medicine, and incursions into our scope of practice. We need to protect our community from Covid, drug abuse, mental illness, and the health effects of climate change. Thus we work on issues ranging from the details of medical practice to global health concerns. It’s a lot. But we do our part, and are glad to have every member to help in whatever way works for you. Thank you for being a part of the SFMMS. Dr. Schrader chairs the SFMMS delegation (with Dr. Ameena Ahmed, newly-elected vice-chair) and is president of the SFMMS.
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EXECUTIVE MEMO Conrad Amenta, SFMMS Executive Director
THE GREAT SINGLE-PAYER DEBATE RETURNS TO CALIFORNIA On January 31st, the California State Assembly was set to vote on AB 1400 (Kalra) - Guaranteed Health Care for All, a bill that sought to establish a single-payer health care system. AB 1400 described a system in which physicians would contract with a publicly-funded health insurance plan to deliver care, not unlike Canada’s single-payer funding arrangement. The bill was ultimately not brought to the floor for a vote because it lacked the votes for passage. Organized medicine has a complex relationship with singlepayer health care, usually opposing single-payer bills. While medical associations have long standing policy in favor of universal healthcare coverage and access, the authors of singlepayer bills often decline to describe the trade-offs inherent with such a transition, making support for these bills difficult. It can be helpful to think in terms of trade-offs, because attendant any transition to a single-payer health care system should be an honest discussion about what tradeoffs the public can accept. Broadly speaking, health care systems can be assessed relative to the following five ideals: • Universal: providing insurance coverage to every person.
• Comprehensive: providing insurance that includes all essential health services.
• Timely: providing sufficient access to the appropriate health care clinician within reasonable time and distance standards.
• High Quality: delivering health services according to medically- and culturally-determined standards of practice.
Think of each of these ideals as sliders that are codependent and can be moved up and down. Move the ‘universal’ slider all the way up, and a system may become less comprehensive or timely. Move the sliders for ‘universal,’ ‘timely,’ and ‘high-quality’ all the way up, and the system becomes less financially sustainable without new taxes, fees, or co-pays. There are many possible configurations, and valid arguments exist for each. I was born in Canada and lived there for 35 years. I experienced a country proud of its universal health care coverage, but that accepts as the price of that universality less-than comprehensive care (E.G., Prescription drugs, dental, and eye care are not covered), long wait-times for elective procedures, and discontinuity in its primary care. Elections are occasionally fought in Canada over whether to set our tradeoffs differently. It’s an ongoing, and fierce, discussion with myriad viewpoints one would expect from a diverse electorate. But Canada, like every country with a single-payer health care system, has determined the trade-offs with which it can currently live. Tradeoffs can be unpopular, however, so the authors of singlepayer bills sometimes decline to propose any. Californians are passionate about universal, high-quality health care, and our single-payer deliberation is far from over. But until legislators trust the public to understand and support a proposal that articulates concrete trade-offs, single-payer bills will continue to be considered unserious and unlikely to succeed.
• Sustainable: accounting for overall system financing.
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SFMMS INTERVIEW Shannon Udovic-Constant, MD, Chair, CMA Board of Trustees Steve Heilig, MPH Pediatrician Shannon UdovicConstant, MD is an SFMMS pastpresident who has risen in the ranks of the CMA to become the chair of their board of trustees, consisting of physicians elected from all around the state. Long with Kaiser Permanente in San Francisco, she tells of her early years in an underprivileged family, her firm decision to enter medicine, and the many challenges now facing the profession and how the CMA is working to confront them.
Let’s start with your own history. Where did you grow up and first go to school? I grew up in Fullerton in Orange County, California. It was a very middle-class community where I grew up, but that wasn’t really my reality. My mom was a single mother of five kids due to her relationship circumstances, and we were living rent-free in my grandparents’ home in order to survive. And we were on MediCal, which impacted our access to healthcare, as we had to drive across the entire county in order to find a doctor who would take her insurance. So that for sure has shaped a lot of my values and motivation for all of this organized medicine work that I do. So you must have been a motivated student too? Oh for sure—I wanted to go away to a good school and knew the only way to do that would be to get good enough grades to get scholarships. I was successful at that and got accepted to UC Berkeley, cobbling together scholarships and loans to be able to pay for it all.
When did you first set your sights on medicine as a career? Well, I always loved math and science and understanding how things worked, plus I always gravitated towards younger kids even when I was young myself. Pediatrics just made sense.
So you were set on going into pediatrics from the start? Yes. I just love young people and I think lots of them know it. From a really young age I would try to connect with other kids. So I wound up going to the Joint Medical Program at UCSF and Berkeley, which was great, and got inspired by great Paul Newacheck, an exceptional health policy expert who I learned so much from. And somebody invited me to join AMSA, the American Medical Student Association, and with them got invited to Washington, DC where we sat down with Congressman Ron Dellums, who listened to us so respectfully that I really saw the power of 12
the white coat—that elected officials would respect us even as medical students. Then I did a general peds residency at UCSF, where I partnered with some other residents from Stanford , Children’s Oakland, and UC Davis including Senator Dr. Richard Pan, to meet quarterly to elevate our advocacy skills and influence.
After training you chose to stay in San Francisco. Yes, and I think because of my upbringing I was drawn to an urban community where the need was high for primary care. And I joined Permanente because of the focus on prevention and care for a population. When did you first get involved with the SFMMS and CMA? Back when I was still in school I did attend some CMA meetings— they were incredibly welcoming to students—and I just listened. Then after residency leaders like Drs. Chuck Wibblesman and Lucy Crain mentored me and brought me to some SFMMS meetings. Early on I was even bringing my son in an infant carrier! I found it all very interesting and was encouraged to run for the SFMMS delegation and board. But in fact I wasn’t successful the first time around. But people reassured me to try again, and I was elected, and here I am, with that reminder to stay resilient and keep trying for what you want. Are you the first woman chair of the CMA board? There have been a number of women CMA presidents, most of them in relatively recent years, but you know, I haven’t really thought of that and don’t really know!
How do you see CMA as functioning in a representative way for the entire profession statewide? CMA is now about 50,000 members strong, from all specialties and areas, working together. We’re proud that we added to our mission statement in 2020 the goal to achieve more health equity and justice, to reflect the greater diversity of both physicians and patients. It’s a large board with designated seats for all kinds of modes of practices. We work to bring the voice of all those that we represent to deliberate and shape health policies for the organizations. The House of Delegates through its quarterly process is able to also set policy based on resolutions from any member or delegation. The delegation chairs then choose the major issues for each year. This change was made several years ago to try to help CMA be more proactive in our policy formation and implementation. It’s a work in progress in how we engage all of our members and we are looking at it carefully to see how we can improve on it even more.
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Historically it wasn’t all that long ago that Kaiser Permanente physicians weren’t even allowed to join, not only because they were seen as coming from some form of “socialized medicine” but from the fear they might “take over” CMA. Now we’ve had medical society presidents. Do such concerns still surface? Certainly, at least in some ways—every voice within CMA wants to be represented, and that’s why the Board is set up to represent each practice environment, diversity of age, and we’re still working on diversity of gender and more, and I think the current board is more reflective of the full scope of California physicians than it ever has been, at least in my tenure.
AMA president-elect Dr Jack Resneck of UCSF has mentioned that he felt the AMA suffered from a “reputational lag,” being perceived as a non-diverse bunch of conservative old doctors stuck in the past. Do you perceive that at all with regard to CMA too? Oh definitely to some degree, as board chair I hear from the whole spectrum of backgrounds and opinions. There is a section that feels our focus should be mostly on payment issues and that doctors must be first and foremost in every way, and then there are other voices saying we are not moving fast enough on topics like racism as a health issue, or climate change and healthcare reform, and then there’s a big group in the middle who are focused on CMA helping them practice the best they can in their daily life. They all overlap. It’s actually fun to try to bridge these priorities. I do feel we can do all of these things but the question is how fast and with what priorities. We accomplish more when we focus, and one of the hardest things a board and CEO can do is choose what they have to say “no” to at a time when we have limited resources and time. And that’s hard, as there is so very much to do, and that we want to do, and yet again, we are most effective when we focus. One big issue in this time, even before the pandemic but especially now, is physician resilience and wellness. I worry about this a lot. I was the chair of the Quality Professional Life committee in my own medical group, and spent a lot of time reading and learning in this area. For so long the message has been on the individual, about self-care and gratitude and all those things, which are incredibly important, but there is also this organizational piece which is crucial too. I wish there was a quick fix, but there’s not. We are going to continue to train leaders with this professional satisfaction/wellness lens, so they can help their own teams try to do the best they can while removing the barriers to having a job well done. Workloads need to be manageable and not require heroics every day just to take care of all of our patients. We also need to remove the stigma of mental health challenges and seeking help for ourselves. Physicians tend to keep plowing along and not get the help they might need. This profession can be hard, especially for the Type A, slight OCD high achievers so many of us are, and we are finally seeing that this can lead to high morbidity and mortality, and doctors feel they can only rely upon themselves and tend to keep their stresses and challenges secret. We need to recognize when we need help and where we might get that without fear. WWW.SFMMS.ORG
We had to change the language on our medical licenses, for one thing. It asked something like “Have you ever sought help for mental health issues?” which doesn’t help or matter, as what matters is: Are you impaired right now. So we were successful in changing that to remove that worry and barrier. It’s hard no matter what. We’d also love to bring back a state level program for assistance and are working on that and how to pay for it.
Let’s touch on some of the big issues CMA has and is facing, starting with COVID of course. First I need to say that I am more proud than ever to be a physician during this pandemic. My colleagues truly stepped up in every way, even when it was frightening, and they all continue to do so. Now I think the next step as we move into the endemic phase is we have to help our colleagues and patients to start to feel comfortable with reintegrating, and to the fact that we will have to continue to step in and out of rules such as masking, indoor activities, and so forth, based on community rates, so that we can live with COVID in the same way that we do with other viruses, now that we have the vaccines to protect us from severe morbidity and mortality.
As a pediatrician you must have looked closely at the very contentious debates about school closures and reopening. The AAP recently put out an alarming report on children’s mental health too. Yes, we talked to everybody we could about the need to get schools back in person as quickly as possible. I think it was appropriate at the beginning to close schools, but we should have had kids back to classes much sooner. And yes, one of the most heartbreaking things to me is the mental health issues among youth. I think I’ve hospitalized more kids for these issues in the last year than I had in my previous twenty years. Of course the mental health challenges pre-dates COVID, but that made things so much worse for so many. Even now there are so many limits on learning, social life, and extracurricular activities and we need to bring all that back safely however we can.
Racism in medicine and the push for more diversity has been a CMA focus of late. Yes, I’ve been proud of this—back in 2014 I co-authored a resolution out of our SFMMS delegation that called on CMA to look into this, and it happened. A first focus has been on our own internal diversity as an association, and now that is broadening into working on equity, diversity and inclusion, with as I said our CMA mission statement committing to achieving health equity and justice. So it’s embedded in the association now, and at our last board retreat there was a lot of support for bringing this perspective into all CMA policy discussions. There is of course lots of work to do there but there is a lot of commitment that has been created to move it forward. My perception is that lots of this push comes from our medical students, residents, and young doctors. Absolutely. The medical student section just put through a package of resolutions focusing on these issues with a focus on public health issues. There is so much energy and passion from them and I am very grateful for their energy and focus.
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You mentioned Medi-Cal as a part of your personal history, and it’s an ongoing struggle to make it work best, and keep it funded, with a new CalAIM effort to improve it. California physicians want truly accessible care, and equitable health outcomes, with affordability. One of our recent major issues was cost containment. Organized medicine has always worked to keep these programs working in a thoughtful way that allows us to practice medicine as we are trained to do. There are many opinions on how to make this work. There are lots of proposals and discussions occurring in Sacramento, such as the push towards single-payer legislation, the Governor’s office of health care affordability, the Healthy California for All commission looking at unified financing options, and more. It’s important for us as California physicians to have our internal discussions to guide our input on these. The CMA healthcare reform technical advisory committee just did a report that is moving through the CMA process so we can engage well in the state level policy debates. Is it safe to say that CMA supports universal access but has very mixed opinions on single-payer concept? CMA is very much in support of universal insurance with meaningful access to care, and that includes reasonable reimbursement so we can keep our offices open. Practices need to be kept viable, and we need to reduce administrative burdens, including the need to employ too many people just to input information and to get prior authorization and so forth.
You mentioned primary care and it is looking like the shortages in primary care providers and access are going to continue to get worse. Is that something we can remedy? Absolutely, and that’s been one of the reasons CMA stands for a true medical home with physician leadership with others practicing at the highest level of their training and licensure.
We need the whole team to make this work. CMA is working through our Foundation to strengthen the pipeline, pushing goals like increasing residency slots in communities where those are most needed, and loan repayments for those who will go back to where needs are great, and protecting Proposition 56 tobacco tax funds to keep Medi-Cal rates higher, especially since lots of our community clinics rely so heavily on those funds. Within medical education there are conversations to make sure the preceptorships show students what a good experience primary care can be. Those of us who are preceptors need to show the parts that are enjoyable. One question is if there is a way to fund the preceptors to be able to spend more time teaching the learners, so that it looks like a job physicians will want to have. And reimbursement levels have to change, as Medicare pits one specialty against another by saying an increase in any one requires a cut to others. That has to change.
How about your own practice—how has all this other work impacted that? You know, I’ve been very lucky to have been able to maintain about 60% time in patient care ever since I had my kids. Both that and my CMA work leak into evenings and weekends of course, but that’s just part of being a professional. I so love patient care, and it provides me with the stories and meaning to engage in the policy work. I am often struck by how often my own patient’s health is impacted by the social determinants of health. I think my work in organized medicine is my own antidote to burnout, to be able to both engage one on one with patients and then move into the broader world of health policy. One thing we’ve learned from COVID is that optimal health policy is more important than ever. And so it feels even more important to work on these issues the best we can.
BOOK REVIEW
WHY READ THE NEW TRANSLATION OF THE PLAGUE BY ALBERT CAMUS DURING AN EPIDEMIC? Jeff Newman MD, MPH
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Though having loved the previous translation about 40 years ago, I had been highly motivated by co-leading a medical school seminar with my close friend—a literature professor. My role, having recently received an epidemiology degree, was to comment on the authenticity of the fictional narrative of an epidemic - while my friend focused on its literary merit. The students engaged enthusiastically in the free-for-all discussion. This was greatly valued by all of us. One of Camus’s literary techniques is keeping the identity of the narrator a mystery until the end. He/she/they does mention that it is one of the main characters, because of the familiarity with all the goings on. It turns out to be Dr Bernard Rieux—the central character. Dr Rieux sends his wife off for specialized medical treatment at the beginning of the novel, with only hints of the plague, and welcomes his mother to
stay for the interim. By the end of the epidemic, he loses both, as well as several of his friends/colleagues. He celebrates the end of the plague by swimming in the ocean with one of his associates. The Plague was written during the Nazi occupation of France. The allegoric themes of courage, cooperation, and resilience—to political as well as medical epidemics—are as relevant today as they were then. As is the need the for compassion with all the clinicians and public health professionals on the front line. For those who cannot read it in French, this translation brings these themes to life and may fortify our commitment to our patients, communities, and colleagues.
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A 2022 Tobacco Control Update:
ACHIEVING THE TOBACCO AND NICOTINE ENDGAME IN AMERICA John Maa, MD In 2019, the CDC closely tracked an epidemic of respiratory illness known as EVALI – the E-cigarette or Vaping Use-Associated Lung Injury, that resulted in 2,807 hospitalizations and 68 confirmed deaths in 29 states and the District of Columbia. The EVALI epidemic ultimately led to significant national progress to reduce the health hazards associated with vaping. The Trump Administration announced in January of 2020 the removal of flavored vaping products containing fruit and mint among other flavors, along with enforcement of the requirement that the remainder of vaping products apply for FDA premarket approval (PMTA) by May 12, 2020 as set by a Maryland court.
The adverse impact of COVID-19 on Tobacco Control A major disruption to this major progress forward against flavored tobacco products was the arrival of the Covid-19 pandemic. The CDC stopped tracking EVALI in February of 2020 to focus on Covid-19. The FDA PMTA application deadline of May 12 was extended 120 days to September 9, 2020 at the request of the FDA, citing the extraordinary circumstances of the coronavirus outbreak. Another setback resulted from false myths that arose about a potential protective effect of nicotine and smoking on Covid-19 transmission and severity, which led to a shortage of nicotine products in France as citizens futilely rushed to purchase nicotine products. The French government responded by restricting the online sales of nicotine gum and patches. This myth confused public health efforts to curb the spread of Covid, as subsequent extensive research clearly demonstrates that smokers are more likely to be admitted to the ICU, require intubation, or die from Covid-19 infection. The original papers suggesting smokers were less likely to acquire Covid-19 were later discredited after links between the authors with the tobacco industry were revealed, and one paper was retracted by the journal. The real truth is that myocardial disease and chronic obstructive pulmonary disease, which often result from a lifetime chronic smoking, are leading risk factors for mortality from Covid-19. An unexpected impact of Covid-19 on the e-cigarette industry included an interruption of the supply chain. About 90% of the WWW.SFMMS.ORG
world's e-cigarette hardware is produced in China, and many factories in Shenzhen closed initially during the coronavirus outbreak, temporarily limiting the US availability of e-cigarettes. Another unexpected surprise came in May of 2020, when it was estimated that more than 300,000 UK smokers may have quit smoking due to Covid concerns. However, the experience across nations with national smoking rates has been variable, as the stress and anxiety of the pandemic may have led some smokers to increase their use of cigarettes. Across the Atlantic, the US experience was the opposite of the UK, as calls from smokers seeking assistance to US quitlines fell significantly in the Spring of 2020, and in 2021 the FTC reported that US annual cigarette sales increased for the first time in 20 years.
FDA action on electronic cigarettes The FDA was given a one year deadline to review the e-cigarette PMTA applications until September 9, 2021. In June of 2021, Juul agreed to pay North Carolina $40 million to settle the first of a number of lawsuits brought by states and localities claiming the company’s marketing practices spurred widespread youth nicotine addiction (an Arizona lawsuit against Juul was later settled for $14.5 million). On August 26, 2021, the FDA denied PMTA applications for 55,000 flavored e-cigarette products, citing their failure to provide evidence that these products adequately protect the public health. This was followed on October 12 with an FDA announcement that R.J. Reynolds would be granted approval to market three of their new tobacco products—the Vuse Solo closed ENDS device and two tobaccoflavored e-liquids. This represented the first time that vaping products had been granted formal permission by the FDA to be sold in America. A final decision regarding Juul’s PMTA application is overdue, and perhaps will come after the confirmation of new FDA Commissioner Robert Califf. Meanwhile, synthetic nicotine has become popular amongst teenagers, (Puff bar is a leading brand). As synthetic nicotine isn’t derived from tobacco, it does not fall under current FDA jurisdiction, though the FDA is exploring whether it can bring synthetic nicotine under its regulatory umbrella. continued on page 16
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A new focus on the Tobacco and Nicotine Endgame Into this shifting landscape, a larger objective in tobacco control has also emerged—to achieve the Tobacco Endgame, which is often defined as a smoking incidence under 5%, targeting an end to unnecessary tobacco related deaths. The public health response to EVALI catalyzed movement towards the Endgame, perhaps best exemplified by the American Heart Association Tobacco Endgame movement to empower teens and young adults to make a difference in the fight against vaping and tobacco use. Perhaps the Covid-19 pandemic may also prove to be a major catalyst to reach a Tobacco and Nicotine Endgame, both in America and around the globe, by serving as a useful teachable moment to motivate active smokers to finally quit. Several nations defined Endgame goals nearly a decade ago, and New Zealand took a major step forward in late 2021 to reach its Endgame goal by proposing a novel legislative strategy to phase out tobacco sales to anyone born after a certain birthdate. Starting in 2023, anyone under age 15 would be barred for life from buying cigarettes in New Zealand, and as the years pass the minimum age to purchase tobacco products will rise accordingly. A similar approach had been adopted in the Massachusetts town of Brookline in 2021, and perhaps state and local legislators in California should follow their lead and consider introducing similar legislation to enable our state to reach its Endgame goal in the next 13 years? Ultimately, a multi-pronged strategy spanning local, state and federal action will likely be necessary to achieve a Tobacco and Nicotine Endgame in America. Other key strategies may include
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increasing excise taxes, implementing graphic warning labels, eliminating flavors including menthol in cigarettes and cigars as announced by the Biden Administration in April of 2021, and lowering the nicotine content in cigarettes. California may be an ideal test state towards the Endgame, given its low smoking incidence and multiple state agencies focused upon tobacco control. Another key step will be through a strong defense of Senate Bill 793 (Hill, San Mateo), the flavored tobacco products legislation signed into law by Governor Newsom in August of 2021, which is being challenged by the tobacco industry through a referendum on the November 2022 California ballot. As we move beyond the pandemic, we should strive to re-harness the progress forward from 2019 and early 2020 with the goal to reduce the burden of tobacco related illness and disability, and enable America to achieve the Tobacco and Nicotine Endgame sooner. John Maa, MD, a general surgeon, is an SFMMS past-president.
An update as this goes to press: A spending bill passed Congress on March 10 that expanded the definition of an FDA-regulated "tobacco product" to include lab-made synthetic nicotine. The bill is anticipated to be signed imminently by President Biden.
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Special Section: Ethical Health Policy
FIXING OUR DYSFUNCTIONAL SYSTEMS AND INSTITUTIONS IS CRITICAL TO IMPROVING OUR PUBLIC HEALTH Mihal Emberton, MD One in four US adults suffers from depression or anxiety 1,2. The ubiquitous nature of these mood symptoms points to systemic and institutional dysfunction as the likely etiology rather than individual dysfunctional brain chemistry. The World Health Organization agrees, with their identification of “burnout” as a global, occupational phenomenon.3 Additionally, our burgeoning understanding of adverse childhood experiences4 and trauma-informed care5 also highlight our realization that dysfunctional systems and institutions negatively impact our mental health, physical health, and wellbeing, and are thus global public health crises.6,7 San Francisco is a remarkable city, and I am grateful and honored to live here. However, like any other system or institution, San Francisco suffers from unconscious biases and inconsistencies within our City General Plan which inflict discrimination and injustice upon our citizens, subsequently harming their health and wellbeing. Dr. Hahn, anthropologist and epidemiologist who received the 2013 Lifetime Contribution Award for Outstanding Dedication to Excellence in Behavioral and Social Science from the CDC,8 and colleagues emphasize that “The historical denial of the civil rights of racial and ethnic minority populations…indicates that civil rights can be a powerful social determinant of health. Deprivation of civil rights has been a prominent factor in the poor health of Black people in the United States…Public health benefits depend not only on the existence of civil rights and regulations, but on their implementation, including their enforcement. Unless implemented, civil rights are promises without benefit. While the scope of efforts to protect civil rights has greatly expanded in recent history, evidence presented here and elsewhere (Reskin, 2012; Smith, 1999; Chemerinsky, 2002) shows that enforcement of civil rights has been uneven and incomplete, and, at least in domains of health care, education, and housing, resistance to civil rights laws and their implementation persists.”9 WWW.SFMMS.ORG
Civil Rights Violations permitted by SF City General Plan A citizen repairing a blighted fence while listening to music is reported to the City by a neighbor complaining that “the resident at this address has been consistently doing construction and playing loud music from 10am-6pm/7pm most days of the week. I would like to request the music volume be lowered or turned off. I can hear it in my apartment all day." This complaint is reported to the Department of Building Inspection for investigation. To any reasonable person, neither “consistently doing construction” nor ‘playing loud music during the day’ imply nor provide evidence of a violation of the City General Plan, highlighting a lack of protection from unlawful and/or unreasonable searches and seizures, a civil right protected by the 4th Amendment of the Constitution. A citizen following 11 SF building codes for removal of blight is issued a notice of violation because "a complaint investigation has revealed the installation of a new fence on a corner lot without the benefit of a building permit.” To any reasonable person, conflicting codes, such as the removal of blight conflicting with new construction requirements, is evidence that inconsistencies exist which violate citizens’ rights to equal protection under the law, protection from extortion, and protection from coercion. The California State Office of Planning and Research requires cities to recognize and remedy such inconsistencies at the origin, rather than giving one element precedent over another, in order to achieve an integrated and internally consistent City General Plan.10,11 A citizen follows corrective actions to “obtain building permit with plans and Planning Department Approval [for a four-foot fence]” but is later mandated to ‘remove an unrelated trellis from the front setback before the four-foot fence permit can be approved.’ To any reasonable person, the expansion of “corrective action,” such that a four foot fence initially needing permit review for approval later requires the prerequisite of removal of a separate structure, is evidence of extortion, coercion, discrimination, and lack of equal protection under the law. During the permit review process, a city agency requests continued on page 18
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Special Section: Ethical Health Policy a Minor Sidewalk Encroachment Permit Application and then responds to the submission of the Minor Sidewalk Encroachment Permit Application by stating that “it is very unlikely we would be able to approve this structure [repaired 4-foot fence] as currently built under a Minor Sidewalk Encroachment permit due to its height and privatizing effect. It would be advisable to instead remove the encroachment or bring the encroachment inside such that it is fully contained within your property lines, and proceed to restore the public right-of-way to standard condition." However, the agency request that the citizen remove the repaired fence, which provides safety to the property and is only one of numerous similar fences in the neighborhood and adjacent neighborhoods, violates 12 city codes, including administrative code, housing code, environmental code, public works code, planning code, and police code, in addition to violating six state and federal laws. To any reasonable person, the attempt to coerce a citizen to violate other city codes, to discriminate against a citizen, and to extort a citizen, clearly violate city, state, and federal law protecting individual freedoms and civil rights.
Social Justice Reforms for City General Plan To remove bias, discrimination, extortion, coercion, and inconsistencies
Citizens suffering repeated discrimination or oppression from a broken system will logically look for ways to circumvent such injustice, like seeking out the aid of Walter Wong,12 a contractor and permit consultant who offered a pathway for citizens to avoid discrimination and oppression from biased policies and processes. Instead, we can and should work diligently and tirelessly to remove the unconscious biases persisting in our city government policies and processes to eradicate the need to protect oneself from social injustice and to improve the public health of San Franciscans. Dr. Hahn and colleagues go on to show that “Protection of civil rights…by laws, regulations, and court decisions and redress of violations of those rights have been associated with marked improvements in the health of covered populations and of intermediate outcomes such as education and income known to produce health benefits… The public health benefits of civil rights implementation can be large and long term. Civil rights thus may be considered a productive arena for public health theorizing, research, policy, action, and practice…The public health community has the opportunity to collaborate with agencies responsible for the enactment and enforcement of civil rights, promoting civil rights as a means of advancing public health and reducing health inequities.”13 Martin Baron, retired executive editor of the Washington Post, underscored our shared purpose poignantly in his 2021 commencement address to Suffolk University graduates when he stressed that “we can either give up on institutions that betray our values, or we can seek to repair them. I urge you to take the latter course. Repair them.”14And, thankfully, we can 18
successfully identify and remove unconscious biases and discrimination from our city policies and processes by •
Enacting an Administrative Code that outlines what constitutes probable cause that a violation of the City General Plan has been committed and ensures that probable cause is established before any investigation is initiated.
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Amending SF Campaign and Governmental Conduct Code, Article III, Chapter 4, Sec 3.400 to either include “unconscious or unintentional bias and/or discrimination,” or to remove the word “intentional.”
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Enacting an Administrative Code that requires city investigators to seek out and identify any possible inconsistencies, such as conflicting codes within the City General Plan; and when inconsistencies are present, city investigators must refrain from issuing a code violation to innocent citizens but instead must assign the inconsistency to the appropriate agency and the Board of Supervisors to provide timely and just code reform.
Enacting an Administrative Code requiring that outcomes of appeals or variances that warrant a re-evaluation and/or update to the City General Plan, be communicated by the citizen and/or arbitrator to the appropriate agency and the Board of Supervisors for timely and just code reform.
• Enacting an Administrative Code requiring that "corrective action" required at the beginning of the permit/enforcement process cannot be expanded later. • Enacting an Administrative Code that prevents city agents or agencies from requesting or mandating “corrective actions” that violate other city codes or state/federal laws.
By engaging in this social justice endeavor, our city agencies can and will be able to collaborate effectively with our citizens to enhance and improve properties, safety, neighborhoods, the urban canopy, open spaces, public health, and the greater good. I do look forward to San Francisco becoming a model of how cities can effectively build partnership, harmony, and justice between citizens and city agencies.
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References on request.
Mihal Emberton, MD, MPH, MS practices at Kaiser Permanente San Francisco and is Clerkship Site Director, Associate Clinical Professor, and received the 2019 Excellence in Student Teaching Award, all at the UCSF Family & Community Medicine. She is a member of the Board of Directors, San Francisco Marin Medical Society, and of the SFMMS delegation to the CMA House of Delegates.
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SFMMS ADVOCACY CASE STUDY: ENDING SMOKING IN RESTAURANTS AND BARS AND MORE
Steve Heilig, MPH
Thirty years ago, tobacco could be smoked almost anyplace a smoker wanted, even though ever more evidence was being published that secondhand or environmental tobacco smoke posed serious health hazards even to non-smokers. In 1994, San Francisco became the first big city to ban all smoking in restaurants, bars, and other public workplaces. And therein lies a story. People of a certain vintage can recall what it was like to emerge from fine dining or less-refined dancing and drinking reeking of cigarette smoke, not to mention coughing. A coalition of health advocates decided to fix that. Led by then-President of the San Francisco Board of Supervisors Angela Alioto, the San Francisco Tobacco-Free Coalition, made up of the local Heart, Lung, and Cancer societies, other Heath and children’s advocates, and more, hosted by the San Francisco Department of Public Health (which, along with UCSF’s leading tobacco researchers could provide scientific and logistical support but as public organizations could not actively “lobby”), and the SFMS, supported local legislation to ban smoking in restaurants. I represented SFMS and as chance would have it was a co-chair of the coalition. The local restaurant association and other business interests were adamantly opposed and marshaled their forces. Tobacco lobbyists in dark suits roamed City Hall and showed up at all Supervisors’ hearings on the matter. At one hearing I, as a surrogate moderator, asked each health group to identify themselves and who funded them, then asked each youth group to show us their posters in support and who funded them (“Um, my mom?”), and finally asked “All the gentlemen in the nice ties to kindly tell us who they are and who pays them and if they’d like their own kids to start smoking tobacco as the tobacco industry so fervently wishes they would?” A mild pandemonium ensued and Alioto
RESOURCE CORNER:
Mindful Yoga for Healers A monthly weekend offering of free Mindful Yoga for Healers. This is specifically for SFMMS members to join their colleagues in order to heal, replenish, restore, and connect! Sign up at https://mindfulyoga.jessiemahoneymd.com/ to be notified of class dates and times.
Culinary Medicine A quarterly Culinary Medicine session with local physician chefs. During these sessions, the physician chefs share healthy recipes, culinary medicine concepts and demonstrate cooking techniques for our SFMMS physician members on their culinary medicine journeys.
asked me “That’s enough of that, but would you like a security escort to your car when this meeting is over?” I didn’t need that, but instead retired to what was then one of the most popular dining and drinking spots in town, a short walk from City Hall. Its famed owner and chef had spoken vehemently against our smoking ban. We were never sure if he was funded by Big Tobacco too, but he said that fine diners came to his place from around the world (true) and that many would stop doing so if they couldn’t smoke there. He favored “smoking sections” as a compromise. Alioto asked me for a response, and I said “I love your establishment, sir, but I bet your wonderful food will taste even better without smoke mixed with it, and besides, if somebody won’t eat there just because they won’t step outside to smoke, they don’t really want to eat there very much, do they? But if you can tell how to enforce a ‘no chlorine’ section in a public pool, we might consider that.” More general hilarity, and once I got to his fine bar, where an old friend of mine worked, he and I noted the nasty glare I was getting from the boss. “I think we are going to ban smoking in here,” I explained. “Excellent!” my friend responded, speaking for countless food industry workers. “Just don’t let him make your drink tonight.” The smoking ban passed. There were challenges and lawsuits and cries of doom, but the policy spread statewide, nationally, and even to other nations. Restaurants thrived. Other local policies banning tobacco advertising, flavored tobacco products, and more have followed. San Francisco was a pioneer of something that now seems common sense. If there are those who would prefer to go back to the Smoky Old Days, they are a small and dying breed indeed. But hopefully many have had healthier and longer lives in clearer dining rooms - and enjoyed their meals more too. Women and Parents in Medicine Sessions Quarterly sessions for SFMMS members that alternate between Women in Medicine discussion topics for those members who identify as women or Parents in Medicine sessions for members to discuss parenting techniques, while balancing work as a physician. Book Club A quarterly book club for SFMMS members. Each quarter, participants choose a new book, usually written by local physicians. Past books include, “Pearls from the Practice of Life” by Dr. John Chuck, “God’s Hotel” by Dr. Victoria Sweet, and “Together” by Dr. Vivek Murthy. SFMMS Members who register for the Book Club receive a free copy of that quarter’s book. For more information, contact Director of Engagement, Molly Baldridge at mbaldridge@sfmms.org.
To view recordings or to register for upcoming events, visit the SFMMS Wellness Page at www.sfmms.org/get-help/physician-wellness.
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Special Section: Ethical Health Policy
ASSIGNING VALUE TO A HUMAN LIFE DURING “CRISIS STANDARDS OF CARE” William S. Andereck, MD, FACP The “lifeboat scenario,” in which physicians are faced with determining who lives and who dies, has been debated for years in the bioethics literature but these discussions have been primarily speculative—until now. The Covid pandemic has forced us to move from the planning stages to the actual enactment of rationing policies developed in the conference room, not the clinical ward. In the Fall of 2020, Alaska announced that it was adopting “crisis standards of care” which would empower health care providers to ration limited medical resources to the most appropriate recipients. What does this mean for physicians who are now being asked to participate in protocols which can require them to remove their patient from life support to make room for another patient who is more likely to benefit? How are the professional obligations to work for our patient’s welfare impacted? Finally, what is a practical approach for the ethical physician operating within “crisis standards of care?" I address these questions here, while arguing that much depends on how one ascribes value to each individual life.
Planning for the unthinkable
In March of 2020, the California Medical Association was asked by the Governor’s office to prepare a policy for rationing respirators if they became unavailable during the height of the first wave of Covid hospitalizations. I was asked to chair a Technical Advisory Committee (TAC) composed of several prominent physicians from around the state to produce this policy. The details of our deliberation have been reported earlier, but the only point on which we could not come to unanimous consensus was at the philosophic core of our deliberations—How do we determine the value of each of the lives available to save? The conventional position, and the one with which we began, is that each life should be assigned equal value when designing rationing plans. Several members of the TAC promoted a different idea. They proposed looking at the expected years of life remaining for each individual. In essence, the goal changes from saving the most individual lives to saving the most number of “life years.” The implications of this shift in focus are staggering when it comes to application. The decision entrusted to health care providers is encapsulated in the dilemma posed in what is called the “Trolley Problem,” initially described by Phillipa Foote in 1974. Her dilemma describes an oncoming trolley which can only be diverted to one of two tracks, each containing people, thus determining who lives and who dies. Consider a 35-year-old and a 77-year-old, both healthy, and both needing the last respirator. Does the 77-year-old have as much claim for further time on earth as the 35-year-old? Someone must throw the trolly switch or nei20
ther patient will get the life-sustaining intervention. The choice may seem clear, but what if the 35-year-old has a disease expected to significantly shorten their life, or a chronic disability? These “slippery slope” arguments are the bane of normative ethics, but real life often requires they be negotiated, nonetheless. I contend that ethical analysis provides the skis to navigate these slopes.
Calculating individual worth
The idea that each person possesses an equal status on earth is quite new in the course of history. The concept began to catch on about 500 years ago, in what is now called the “Enlightenment.” Until then, most humans were considered little more than the property of their rulers. It needs to be recognized that the idea of the “Rights of Man” is primarily a European one, with an emphasis on “Man.” White is assumed. Although the gender, race, religious, and sexual preferences have been included recently, the concept of equal value remains intact. In America, a sense of positive right of expression and freedom has progressed to a belief that the freedom of the individual supersedes the benefit of the community. There is no better example of this attitude than those who chose to forgo Covid immunization despite the increased risk to family and neighbors. America has never been a country to give more than lip service to the idea of community obligation. We value our individualism. I attended meetings with colleagues in Europe for many years while listening to them talk about “Solidarity.” At first, I thought they were referring to a Polish labor union. It took a while to understand their willingness to step aside for the good of others. When chided on what was perceived to be the selfishness of Americans, I had to remind my friends that we were the ones that left. For freedom, we claimed. Refusals of the Covid vaccination have led to a backlash that demonstrates an interesting ethical shift from the unrestricted freedom of the individual toward a resurgence of community responsibility (communitarianism). It should never be assumed that moral standards are fixed. Society is being torn apart by fortunate individuals profiting heavily from their freedom, while many others are shut out of the benefits. A leveling is inevitable. Could the ethical paradigm be moving beyond the privileges of the autonomous actor and toward a time favoring collective needs over individual preference? Our devotion to individualism may, at some point, be supplanted by a communitarian spirit in which individuals in a society recognize that others would benefit more from an intervention, and freely cede their claim. But we are not there yet. Our TAC eventually stuck with the “whole life” concept over the one proposing “saved life years.” It is
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not that we did not see the value of saving the most years possible, we also recognized its complexity and the need for more public discussion and acceptance before endorsing it in policy. Practically, our decision was a prudent one, as most of the proposals containing the total life year concept were denounced vigorously by disability rights groups and the disenfranchised. In reality, we just played it safe. America is not ready. America may not be ready, but the rest of the world does not share our values in the same way. To illustrate an important difference, in 2019, I was having dinner with a Chinese bioethicist from the University of Beijing. Earlier that day she had given a presentation on the role of medical care in Chinese culture. Our discussion turned to distributive justice. She explained that the English word that would best confer the Chinese concept of “Justice” is “Harmony”. The goal of Justice in China, according to my colleague, seems to be restoring and maintaining harmony within the system, rather than defending individual rights and freedoms.
Practical Applications of Distributive Justice: From the imagined to the real
The goods and benefits of a society can be distributed among its members in a variety of ways. Our current system, focused on preserving the most lives possible, regardless of their remaining life years, depends on a method of distribution that is random. Essentially it is based on the idea of “first come, first served,” as long as the patient has a chance of survival to discharge. Physicians argue that asking them to weigh multiple contextual factors beyond prognosis for survival is confusing and detracts from their purpose and effectiveness. So, if there is value in increasing the number of years of benefit, how could the potential for more life years be included in the process? The principles of distributive justice can be applied at two levels. The first floats high above the fray, at the level of the “statistical individual.” The view is too distant to pick out individual actors. Decisions made at the statistical level are plans for future action. They have no direct impact on an identifiable person and should be formulated in what philosopher John Rawls calls a “veil of ignorance.” At the statistical level, everyone setting up policies and rules for the future is willing to accept their lot as determined by the policy adopted. A second application of distributive justice is at the level of the “identifiable individual.” Now the perspective has left the clouds and entered the trenches. Decisions at the bedside are personal, involving the emotional and contextual features that make each case unique, and more complex. The specific dilemma feared by clinicians under “crisis standards of care” is having to remove their survivable patient from life support in favor of someone else, who scores higher. My approach to this “dilemma” might be considered a Goldilocks one, in that I would prefer to consider a balance between both levels of decision-making. This requires keeping in mind that events occur in three phases: the anticipation, the actual event, and the retrospective, or period of reflection and reframing. I propose that the level of application of distributive justice be based on the phase of the event. The anticipation phase involves planning. When considering the disembodied statistical other, it might be possible to frame strategies for discriminate use of limWWW.SFMMS.ORG
ited resources, including the valuation of potential life years. A statistical evaluation can also be used in the retrospective phase, as lessons will be learned during an event that leads to adjustments of the plan during the next anticipatory phase. “No battle plan survives first contact with the enemy.” – Helmuth von Moltke, German military strategist Applications of justice during the phase, or moment, of the actual event can be challenging. Too often it is the case that the best laid plans are found wanting. Decisions at the bedside occur in another arena, that of the “identifiable patient.” What was an exercise in ethics and logic in the conference room is now a human enterprise in the hospital room. The rules have changed. Real people are involved. Now, in the moment, a physician’s responsibility to honor each patient’s individual prognosis supersedes duties to unknown “others.” Decisions about continued treatment are confined to each patient’s likelihood to survive to discharge, unless the patient or surrogate feels otherwise. The complicated calculus about the most life years may be considered when designing an admission strategy to the ICU, but once the patient is admitted, the calculus becomes too distracting. Soldiers tell us that in battle, you are no longer fighting for a cause, or your superiors, you are fighting for the comrade next to you in the foxhole. That same focus applies at the bedside.
In summary
When attempting to distribute medical interventions justly, in times of scarcity, there are two levels of application that can be applied depending on the phase of the event in question. Application at the level of the statistical person is appropriate in the planning or anticipation stage, as well as in the retrospective analysis. At this point, concepts such as life years saved can be introduced. Once a course of treatment is engaged, the identifiable person standard requires medical providers to focus treatment decisions on maximizing the odds of survival for each individual, unless survival to discharge is unlikely despite treatment, or the patient declines the proposed treatment. Crisis standards of care which focus on maximizing the number of years may determine who gets thrown into the soup, but not how the ICU team cooks it. The second point is that moral standards can change. Autonomous persons raging against the world may no longer represent the desired norm. A composite individual, working for the betterment of the whole, may become the new ideal. How would it feel to live in a society with everyone singing in harmony? Dr. Andereck has a private practice in Internal Medicine in San Francisco. He is also the Medical Director for the Program in Medicine and Human Values at Sutter Health. The author would like to acknowledge the contribution of PMHV bioethicist Robert Fulbright, MA, JD for his review and comments on this manuscript.
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Special Section: Ethical Health Policy
DYING WELL AND MORAL FORMATION: A Trainee Perspective on Ethics During the COVID-19 Pandemic Harrison Hines, MD Balancing the competing aims of individual autonomy and public safety has dominated the moral discourse of healthcare throughout the pandemic. Striking that balance is vital and should remain the primary focus of discussion, especially as medical ethics has unfortunately been subsumed into the political tribalism that engulfs our society. However, COVID-19 raises other pressing questions that should not be ignored. In particular, equipping individual clinicians and health systems with tools for weighing the benefits of human interaction—like allowing visitors in ICUs—against the risks of exposure will be critical in our preparation for the next pandemic. Further, the virus’ impact on trainee education has been marked; the value of hands-on learning during a pandemic must be addressed as institutions re-write protocols and policies. These questions are just a few of several that are often under-examined in discussions around institutional reform as we learn to live with COVID-19.
Public and Individual Ethics
In his book The Anticipatory Corpse: Medicine, Power, and the Care of the Dying, Jeff Bishop explores the moral veil covering modern medical practice and how it can shroud a doctor’s vision of patient care. He argues that, somewhere in the recent evolution of the profession, the source material for how physicians understood patients turned from living persons to nonliving information that could be better controlled. For example, a doctor’s education begins with learning the norms for human anatomy through cadavers; all future variety and dynamism in living patients is evaluated in reference to that original, nonliving body. Nuance is layered upon that foundation to account for variations in human anatomy, but that original body defines the norm upon which other living bodies must be judged. Bishop contends that early education bridles a young physician’s vision of human flourishing; it contributes to medicine’s trend toward striving for technical control over how we suffer from disease rather than imagining how to help patients’ narrate their lives well amid suffering. Whether explicitly stated or not, most students learn that the good end of medicine has more to do with mastery of disease than the promotion of health. The scientific advances achieved over the last century are phenomenal and have saved countless lives, and Bishop’s project is to highlight how we can continue advancing while also remembering the lived human experience at the core of it all. Just as learning the technocratic intricacies of pathology forms the foundation of medical training, caring for patients 22
through the pandemic feels like a similar morally defining experience for me as a resident. In particular, my calculus weighing public safety against individual dignity has been influenced by experiences with patients dying in the hospital. Part of my work involves covering the neurocritical care unit. Most of our patients have either an intracranial hemorrhage or a massive ischemic stroke, both of which carry high rates of morbidity and mortality. During various infection peaks in the pandemic, the hospital adopted a no visitation policy to protect patients and staff. As a result, our patients in the ICU could not have any visitors at times, despite the devastating nature of their injuries. Many patient families had been marginalized by society and healthcare systems in the past, and they told me not being able to visit their sick family member felt like another affront. However, the policy allowed patients on comfort care to have family members visit to say goodbye. For many of my patients for whom the neurologic prognosis seemed grim, this policy posed a painful moral predicament. Countless families told me that they wanted to see their loved ones, but they did not want to transition to comfort care in order to do so. Families felt as if they were being told that the only way to obtain visitation permission was if they were willing to “kill them,” as one patient’s son told me. Those comments struck me. As a physician, I affirm our obligation to protect public health and maintain the social trust. At the same time, as a human, I could not imagine the anguish those families felt as they faced that decision. I recognized the impetus behind those measures, and yet I felt torn. It seemed as if the demands of public health were in direct opposition to my desire to help people die with a modicum of dignity and in the presence of their family members. Further, it felt like yet another injury upon many disadvantaged patients who had already been left behind by health systems in the past. Family meetings about a patient’s neurologic prognosis became difficult as often family members had only been able to see their loved one over video. As the pandemic drags on, the solutions to these moral challenges remain opaque, but the obstacles themselves have lessons to teach. First, the stakes are more tangible. Every clinician has experience with treating COVID-19 infected patients or their family members, and many have faced deep ethical questions in caring for them. Those individual stories ground abstracted moral discourse in the lived experiences of our patients. Second, the importance of preparing our ethical frameworks for the next pandemic is patent. This virus barreled through the country,
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leaving scores of clinicians alone to face a threat that no one understood. Health systems were forced to make impossible choices regarding resources—PPE, clinical staff, hospital beds— absent clear guidance on how to weigh competing goods. Practice patterns varied across California, and the task of tackling both the ethics of pandemic control and the logistics of resource allocation made creating a unified response challenging. As our public health institutions continue to support our communities, I think it is imperative that we the reflect upon the moral injury that our patients and our health care practitioners have faced throughout this pandemic. We must emerge from this travesty with a more holistic vision of the good, both public and personal, as we prepare for the next outbreak.
Moral Formation
In addition to the problems posed by weighing individual versus public health ethics, the pandemic’s impact on medical education has been profound. Graduate medical education has undergone a seismic upheaval as health professions schools have struggled to both educate and protect the next generation of clinicians. Traditionally, hands-on clinical rotations are among the most morally formative experiences for trainees. Ethics—both population and individual level—is framed in the context of proximate human suffering by elevating the needs of the specific persons in front of the clinician. The COVID-19 pandemic has disrupted that moral framing by forcing trainees and educators to re-examine the value of learning against the quantifiable risks of infection. In many medical schools across the United States, the early stages of the pandemic saw a swift transition to fully virtual preclinical rotations and cancelled in-person clinical rotations. Across California, nursing schools lost clinical placements for their students, depleting the already thin selection pool for them to complete their rotations. Learner responses differed: some decried the loss of clinical experience, while others lauded their institution’s commitment to student safety. COVID-19 forced a response: how essential are students to the function of a health system? The years living with the pandemic and the development of effective vaccines have clarified the answer. Students are now back in hospitals for rotations and many pre-clinical courses operate using a hybrid model. Clinical educators remain in short supply as COVID-19 exposures and infections decimates the workforce, but most institutions and learners have decided that giving students at least some handson experience is worth the risks. Committing to student education despite those risks is a bold declaration of values. It asserts that to stand by patients who are suffering, knowing the risks of infection, is itself part of the moral formation of clinicians-in-training. Managing personal risk in the pandemic has become a daily calculus of weighing the benefits of an action versus the potential for infection; e.g. is travelling to see family worth the exposure, how important is it for one’s children to participate in team sports, etc. As health systems re-institute in-person clinical rotations for students, they are laying the foundation for a moral calculus of how to evaluate the benefits versus risks of patient care that their students will carry throughout their careers. Given the risks (much mitigated by the vaccine), asserting that students should return WWW.SFMMS.ORG
to the bedside models the value our systems place in education and in caring for people who are suffering. One student I supervised in recent months echoed that sentiment: they said that coming into the hospital in the pandemic was not only good for their learning, but ethically the right thing to do. Each individual must appraise the risk themselves, and helping students understand the factors impacting that choice is a critical component of learning how to be a clinician. Training for residents and fellows has roiled as well, though in ways disparate to that of students. During the 2020-2021 academic year, about 13,600 resident physicians were training in California. With just over 115,000 physicians active in the state, residents (not even including fellows) constitute a substantial proportion of the physician work force. A large number health systems depend on residents to operate at all. In contrast to the student experience, for countless residents and fellows, the demands of patient care have surged. Trainees were reallocated into intensive care units, emergency departments, and screening clinics for patients with respiratory symptoms. As society has ridden waves of viral variants causing spikes in COVID-19 cases, resident hours have increased, and the work has intensified. Several studies found burnout rates rose exponentially along with worsening of depression and other mental health disorders. While many of my colleagues are eager to care for vulnerable patients, the volume has been burdensome. Fellows and residents straddle the divide between education and work by both being learners as well as primary clinicians. Residents, already strained by the pressures of training, have been pushed to their limits struggling through the pandemic and are morally exhausted. The long-term moral impact of shouldering that work while also caring for oneself and one’s family remains to be seen. However, as systems prepare for the next pandemic, planning for clinician burn out will be key. Maintaining the health of the workforce must be a priority to ensure high quality of patient care.
Conclusion
This essay has examined only a few of the myriad moral questions generated by COVID-19 that must be addressed as we reform our public health system. Societally, balancing the risks and benefits of care for the dying and visitor policies will mitigate the impact of moral injury for everyone: both the clinicians and for the patients/families (in particular vulnerable families slighted by healthcare institutions in the past). In addition, creating clear ethical frameworks for clinicians to mobilize when making hard decisions about their practices will contribute to a more unified response in the future that streamlines operations across the state. Re-imagining how trainees learn and work to ensure a balance between those objectives will foster the moral formation of young clinicians and help guard against undercutting their education as well as overburdening them with work. The medical community has been heroic during this tragedy; evaluating these ethical questions in the wake of this disease will support our clinicians now and into the future.
Harrison Hines is a 4th-year Neurology resident physician at UC San Francisco.
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Special Section: Ethical Health Policy
Commentary
AXIOM: Democracy is Necessary for Public Health to Thrive George Fouras, MD I will confess to you that I had become complacent. Secure in feeling that in the course of US history, the concept of the peaceful transition of power and the stability of our democracy was solid. But the events of last January 6th have shown just how fragile democracy can be. Some may think the example that I will share here is extreme. But we are witnessing the laying down of the foundation for something such as I will describe, recurring. It is an insidious process. The systematic erosion of our democracy through the spreading of lies and misinformation to manipulate people into questioning the integrity of elections and to generate hatred for people who do not believe in what they do. And yes, this has great implications for medicine and public health. My parents were born in the Peloponnese area of Greece. My father grew up not far from Kalavryta when in 1944, in an effort to eliminate resistance guerrillas operating in the area, the German army gathered all of the men and boys into the town square and summarily gunned them down. The women were corralled into a local school that was then set on fire, but many of them escaped. My grandfather, who was the local physician for several villages in the area, was summoned to try to save as many of the dying men as he could. He later told my parents that as he was riding to Kalavryta, he could hear the screaming of the women in their grief in the distance. One young boy, who would become the best friend of my father, survived the event by hiding under the skirt of his mother. In Athens, my mother was 10 when the Nazis began their occupation of Greece. Over the next 4 years, she experienced the horrors that come with fascism. Everything was rationed. Bread was made by grinding corn husks into flour. She would witness people dead in the street from starvation as she walked to school. In 1944, five men from the area were hanged from a tree, for the rest of the citizens, including my mother, to witness. Their names now memorialized on a monument near the town center. Fast forward to now. The United States Dept. of Homeland Security has noted that the presence of violent white supremacists is “the most persistent and lethal threat” facing us today. In addition, the Center for Strategic and International Studies notes the significant rise in the number of far right attacks and plots over recent years. For the last four years we have been inundated with lies and misinformation, so much so that I fear we have become numb to its effects. But we have witnessed our elected leaders not only embracing the rhetoric, but actively participating in its dissemination. In January 2021, we witnessed 147 representatives and two senators move to reject the results of the Electoral College under false pretenses and imply that the election was “stolen.” Their fealty to one man, placing party over country, and abrogating their sworn oath to defend and uphold the Constitution—meaningless to them. None of them deserve to be in elected office. All of them should be held accountable. This group of legislators are likely to be heterogenous in scope. At one extreme, it is possible, if not probable, that some of them aided and abetted the insurrectionists while at the other end, 24
fear for their political lives and immense peer pressure was enough for them to sacrifice their principles. The House has convened a subcommittee to investigate the insurrection, and there is evidence that several of the legislators were not only interested in overturning the election, but were actively complicit in the January 6th events. Our mission and duty is to take care of our patients, to preserve the integrity of our profession, and to promote public health for the benefit of us all. But I would put to you, that without a stable democracy, nothing we stand for would matter. And I am deeply concerned that we may be willing to compromise our principles and tolerate the speech or actions of a public figure because we seek to weigh the advantages of that person’s legislative power to us versus the deleterious effects of their actions to the Republic. Our democracy and its preservation is the single most important factor for maintaining public health. Some actions are underway, but holding people accountable is not an easy task. Recently, the political action committee (PAC) of the American Medical Association (AMPAC) voted on a six-month moratorium for political donations to the individuals who challenged the Electoral College results. The PAC for the American College of Surgeons chose to hold donations for two years, while the PAC for the American Academy of Child and Adolescent Psychiatry elected to ban donations indefinitely. In addition, several large corporations, including Toyota and AT& T—who had advertised that they would no longer give political contributions to politicians who supported the “big lie” of stolen elections and the January 6 insurrection—reneged after approximately six months, and only reversed this behavior after large politically active organizations called them out on this hypocrisy. So what else are we to do? I propose the following: 1) That for the next year, no member of Congress who participated in the spreading of disinformation, the attempt to negate the results of the election, or who attempted to constrain the democratic process, receive any support, be it monetary, or in kind. 2) That our institutions and government affairs committees develop policies that are transparent, and fair, to hold our legislators accountable for their actions and words. To demonstrate for our members, and the public, that we support our democratic principles without compromise. 3) To develop criteria that is both fair and transparent, that may be used to determine whether a candidate for office qualifies for support by our political action committees. It is imperative that we be clear, to our colleagues and our patients, that we will not support any person or institution who seeks to undermine our government, either overtly or covertly. January 6th was our clarion call. Do we take a stand? Or risk oblivion.
George A. Fouras, MD, DFAACAP, is a child and adolescent psychiatrist and past-president of the SFMMS.
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LEAVE NO CALIFORNIAN BEHIND Sandra R. Hernández, MD Not long ago, the idea of universal health coverage was a dream — a cherished goal to strive for. Now California, the largest state in the nation, is poised to make that dream a reality. Earlier this week, Governor Gavin Newsom released a budget proposal to remove all barriers to Medi-Cal enrollment based on immigration status. In recent years, California eliminated such barriers for Californians with low incomes under the age of 26 and over the age of 49. The governor’s latest plan would finish the job for the rest of California’s immigrant population — and make history in the process. Covering everyone has never felt more urgent. The COVID-19 pandemic reminds us daily that we are all connected by health. It has made all of us more aware of the many ways in which we depend on each other to be and stay well. That is why universal coverage isn’t just about making history. It’s about making a healthy, prosperous future together. While California has reduced inequities in coverage over time, it hasn’t eliminated them. As a new CHCF report shows, noncitizen adults are more than three times more likely to be uninsured than their citizen counterparts. This disparity persists despite the vital role that Californians without citizenship play in every aspect of our society and economy. Universal coverage is within reach because of the hard work of so many Californians — especially immigrants and their
families and friends — who came forth to tell their stories and demand change. It is feasible because whenever we as a society have expanded coverage, the benefits have been so clear. Of course, coverage alone won’t guarantee that people get the care they need, but it is a necessary precondition. We must also continue to work with similar urgency to improve access and quality of care for everyone enrolled in Medi-Cal. When it comes to making sure everyone has security and health opportunities that coverage provides, the future starts now.
Sandra R. Hernández, MD, is president and CEO of the California Health Care Foundation. Prior to joining CHCF, Sandra was CEO of The San Francisco Foundation, which she led for 16 years. She previously served as director of public health for the City and County of San Francisco. Sandra practiced at San Francisco General Hospital in the HIV/AIDS Clinic from 1984 to 2016 and was an assistant clinical professor at the UCSF School of Medicine. She is a graduate of Yale University, the Tufts School of Medicine, and the certificate program for senior executives in state and local government at Harvard University’s John F. Kennedy School of Government.
California governor Gavin Newsom discusses his budget proposal, dubbed the California Blueprint, on Thursday, January 13, in Santa Clara, California. Photo: AP / Noah Berger
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Emergency Department Crowding in San Francisco:
INCREASING EFFECTS ON THE EMS SYSTEM AND NEW COUNTERMEASURES TO IMPROVE PATIENT FLOW John Brown, MD The San Francisco Emergency Medical Services (911) System, like much of the City’s health care delivery system, has been struggling to cope with COVID pandemic surges, increases in opiate overdoses, behavioral health patients and staffing challenges despite an overall decrease in patients accessing the system for care. EMS is often the health care provider of last resort especially for patients who cannot access more traditional sources of both primary and emergency care services. Our long standing, strong relationship with our Receiving Hospitals from multiple health care systems, has come under pressure from Emergency Department crowding that threatens to undermine our ability to respond appropriately to EMS calls. During the past 18 months of the COVID pandemic, EMS call volume dropped precipitously but has been increasing at a rapid pace over the last several months as illustrated in this chart showing the volume of EMS incidents per month since 2017.
Our ambulance diversion policy allows emergency departments that are under stress and believe that they cannot accept another patient without providing them a lowered standard of care can divert ambulances away until the system has 50% of our core receiving facilities on diversion. The rate of change in ambulance diversion has accelerated past EMS transports since mid-May of this year as illustrated in this chart contrasting the percent of change of ambulance diversion and EMS transports. 26
An additional complication is that ambulance patients have experienced offload delays at an increasing rate in the same timeframe, far exceeding the California state goal of :20 illustrated in this chart of the average number of minutes of APOT interval over the last two years.
These factors, along with staffing issues caused by antiCOVID measures and retirements are causing increased frequency of ambulance depletion in the 911 system. We are having more and more frequent periods of time when we cannot assign an ambulance to a 911 call as shown in the following chart of 30 day average daily events when we ran out of ambulances (called Medic to Follow, or MTF events).
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This means that patients who could potentially have the greatest medical need are unable to obtain ambulance assistance more and more frequently in San Francisco. While not the only contributing factor, having ambulances delayed at hospitals or delayed driving longer distances to hospitals not on ambulance diversion adds to this resource depletion. We have never experienced this degree of depletion before even at higher volumes of 911 calls. The San Francisco EMS Agency recognizes the severity of the problem and the increasing likelihood of negative impact on patient care. We have supported countermeasures to both decrease the flow of patients into the Emergency Departments from EMS and to improve / level load the distribution of patients to hospitals in the system. Our first intervention will be at the intake of the 911 call at our dispatch center (Division of Emergency Communications). The Department of Emergency Management is pursuing funding for RNs to work side-by-side with 911 dispatchers to refer low acuity calls once processed through our triage protocols to medical advice and appointment lines. We are also pursuing links with non-ambulance transport services and response by behavioral health and other specialized, non-transporting prehospital teams (this has already started with the Crisis Response Teams system). We now have a cadre of over 30 Community Paramedics in partnership with the San Francisco Fire Department that also respond on special “EMS 6” units, engaging patients who are high utilizers of medical services and attempting to redirect their use of 911 to more appropriate and effective services. We continue to promote transport of appropriately screened 911 patients to the Sobering Center and Psychiatric Emergency Services at Zuckerberg San Francisco General Hospital without having to utilize Emergency Department services. We have assisted EMS provider agencies with training material and secured state approval to provide point of care COVID testing of patients so that the capacity of both Sobering and PES facilities will increase to pre-pandemic levels and beyond.
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Finally, we developed a means to level load the 911 patient destinations across all receiving hospitals in the system, which is called Centralized Ambulance Dispatch Determination. Currently staffed with either a Base Station Physician or senior Paramedic Supervisor, the CADDie pilot has access to ambulance data system-wide and for the busiest 8 system hours per day redirects ambulance traffic away from critically impacted emergency departments. The EMS Agency is actively pursuing ongoing and expanded funding for this system, likely next moving to 12 hours/day live coverage and eventually to 24 hour a day coverage based out of the 911 dispatch center. Despite these measures, our ability to respond to our patients is diminished. Therefore, we are planning to institute changes in our ambulance diversion and ambulance patient offload time policies to decrease reliance on these measures to solve the emergency department crowding issue. There are many similar jurisdictions in both California and through the United States that have successfully eliminated ambulance diversion and implemented offload delay goals that exceed our own. The state of Massachusetts eliminated ambulance diversion in 2009 and subsequent studies failed to show worsened patient outcomes or increased ambulance patient offload time delays. While there was interest at the American Medical Association policy level to extend this practice to other states, we have not seen progress elsewhere. Ambulance patient offload time delays statewide led the legislature in 2019 to task the California EMS Authority to implement a target of :20 and initiate statewide reporting on progress. You can find their current report and background on the EMSA website at https://emsa.ca.gov/apot/ The EMS Agency has embarked on a collaborative effort to make these policy changes as implementable and able to succeed as possible. I am asking the SFMMS members with active hospital practices to engage with their facility’s emergency departments and hospital leadership to help improve the crowding situation. We realize that EMS is only a part of the hospitals’ overall mission, which includes patients that self-present for emergency care, patients who utilize other outpatient services at these facilities and patients in need of urgent, semi-elective and elective in-patient procedures. It is only though systematic, consistent, accountable, and equitable processes that we will be able to lessen the impact of this emergency department crisis and improve the outcomes of our EMS patients. Dr. Brown is the Medical Health Operations Area Coordinator for the San Francisco Department of Public Health, an emergency physician practicing at San Francisco General Hospital and a Medical Officer on the Disaster Medical Assistance Team CA-6.
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Special Section: Psychedelics and Medicine
From Underground to In the Lab:
THERAPEUTIC USE OF PSILOCYBIN IN PSYCHIATRY AND ADDICTION MEDICINE Andrew Penn, MS, PMHNP and Josh Woolley, MD, PHD Psilocybin is a naturally occurring tryptamine alkaloid from mushrooms of the psilocybe genus that initially evolved likely as a natural defense against predation (Reynolds et al., 2018). It is a prodrug of psilocin (4-hydroxydimethyltryptamine) and has been used by Indigenous peoples of Central and South America for centuries in healing and visionary enhancing ceremonies (Wasson, 1980) and may have been an ingredient in the kykeon, the brew consumed during the Eleusinian mysteries of ancient Greece (Muraresku, 2020). Psilocin is a serotonergic (5-hydroxytryptamine, 5-HT) agonist, primarily exerting its psychedelic effects through the 5HT2A receptors but also binding to 5HT2C, 1A, and 1B receptors (Halberstadt & Geyer, 2011). Ingestion of psilocybin can cause profound, dose-dependent changes in sensory perception and cognition including auditory and visual hallucinations and derealization (Kaelen et al., 2015; Kometer & Vollenweider, 2018). These effects last 3 to 6 hours after oral ingestion. Psilocybin and related compounds were investigated as therapeutic drugs in the middle of the 20th century; became an important sigil of the youth culture of the 1960’s before being banned as a dangerous intoxicant; and for the last 20 years, have been the subject of careful scientific study as a medicine to treat depression, anxiety related to end of life, and perhaps most curiously, addiction (Bogenschutz et al., 2015; Davis et al., 2020; Griffiths et al., 2016; Johnson et al., 2014; Reynolds et al., 2018; Ross et al., 2016; Sessa, 2012). Only 15 years ago, in 2006, the first clinical trial of psilocybin of the current era as a treatment for obsessive compulsive disorder (OCD) was published by Carlos Moreno at the University of Arizona. Since then, each year has brought not only more studies, but a greater diversity of clinical indications, including anxiety at the end of life or secondary to long term HIV Diagnosis (Anderson, 2020), tobacco use disorder, depression, and alcohol use disorder. The reader is directed to an excellent review by Thomas (2017) of these studies. Other psyche28
delics, such as MDMA, (3,4-Methyl enedioxy-methamphetamine), are under investigation for the treatment of post-traumatic stress disorder (PTSD), but are beyond the scope of this article. These studies are being undertaken at some of the most august universities in the world, including Imperial College, London, New York University, Yale, Johns Hopkins, and our own institution, the University of California, San Francisco. To the uninitiated, the use of a drug that has been placed under schedule 1 of the controlled substance act, especially to treat other substance use disorders, may be surprising, or even seem foolhardy. Importantly, modern studies indicate psilocybin is generally well tolerated (Bogenschutz & Ross, 2018), has low physiological toxicity, and is not associated with compulsive drug seeking (e.g., Amsterdam et al., 2011; Tylš et al., 2014). To understand the potential value of psychedelics as therapeutic agents, one must first understand the context in which they are used, and the neurological mechanisms that may allow them to help patients become “unstuck.” This article will discuss the context in which these drugs are used, the theoretical mechanism of action for their effects in the brain, and finally, will discuss our ongoing research projects. How these drugs are used in therapeutic clinical trials is markedly different than how people typically use these drugs recreationally. Unlike in recreational settings where these drugs are often used to enhance a bacchanal, in clinical trials psilocybin is used as a means of catalyzing the therapeutic process (Sessa, 2012). The drug is only given, usually once, in the setting of a comfortable, living-room like environment where the patient is accompanied at all times by two therapists (traditionally a male-female dyad, but this is beginning to change to acknowledge the nonbinary nature of gender identity). The patient has spent several hours before the drug dosing day with both therapists, in preparation therapy, discussing the therapeutic goals of the session, fears about what might emerge, learning about the effects of the drug, and understanding the
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protocols in place to ensure safety and comfort for the patient (Johnson et al., 2008; Penn et al., 2021). The therapy provided on the drug dosing day is largely supportive, with therapists encouraging the patient to direct their attention inward, and to be open to what thoughts or emotions emerge for them. Eyeshades and music played over earphones encourages this inward orientation. Should emotional or physical distress emerge for the patient during the session, therapists and an on-call prescribing clinician support the patient through challenging portions of the session, which can usually be achieved through reassurance alone. Most of the therapy occurs in the days following the session, in what is known as integration psychotherapy. It is in these sessions that the same therapists debrief the drug experience, search for overarching themes and insights, and help the patient integrate these findings into real behavioral changes that may lead to a prolongation of psychotherapeutic effects. The outcomes of extant studies have been impressive. A pilot study of psilocybin assisted therapy in alcohol use disorder also demonstrated dramatic effects (p=<.05) persisting during the 36 weeks following the therapy (Bogenschutz et al., 2015). A similar persisting reduction in use of tobacco, was found with 80% of subjects treated with psilocybin assisted therapy remaining abstinent from tobacco use six months after the treatment (Johnson et al., 2014). A recent study of the antidepressant effects of psilocybin done at Johns Hopkins (Davis et al., 2020) showed a large effect (d=2.2, CI 1.4-3.0, P=<.001) compared to a wait list, at five weeks after the treatment. Another recent study comparing psilocybin to escitalopram in the treatment of depression found that the two treatments were similarly effective against depression, but that psilocybin was better tolerated and demonstrated improvements in secondary measures of quality of life (Carhart-Harris, et al, 2021) The endurance of the therapeutic change after psilocybin ingestion in clinical trials highlights a provocative difference between psychedelic therapies and traditional psychopharmacology, where the benefit of the medication is quickly lost once the patient stops taking it. How such enduring effects can be maintained long after the psychedelic drug has been cleared from the body is currently a mystery and the focus of intense study. One hypothesis for how this is possible derives from patient reports that after a single dose of psilocybin in the highly supportive therapeutic setting (i.e. preparation and integration therapy with two therapists) of modern clinical trials, many people notice they are able to shift rigid and long-held patterns of thinking and behavior. For instance, many patients report seeing things in new and surprising ways and feeling like they can engage with challenges using more open and flexible approaches. Supporting these subjective reports, basic science studies and clinical trials have found that psilocybin may enhance cognitive flexibility, the ability to shift perspectives and reconfigure responses, which is commonly impaired in depression, addiction, and many other neuropsychiatric disorders (Heink et al., 2017). Fascinatingly, these behavioral changes may be promoted by psilocybin’s enhancement of basic mechanisms of neural plasticity (Inserra et al., 2021), the ability of the brain to change and adapt to new information (Liu et al., 2017). WWW.SFMMS.ORG
There is also interesting data from studies using neuroimaging techniques including functional MRI (fMRI) and electroencephalogram (EEG) supporting this hypothesis. For instance, multiple studies have found that neural activity both within and between stable networks in the brain are decreased during the acute effects of psychedelics. Furthermore, neural activity in brain regions crucial for thinking about oneself (so called selfreferential processing) is the most strongly affected by psychedelics (Carhart-Harris et al., 2012, 2016; Palhano-Fontes et al., 2015). Finally, psychedelics also appear to increase the amount of randomness or uncertainty in activity and connectivity within the brain, i.e. increasing neural entropy. Taken together, these findings have been used to suggest that a single administration of a psychedelic can reset the brain into a more flexible state, which could allow for a less rigid set of behaviors. Because of the enormous potential of psychedelics to address unmet medical needs of people living with neuropsychiatric disorders, a team of scientists and care providers across disciplines came together to form the Translational Psychedelic Research (TrPR) Program at UCSF (psychedelics.ucsf.edu). Our team aims to link basic science discoveries to impactful, real-world clinical care through creative and rigorous studies. Through collaboration, we hope to provide important safety and efficacy data and shed light on how psychedelics might work for specific health conditions. We are currently part of a multisite trial of psilocybin assisted therapy for depression https://clinicaltrials. gov/ct2/show/NCT03866174. We have several other studies starting in late 2021 or early 2022 that will examine psychedelic treatments for people living with a variety of neuropsychiatric disorders—chronic low back pain, bipolar disorder, methamphetamine use disorder, and Parkinson’s Disease—and explore the potential roles of neural plasticity and anti-inflammatory effects in each. Through these projects, we and other research teams around the world will help determine if and in whom these drugs can be effective treatments. Bibliography available by contacting sfmms.org.
Andrew Penn, MS, PMHNP is an Associate Clinical Professor, UC San Francisco, School of Nursing, Co-Investigator, Usona sponsored Phase 2 study of psilocybin facilitated therapy for major depression, Translational Psychedelic Research (TrPR) Program.
Josh Woolley, MD, PHD is an Associate Professor, UC San Francisco, Department of Psychiatry and Behavioral Sciences,TrPR Program Director.
This work was presented at last year’s SFMMS/David E. Smith Addiction Conference; the 2022 conference will take place Friday, June 10, via Zoom. Details coming soon.
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Special Section: Psychedelics and Medicine
HOW COVID-19 OPENED THE DOOR TO A NEW ERA IN PSYCHEDELIC MEDICINE Shoshana Ungerleider, MD From Wall Street to Hollywood, psychedelics are having a cultural moment. For those of us who grew up in the “this is your brain on drugs” era, it’s hard to let go of stigma—and the mental image of an egg sizzling on a hot pan. But as a growing number of states and cities move to decriminalize drugs, and investors flock to an emerging market for psychedelic health care, substances like psilocybin, ketamine and LSD are edging into mainstream culture—and setting the stage for a paradigm shift in modern medicine. Within the next few years, we could see psychedelic therapies prescribed for refractory depression and post-traumatic stress disorder (PTSD), or used in palliative care among those facing a life-limiting illness. But first we need to more deeply understand the benefits of psychedelic treatments. Right now, we are in the perfect storm to accelerate continued study—and health care workers are on the front lines. It’s no coincidence that psychedelics are entering the conversation at the moment we most sorely need new ideas in mental health care. The world is experiencing mass trauma from COVID19. It will take years for us to truly understand the magnitude of the pandemic’s toll on our collective mental health, but on the front lines, the picture is much clearer. In a recent survey of more than 20,000 frontline medical workers, 38% reported experiencing anxiety or depression during the pandemic, and 49% suffered burnout. Another survey found nearly one-quarter of all health care workers showed signs of probable PTSD. When the American Association of Critical-Care Nurses surveyed 6,000 of their members this year, 66% said they had considered leaving their jobs because of the pandemic. “No amount of money could convince me to stay on as a bedside ICU nurse right now,” a Seattle-area nurse wrote in a resignation note posted on Twitter. “I can’t continue to live with the toll on my body and mind. Even weekly therapy has not been enough to dilute the horrors I carry with me from this past year and a half.” Among health care workers, the prolonged battle against COVID-19 has intensified a long smoldering problem. Facing a fragmented medical sytem with frequently misaligned incentives, health care workers have been grappling with anxiety and depression—even before COVID, the suicide rate among doctors was more than twice that of the general public. From support groups and training to apps that monitor mental health, there are a number of programs that aim to solve and treat the problems leading to clinician burnout. But most have barely scratched the surface, and the prevalence of burnout during the pandemic has led researchers to explore alternative solutions—including psychedelic therapies. 30
A new study at the University of Washington is evaluating the efficacy of psychedelic-assisted psychotherapy using psilocybin for frontline health care workers experiencing COVID-related distress. “The situations that frontline doctors and nurses are facing is unprecedented,” says Dr. Anthony Back, who’s leading the study. “The symptoms of depression, burnout and moral injury call out for research that looks at whether psychedelics can play a role in healing the healers.” The U.S. is not alone in seeking alternative therapies for the growing number of health care workers in crisis: at Vancouver Island University in Canada, the Roots to Thrive ketamine-assisted therapy program treats health care providers and first responders with PTSD, depression, anxiety and addiction. Realizing the potential of psychedelic-assisted therapy with health care workers is not without its challenges. For medical professionals, there’s a culture of perfectionism that makes asking for help a sign of weakness. Not only do health care workers seeking psychedelic-assisted therapy face the stigma associated with the use of these medicines, but there’s a stigma around seeking help in the first place. Just past these barriers and stigmas, however, there’s enormous potential. If these studies and programs are successful, they have the potential to alleviate the symptoms of stress, burnout and depression that health care workers are feeling. They may even stop medical professionals from leaving the workforce at an alarming rate and avert the looming disaster of a worldwide health care worker shortage. The halo effect could be enormous and offer the possibility of treating others in high-stress fields. Healing the healers is a win-win, and everyone can potentially benefit from better health care outcomes. The pandemic’s toll on health care workers affects the level of care that they’re able to provide—and you probably don’t need the World Health Organization’s official definition of burnout to tell you that it’s characterized by reduced effectiveness at work. If psychedelic treatments have the potential to alleviate any person’s suffering, they are worth studying. But because they have the potential to alleviate a great many peoples’ suffering— both directly and indirectly by improving the mental health of our frontline clinicians—we need to invest in studying them further and faster.
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Dr. Shoshana Ungerleider is a practicing internal medicine physician at CPMC in San Francisco, host of the TED Health Podcast and founder of endwellproject.org. A previous version of this piece appeared in TIME magazine.
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COMMUNITY MEDICAL NEWS Kaiser Permanente
Kaiser Permanente San Rafael
Maria Ansari, MD
Naveen Kumar, MD
In November 2021, the CDC’s National Center for Health Statistics released provisional data showing an estimated 100,306 drug overdose deaths in the United States during the 12-month period ending in April 2021, a 28.5 percent increase over the same period the year before. Since the start of the COVID-19 pandemic, our psychiatric colleagues at Kaiser Permanente San Francisco have seen a 20 to 30 percent increase in intake for anxiety, depression, and suicidal ideation. Early in the pandemic it was widely reported that alcohol sales rose by 20 to 30 percent, and within six months we had a corresponding 15 to 30 percent increase in people requesting treatment services. Another factor is the increased availability of the extremely potent synthetic opioid fentanyl. Easy to ship, even through the U.S. mail, fentanyl is being pressed into pills resembling prescription drugs. The result is that we are seeing a rise in overdose among people who are not regular drug users. The current situation is focusing attention on the importance of medication-based treatment, an area in which Kaiser Permanente has led the way. We offer all three medical treatment options: buprenorphine, naltrexone, and methadone. Every Kaiser Permanente medical facility has the ability to prescribe buprenorphine at the community standard, and we contract with methadone clinics in every community. An important component of medical treatment is availability of the life-saving opiate blocker naloxone. At Kaiser Permanente, naloxone is a covered benefit, and is provided to every patient with opiate use disorder. Another important area of focus, often overlooked, is education and training of primary care providers to better spot problems with addiction and alcoholism. The majority of patients with use disorders will show up in the medical system long before they ever make it to a treatment service, and appointments provide opportunities to ask about drug and alcohol use. For this reason, we added questions about alcohol use to our “rooming tool” years ago, so that questions about alcohol intake are similar to taking a vital sign, just like our longtime question about tobacco use. The more we talk about these issues, the more we normalize them, and the less stigma there will be.
With so many Marin County residents entrusting Kaiser Permanente with their care, we were pleased to open the new San Rafael Park Medical Offices in July. For more than 60 years, Kaiser Permanente San Rafael has been a part of Marin County, caring for our patients and promoting the health and well-being of our community. The new offices were designed with the community in mind, guided by our commitment to high-quality care, high levels of customer service, and convenience. San Rafael Park Medical Offices offer comprehensive primary care and onsite access to pharmacy, lab, rehabilitation therapies, imaging, endocrinology, and eye services—all under one roof. The departments and services available at San Rafael Park Medical Offices: Adult and Family Medicine; Endocrinology; Health Education; Imaging; Lab; Ob-gyn; Ophthalmology; Optometry; Outpatient Eye Surgery Suite; Pediatrics; Pharmacy; Physical/Occupational Therapy; and Vision Essentials (includes Optical Sales). “At this new technologically advanced building, our members can expect to receive the same high-quality, integrated, and industry-leading care they’ve come to depend on,” says Naveen Kumar, MD, Physician in Chief, San Rafael Medical Center. “I have tremendous gratitude for our care teams, whose clinical excellence is reflected in this beautiful new space.” The project represents years of hard work and thoughtful collaboration with environmental stewardship top of mind. One example was the decision to repurpose an existing building instead of constructing one from the ground up. The three-story, 145,000 square-foot building has features like all LED lighting, electric vehicle charging stations, reclaimed water in the plumbing fixtures, and solar panels, which provide 100 percent of the building’s electrical needs. There are also bike racks and commuter showers to make it easy to leave the car at home. The San Rafael Park Medical Offices was years in the making and is a testament to the San Rafael leadership team’s long and deep commitment to our community. We welcome the opportunity to serve the broader Marin County and surrounding communities in our spacious new building.!
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WELLNESS
FEEL BETTER BY OPTING OUT OF "COLLECTIVE SUFFERING" Jessie Mahoney, MD Having fun and enjoying life while others are suffering and struggling is something many physicians judge themselves and each other about. Medical training taught us that struggling, suffering, and hard work is what’s needed to accomplish things of value. They are what “good doctors” do. Humility and perseverance and determination were also encouraged. It is hard to switch out of this mindset, especially covid and in 2020, 2021 and now 2022. There is much inequity, injustice, overwhelm, toxicity, overwork, illness and death. Feeling light, having fun, and enjoying life very often feels “complicated” and challenging for those working in healthcare especially. Some do well with switching it on and off—they have immense fun on vacation or a weekend day—almost as a task to make up for suffering. Most physicians struggle with finding and allowing lightness and joy in our daily our lives. Is it ok to have fun, be light, and enjoy while others are sad, overwhelmed, suffering injustices, in quarantine, sick, and/or working in overcrowded clinics and hospitals? “It’s our call to experience joy even
as we work for better.”
– Rhonda Magee, PhD.
This thought has helped me shift my perspective. Professor Rhonda Magee shared it last year, in a Mindful Healthcare Collective book club discussion about The Inner Work of Racial Justice · Healing Ourselves and Transforming Our Communities Through Mindfulness. I now intentionally practice allowing joy and experiencing pleasure even as I work for better. Mindfulness and coaching have helped me embrace being able to find joy and have fun when the opportunity presents itself. More fun, joy, and lightness are what’s needed in this crazy world especially if you work in medicine. And they are the way through. Play, fun, joy and lightness help you to see creative solutions and be part of the solution. I encourage all my colleagues in medicine to make a personal commitment to experience more daily joy, laughter, connection, love, and play - in spite of the chaos around us.
“It’s our call to experience joy even as we work for better.”
– Rhonda Magee, PhD.
I hope we also encourage our colleagues to do the same.
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Honoring Past Januarys The month of January was notoriously hard for me as a physician. January in Pediatrics is generally overfull of flu, RSV, and very sick children. January was made even worse for me because for years on end, in January, I would diagnose at least one, sometimes several, children with severe life-altering medical issues—cancer, genetic anomalies, or severe chronic diseases. Perhaps in adult medicine, this is expected but in Pediatrics, it is very heavy and not our normal. For me, it always seemed to happen in January. January became not a new beginning, but a time of grief and fear. It became a month of waiting for the shoe to drop. I would always try to take a little time off to help me make it through. But I literally would not fully exhale until the month was over. Every January still, the memories and emotions still bubble up. Because I am human. Every January, I do the work to process once again that bad things happen to wonderful people—all the time. But now I carry a tenderness and compassion not only for each and every one of my January families and their heartaches but also for myself as a healer. Coaching and mindfulness helped me get to this place where I no longer want to hide and avoid January. I can show up for January from a more whole and healed, kind, loving, and compassionate place. I can now feel full of love, curiosity, and warmth for the fullness of life - both the good and the amazing and the very, very bad. Helping others get to this place has been a part of my own healing and an important part of how I honor those I took care of. Helping others to feel whole, healed, supported, hopeful and excited again is my passion and my gift. It always has been. It's why I started in physician wellness my very first year as an attending in 2002. It only took four Januaries as a resident and one as an attending for me to see how inadequate the support for healers was and decided I had to be part of the solution. In 2003, when I started this work, there was no systemic or cultural support for physicians as humans—and literally no acknowledgment that we would need support for our emotions and hearts. Today it is better but we still have a long way to go. January reminds me of my purpose. To help all healers know that they are deserving of as much fun, light, joy, compassion, support and as full happy, and healthy lives as everyone else on this earth. Our systems and culture needs to change but there are many options out there to help you feel more healthy and whole along the way. Whatever your personal version of January is please don’t keep it bottled up inside. You are worth taking time to process it, honor it, and heal it. Life is better on the other side. continued on page 36
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WELLNESS Care for Yourself Well There are no prizes for the most suffering. I had a medical procedure done recently. I handled it much differently than I would have in the past. As a result, my experience and that of those caring for me, was much improved. In the past, I would schedule medical appointments and screenings during my lunch break. Or sneak them in between patients. Or be in a hurry to pick someone up after. Or do chores on the way there or on the way home. My past approach was to fit my own care into the cracks of my day and my life so as not to inconvenience anyone and to be there to care for everyone else. I have gotten IV antibiotics during lunch on more than one occasion. I have arranged with an on-call surgeon to stay NPO all day and check myself into the pre-op area for an urgent surgery—after my clinic ended. I have gone into labor while on call. In retrospect—I should not have done any of this. It didn’t make me a better or more committed doctor for my patients and it certainly wasn’t healthy for me. I have learned took care of myself. It is unfamiliar and lovely. What does this look like—scheduling appointments on a day off. When you can do it “well.” Not waiting for a day off but arranging a day off. You deserve it and so do those taking care of you. When we care for ourselves well we also model to our patients to do the same. Health and healthcare could be transformed if slowing down, nourishing ourselves, and showing up unrushed and mindfully was the norm. On the day of my procedure, I started my day with coffee and yoga. I followed this by a mindful walk on the beach—no AirPods or podcasts—just fresh air, deep breaths, movement, and relaxation. I then asked my husband to drive me and keep me company. A ride wasn’t “required” but it was luxurious to have a driver and someone to chat with. And then—since I knew my husband couldn’t go in with me—I asked if he would go to get some tulips at Trader Joes while he waited.
This might sound luxurious and overly indulgent but what if it is not? What if it is taking good care of yourself. You and every human are worth it. There are no prizes for the most suffering. And there are so many gifts when you choose to take good care of yourself.
Dr. Jessie Mahoney is a Pediatrician, a certified life coach for physicians, and a yoga instructor. She is the Chair of the SFMMS Physician Wellness Task Force. She practiced Pediatrics and was a Physician Wellness leader at Kaiser Permanente for 17 years. She is the founder of Pause and Presence Coaching where she supports and empowers her physician colleagues using mindfulness tools and mindset coaching. She specializes in helping ease career transitions and burnout, parenting struggles, and relationship challenges. She is a leader of the Mindful Healthcare Collective and is co-host of the Mindful Healers Podcast. She teaches virtual weekly yoga to physicians and other healthcare providers and leads yoga, coaching, and wellness retreats in spectacular natural locations. You can read her blog at www.jessiemahoneymd.com. You can connect with her at jessie@jessiemahoneymd.com.
Wellness Podcast Recommendation: The Mindful Healers Podcast Episode 52. Play Is Essential For Adults Too “We don't stop playing because we grow old, we grow old because we stop playing.” Check out this podcast that discusses the importance of play at all ages. It features Dr. Brooke Buckley, CMO of Henry Ford Wyandotte Hospital.
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