January/February 2020

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

ADVOCACY & EDUCATION: Disaster Readiness, Vaccination, Vaping, Addiction, and More

PLUS The Annual SFMMS Medical Trainee Writing Contest

Volume 93, Number 1 | JANUARY/FEBRUARY 2020

IN THIS ISSUE

SAN FRANCISCO MARIN MEDICINE JANUARY/FEBRUARY Volume 93, Number 1

ADVOCACY AND EDUCATION FEATURE ARTICLES

MONTHLY COLUMNS

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Membership Matters

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President's Message: Connection is Crucial Brian Grady, MD

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CMA Legislative Wrap-Up Janus L. Norman

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Health Care at the Border is a Humanitarian Crisis that must be Addressed Peter N. Bretan, MD Coronavirus: Modeling a Balanced Response to COVID-19 Tomรกs Aragรณn, MD, DrPh and Matthew Willis, MD, MPH

10 The SFMMS 2020 Medical Trainee Essay Contest 20 Being Crew, Not Passengers: Improving Medical Disaster Response in San Francisco

Scott J. Campbell, MD, MPHH

22 Truly Effective Disaster Preparedeness: Will we be

Ready Next Time?

Christopher Colwell, MD 24 A Salve for the Conflagration Era

Ian McLachlan, MD, MPH

26 San Francisco Hopes to Improve Care for People with Mental Illness Living on the Street

Brian Krans

28 Here's How to Fight Addiction. Trust Me, I'm in Recovery

Paul H. Earley, MD, DFASAM 30 Congress Needs to Act Against Vaping Epidemic

Senator Dianne Feinstein

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House of Delegates Report Michael Schrader, MD, PhD and Steve Heilig, MPH

36 Upcoming Events

COMMUNITY NEWS 16 Kaiser News Maria Ansari, MD

32 Chinese Hospital News Sam Kao, MD

36 19th Annual UCSF CME Conference on Developmental Disabilities Lucy Crain, MD, FAAP

36 St. Francis Memorial Hospital Expands Behavioral Health Unit

OF INTEREST 7

2019 Year in Review

36 Advertiser Index

SAN FRANCISCO

MARIN MEDICAL SOCIETY

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

MEMBERSHIP MATTERS Protect Access and Control Health Care Costs for CA Patients; Oppose the So-Called “Fairness for Injured Patients Act” Wealthy out-of-state trial attorneys have filed an initiative for the November 2020 ballot that would substantially raise health care costs for all Californians, reduce access and exploit patients for profit. While most reporting to date has focused on the proposed changes to California’s existing law—the Medical Injury Compensation Reform Act (MICRA)—this misguided initiative would effectively eliminate California's medical lawsuit limits to create new financial windfalls for California's trial lawyers. Proponents of this measure must collect 623,212 valid signatures, which must be verified no later than June 25, 2020.

Recent reports show that they’re on track to meet those numbers and qualify for the November ballot. In 2014, our coalition fought and handily defeated Proposition 46, clearly saying NO to changes in MICRA that would have quadrupled the cap on non-economic damages. This measure goes far beyond what Proposition 46 would have done and the cost to taxpayers would be substantially greater. Proposition 46 taught us the power of a strong coalition, and this time around it will be even more important. To learn more about the new initiative, and to donate to the “no” campaign, please visit protectmicra.org.

DHCS Launches Effort to Screen Patients for Childhood Trauma

The California Department of Health Care Services (DHCS), in partnership with the California Office of the Surgeon General, is creating a first-in-the-nation statewide effort to screen patients for trauma and the increased likelihood of ACEs-associated health conditions due to toxic stress. DHCS’s ACEs Aware initiative (acesaware.org) offers provider training and clinical protocols for screening children and adults for ACEs. DHCS will pay Medi-Cal providers to perform trauma screenings for children and adults with Medi-Cal coverage. Medi-Cal providers must take a certified training and self-attest no later than July 1, 2020, to having completed the training in order to continue to be reimbursed for ACEs screenings. Read more at http://bit. ly/2uy8GqA.

Fake Board Representative/DEA Agents Extortion Scam

Scam artists posing as U.S. Drug Enforcement Administration (DEA) agents or Board staff are calling California physicians as part of an extortion scheme. The scammers identify themselves as DEA agents or Board staff calling about ongoing investigations regarding their license issued by the MBC. The scammers tell victims their license may be suspended for illegal drug trafficking and the suspension means they will not be able to practice. The scammers’ phone number may show up as the Board’s toll-free number (800) 633-2322. No DEA agent or Board staff will ever contact physicians by telephone to demand money or any other form of payment. If you receive a call such as the one described, refuse the demand for payment. Read more about what you can do at www.mbc.ca.gov/News/Fake_DEA_Agents.aspx.

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Federal Advocacy Update: What to Expect In 2020 There are a number of important health care issues that will be before lawmakers this year. Among these issues are two bipartisan health care issues extremely important to voters surprise medical bills and skyrocketing costs of prescription drugs - that might rise above the fray and move to the President’s desk. Learn more about these and other federal health care issues the California Medical Association (CMA) will be working on this year in our Federal Advocacy Update: What to Expect in 2020 (http://bit.ly/2SgthZE).

Apply Official ICD-10 Guidance for Vaping Encounters

Thousands of cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have been reported from across the U.S. to the Centers for Disease Control and Prevention. Physicians and medical coders can now turn to an official document for guidance on coding encounters related to e-cigarette use, covering EVALI, toxicity, dependence and symptoms. You also can look forward to potential new ICD-10 codes related to vaping. Read more at http://bit.ly/2uDiNdI.

CMA President Peter N. Bretan, MD Issues Statements on Public Charge Ruling and President Trump’s Threat to Withhold Funding over Abortion Policy

CMA President Peter N. Bretan, M.D., issued a statement in response to a recent Supreme Court ruling allowing the Trump Administration's "public charge" rule to take effect: "The California Medical Association remains steadfast in our opposition to the Trump Administration’s public charge rule because it targets immigrant families, jeopardizes public health and will deter millions of people from receiving critical health care services. Of particular concern is the effect that the rule could have on children’s health. If parents are fearful that utilizing health care services could jeopardize their immigration status, families might forgo critical and potentially lifesaving care. Additionally, the lack of needed vaccinations will contribute to disease outbreaks in all segments of the population. This rule will have a dramatic impact in our state. More than 10 million immigrants call California home and half of all children in the state having an immigrant parent.

We should be working together to find ways to make care more affordable and more accessible to all Californians.”

Dr. Bretan also responded to the Trump Administration’s threat to withhold federal funding because of the state’s requirement that health insurance plans cover abortion: “The California Medical Association strongly supports state policy that ensures access to care for patients. The latest actions from the Administration are counterproductive and a step in the wrong direction, and we will continue to fight for access to high quality health care for all Californians.” SFMMS has actively contributed our voice to this important public health issue at the local, state and national levels.

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Volunteer Opportunity: Clinic by the Bay Volunteers are essential to the mission and operations of Clinic by the Bay. Not only does Clinic by the Bay offer equitable health care, it also provides an opportunity for meaningful civic engagement and multi-generational learning. More than half of its operating budget is received through the in-kind services of volunteer staff. The clinic engages retired and practicing medical professionals, medical students as volunteers to provide compassionate, and high-quality health care for low-income, uninsured adults in the community.

Volunteer orientations are scheduled every six weeks. If you are interested in joining the volunteer team, or would like more information, please contact Clinic by the Bay Executive Director, David Wallace, at executivedirector@ clinicbythebay.org.

CMA Endorses Call to Action on Climate, Health and Equity

Following a surge in the number and intensity of climate change-related health harms, health and medical groups have joined together to outline The Call to Action on Climate Health and Equity: A Policy Action Agenda to protect the health and safety of all people in the U.S. The package of 10 key policy priorities aims to lower current and future health harms from air pollution and climate change, while also substantially improving the health of people and communities across the nation, increasing health equity, reducing health care costs and building a climate-resilient health system. The Call to Action on Climate Health and Equity is available at climatehealthaction.org.

The MIPS 2019 Data Submission Period Is Now Open

The Centers for Medicare & Medicaid Services (CMS) has opened the data submission period for Merit-based Incentive Payment System (MIPS) eligible clinicians who participated in the 2019 performance period of the Quality Payment Program (QPP). Data can be submitted and updated until 5:00 p.m.

Pacific time on March 31, 2020. To learn more about how to submit data, check on your initial 2020 MIPS eligibility, or for more information about MIPS, visit the QPP website at qpp.cms.gov.

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JANUARY/FEBRUARY 2020 Volume 93, Number 1 Editor Gordon L. Fung, MD, PhD, FACC, FACP Managing Editor Steve Heilig, MPH Production Maureen Erwin EDITORIAL BOARD Editor Gordon L. Fung, MD, PhD, FACC, FACP Toni Brayer, MD Chunbo Cai, MD Linda Hawes Clever, MD Anne Cummings, MD Irina deFischer, MD Shieva Khayam-Bashi, MD John Maa, MD David Pating, MD SFMMS OFFICERS President Brian Grady, MD President-elect Monique Schaulis, MD Treasurer Michael Schrader, MD, MPH, PhD, FACP Immediate Past President Kimberly Newell Green Editor Gordon L. Fung, MD, PhD, FACC, FACP SFMMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Erin Henke Manager, Operations & Administration Ian Knox 2020 SFMMS BOARD OF DIRECTORS Edward Alfrey, MD Tomรกs J. Aragรณn, MD, MPH Ayanna Bennett, MD Julie Bokser, MD Anne Cummings, MD Nida F. Degesys, MD Beth Griffiths, MD Robert A. Harvey, MD Zarah Iqbal, MD Michael K. Kwok, MD Jason R. Nau, MD Stephanie Oltmann, MD William T. Prey, MD Sarita Satpathy, MD Dennis Song, MD, DDS Kristen Swann, MD Kenneth Tai, MD Winnie Tong, MD Matthew D. Willis, MD, MPH Joseph W. Woo, MD Andrea Yeung, MD

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PRESIDENT’S MESSAGE Brian Grady, MD

CONNECTION IS CRUCIAL "If all we accomplish is a new friendship, a new partnership, or a new connection, then it will have been worth it".

Dear Friends, Let me begin by wishing everyone a belated Happy New Year.

I am humbled by the opportunity to serve as President of our Medical Society this year.

2020 stands to be a historic year, locally and beyond, for many reasons.

Physician burnout and distress is a real crisis. In 2017, 42% of physicians screened positive for symptoms of depression.

Each year, 200-300 physicians in the US commit suicide. This is 2-3 times the rate of the general population. If this were occurring in any other group, we might label it a crisis.

I believe one key is to combat the sense of futility and isolation that the modern practice of medicine can produce. The importance of connection cannot be underestimated. Cancer support groups work in part by reducing the sense of isolation, thereby lowering adrenaline and cortisol levels. This might allow the immune system to function better and improve survival. We are flooded with adrenaline and cortisol every day. It takes 2 weeks for our systems to recover from a cortisol spike.

We might not be able to prevent this, but what can we do to foster the good neurotransmitters: the dopamine that comes from accomplishments, the serotonin that comes from recognition and appreciations, and the oxytocin that comes from belonging and connectedness (collegiality, bonding, and, yes, even love)?

I wanted to start by asking, “How can the Medical Society help you?” (Actually I want to turn that around and say, “How can you help the Medical Society?” with apologies to President Kennedy). But seriously, there is no way to underestimate the power of involvement and connection in fostering feelings of purpose, gratitude, and ultimately, happiness.

What do you value? Are there problems, challenges, or opportunities in your daily practice? Prior authorizations, EHR issues, MIPS? Are there social or political issues important to you that the combined power of the SFMMS and the CMA could address?

Perhaps the simple act of getting together with colleagues and friends to share, network, or vent.

If all we accomplish is a new friendship, a new partnership, or a new connection, then it will have been worth it.

Dr. Brian Grady, a graduate of UCSF medical school, is a urologist practicing for two decades at CPMC, CPMC/Mission-Bernal, Saint Francis, Saint Mary’s, Chief of Staff at Seton, and has been an SFMMS delegate to the CMA, president of the CMA resident physician section, and a longtime SFMMS board member.

Respect Due to Frontline Clinicians Regarding “S.F. plans sobering center for meth” (Page One, Feb. 6, San Francisco Chronicle): Thanks to Heather Knight for her story on San Francisco’s upcoming sobering center for methamphetamine users, the only such facility in our entire country. I do take exception to her use of the word “broken” while describing the city’s mental health and drug addiction treatment services.

A better word is “overburdened”: the nation’s growing disparity in mental health services and underfunding of addiction care has made San Francisco ground zero for these endemic conditions. In my 30 years as a physician, I have found the majority of health care providers working with this vulnerable population to be compassionate, dedicated and extremely competent.

Let us pay tribute to those professionals working with this challenging population and let us applaud San Francisco for using new and innovative approaches to this difficult problem.

Joseph Elson, MD WWW.SFMMS.ORG

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CMA HOUSE OF DELEGATES (HOD) REPORT:

HEALTH POLICY AT WORK From San Francisco/Marin to the State, Nation, and World?

Michael Schrader, MD, PhD, and Steve Heilig, MPH Making good health policy and getting it adopted and acted upon is one of the primary goals of the SFMMS, and is primarily done via our elected delegation to the California Medical Association. TWe bring new ideas first to our own group for revision and adoption, then to the CMA for the same, and, if a national issue, to the AMA. In this manner the SFMMS has likely brought more adopted policy to the CMA and AMA than any other county medical association, with measurable impact in areas such as tobacco control, reproductive health and rights, HIV policy, environmental health, and much more. We are thus one of the “noisiest” county associations in terms of formulating policy for the CMA, AMA, and beyond, and proud of that.

It starts with good ideas and research, and the drafting of a concise, evidence-based statement or resolution. The CMA HOD adopted a year-round resolution process a few years ago, with much input done online, to expedite the review and processing of policy. Previously resolutions had been submitted on a yearly rather than a quarterly schedule. The new intention was to decompress the annual HOD meeting but more importantly to create a channel to make and implement policy to address challenges with alacrity.

The year-round resolution process is relatively new and possibly confusing to the uninitiated. The SFMMS continues to submit a good number of successful resolutions to the CMA that have subsequently been adopted by the AMA as national policy.

A recent example of a successful resolution is the accompanying resolution urging the restriction of vaping prior to FDA review.

This resolution was originally written to support Supervisor Shaman Walton’s San Francisco initiative to ban vaping products prior to FDA review. Our intent was to garner CMA and perhaps AMA support to oppose the JUUL-backed Proposition C. In fact, the SFMMS had developed vaping policy as far back as 2011, in concert with our local health department and others, which had gone on to form the basis for not only CMA policy but that of our city and county itself.

Resolutions may be drafted by any SFMMS member. The format is simple: Several “whereas” clauses presenting the problem and citing evidence, followed by one or more “resolved” clauses proposing an action by the CMA. These resolutions are more a brief framework than a detailed analysis. The scope of subjects for resolutions should be ideas or positions that are germane to the medical profession and public health.

While it is possible for CMA members to submit resolutions directly to the CMA, most resolutions are submitted by district delegations. This gives the delegation the chance to review and make ameliorations to strengthen or modify the resolutions, and to endorse and garner co-authors and statewide support, to improve their chances of approval. Resolutions that are submitted to the CMA are then researched by CMA staff and submitted to councils for their recommendations. The council recommendations may be to reject or accept a resolution with or without revisions. Or the resolution may be deemed as already covered by existing policy and thereby unnecessary.

A current case study: With our vaping resolution, asking for a full moratorium on all vaping product sales until the FDA conducted a full review, the resolved clause calling for a full ban was initially significantly watered down in the CMA process. But we didn’t give up there. We then lobbied the CMA Board of Trustees to preserve the original language of the clause and ultimately prevailed. We were then able to use the resolution to also obtain backing by the CMA for the No on Proposition C campaign. Further, we were able to garner AMA support for No on C as well – one of the first times AMA weighed in on a local proposal. At the same time JUUL was being exposed for major ethical lapses and vaping-associated lung disease was being characterized as a significant public health risk, even a lethal one. Ultimately Proposition C was massively defeated in a landslide vote by San Francisco voters. And the AMA is now weighing in on the national debate on how to best regulate vaping products and obtain a fair FDA review.

Suspending Sales of Vaping/Electronic Cigarettes Until FDA Review Michael Schrader MD, John Maa MD, and Lawrence Cheung MD RESOLVED: That CMA supports regulations that would prohibit the sale in of any e-cigarette or other vaping product that has not undergone FDA pre-market review until the FDA completes its review and allows the products to be sold; and be it further RESOLVED: That this be referred for national action (AMA).

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EDITORIAL:

HEALTH CARE AT THE BORDER Is a humanitarian crisis that must be addressed Peter N. Bretan, MD America’s politics is more divisive than ever. As we head into this election year, our public discourse too quickly devolves into a shouting match without any nuance or effort at mutual understanding. There is perhaps no more divisive issue in today’s America than immigration, which tends to only further polarize people into one of two political camps.

As physicians, our responsibility is to look past those types of extraneous labels and divisions and to see each person’s individual humanity. We treat our patients regardless of external factors like economic circumstance, cultural heritage or which side of an imaginary political boundary the patient finds themselves on. The oath we all swear does not mention political borders or things that arbitrarily separate us. Our job is to care for all patients without prejudice and to the best of our ability.

It was in that spirit that I joined dozens of my fellow physicians to ask U.S. Customs and Border Protection officials to allow us to vaccinate detained migrant children. This was an act of medical compassion, not politics. Three children in U.S. Custody died from influenza in 2018. Simply administering flu vaccinations would help protect the health not only of the children and those being detained, but of the workers and officials who come into contact with them on a daily basis.

While we were denied access to treat these patients, what I saw at the border opened my eyes, underscoring both the importance of vaccinations and the need for more humanity in the way we treat other people. This has nothing to do with one’s feelings about a border wall or what political party they belong to. To see through the eyes of a physician is to see a humanitarian crisis that must be addressed.

On a personal level, I have a deep connection to those who find themselves underserved or unable to access needed medicine. My family was among the thousands of Filipino immigrants who came through the ports of San Francisco and went to work in the fields to build our state’s agricultural industry. These workers are the backbone of one of our state’s most important industries, but many lack basic access to clean water, housing and health care.

The stories from those who had been inside these border control camps were shocking. Though they are only supposed to be held in these facilities for up to 72 hours, many wind up there for several months. The facility itself looked like a prison.

It was gated off and surrounded by armed guards.

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One person I talked to who had spent time inside described the scene for me. Inside this facility are rows of 10x14 cells, each of which hold 20-30 people. There is only a hard cement floor. They are cold – somewhere in the neighborhood of 55 degrees. There is barely a place to sit or lie down.

In each cell, there is a single sink and a toilet that is in the open and shared by dozens of others being held.

I asked about the background and medical health of those being held. Migrants who come from Mexico usually have some vaccinations like diphtheria, tetanus and other basics, but most don’t have the flu vaccine.

But migrants from Guatemala and other Central American countries often don’t even have those vaccinations. The risks for an outbreak and infection are great, and should be addressed by our government. ity to use my voice for those who are not heard and to promote public health. We must do a better job of caring for people who come to our country seeking asylum while they are in our custody and care. Regardless of your personal views on immigration, there are steps we can take to protect public health and ensure that people are treated with humanity and respect.

The California Medical Association can and should be a voice for that humanity. That is my vision and my goal for my presidency – to help transcend the divisiveness of our politics and bring physicians together to fight for common goals of protecting public health and promoting common decency.

SFMMS member Peter N. Bretan Jr., M.D., is a urologist and kidney transplant surgeon who gave up his Bay Area practice to serve patients at a safety net hospital in Watsonville. He is the 152nd president of the California Medical Association (CMA) and the first Filipino-American physician to serve as CMA president. The SFMMS initiated CMA policy on this topic with a policy resolution urging vaccination of migrants.

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CORONAVIRUS:

MODELING A BALANCED RESPONSE TO COVID-19 Special Communication from our Public Health Officers Tomás Aragón, MD, DrPH and Matthew Willis, MD MPH As physicians we can reduce public misperception, fear and discrimination in our response to COVID-19, staying grounded in the latest evidence. We can remind our patients that currently, the best way to prevent the spread of infection is to practice consistent hand washing, cough or sneeze into your sleeve, and stay home if you are sick. We can reinforce that masks do not prevent illness, but can be helpful for sick people to wear, so that they do not spread germs to others.

Let’s come together with compassion and unity during this stressful time. It’s good for our health, and for the health of the communities we serve.

Tomas Aragon, MD DrPH, Public Health Officer, City and County of San Francisco.

The spread of novel coronavirus (COVID-19) has been declared a global health emergency by the WHO. This is a serious and rapidly developing situation, affecting thousands of people worldwide. As the virus spreads beyond its origins in Wuhan, China, the medical community must model a balanced, proactive and informed response.

Currently, a person’s risk for the illness is based primarily on where they, or someone they have had close contact with, have travelled. There is no racial, ethnic or cultural basis for the disease. Yet, we know that bias is already surfacing. Members of the Asian community, especially the Chinese community, have been subjected to discrimination and exclusion, in Asia, Europe, Australia and the United States.

News media are reporting from around the world stories of hostility and discrimination toward Chinese customers and students, and insults hurled in person and on social media. This is unacceptable and harmful. This is a common and unfortunate societal response to epidemics, and we must do better.

We know that racial, ethnic and cultural discrimination cause bad health outcomes. In the case of an emerging illness, stigma about the illness makes people less likely to come forward, to seek help or ask questions. That makes it harder to fight the disease and protect community health.

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Matthew Willis, MD MPH, Public Health Officer, Marin County.

Resources The San Francisco Department of Public Health has two relevant websites: For clinicians: https://www.sfcdcp.org/infectious-diseases-a-to-z/coronavirus2019-novel-coronavirus/ For the general public: https://www.sfdph.org/

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The SFMMS 2020 Medical Trainee Essay Contest

THE SFMMS 2020 MEDICAL TRAINEE ESSAY CONTEST "What patient has had the biggest impact on you so far and why?"

This year’s medical trainee contest – open to students, residents, and fellows – drew 29 usable entries. Once again we asked a very brief question about a wide-open subject – their most memorable patient encountered thus far. Two winners are being selected by vote of SFMMS leadership, to be read aloud at our annual gala, but we trust you will find all of these worthy reading. – The Editors

The day I learned you had cancer, I was the senior resident on a general surgery service, responsible for 25 patients whose diagnoses and labs I could recite from memory, but whose stories I couldn’t even begin to tell. It seemed fake at first, faded into the surreal, and settled out as achingly unfair: how could a vibrant 28 year old with a future overflowing with possibility be planning a star-studded event to help girls choose science careers one day and facing stage 4 ovarian cancer the next?

I thought about this each day before rounds as I mindlessly stirred my coffee and every time I scrubbed in to a case in the operating room. I have followed your lab trends, read all of your pathology reports, and shown videos of your scans to my surgery attendings, in attempt to rationalize something so painfully unfair and to cloak my feelings of sadness and helplessness in the familiar comfort of medical jargon. I have never taken care of you directly, my beautiful friend, but you have been the most transformative of patients for me.

Because the truth is, I started seeing you in all of my patients: the 50 year old woman with newly diagnosed colon cancer, the 18 year old boy whose room was decorated with cards and photos from friends, the 75 year old man whose family kept vigil at his bedside, the 65 year old woman with ovarian cancer and a bowel perforation. I wondered whether you would find me to be kind and compassionate if I was rounding on you in the morning, whether you would think I responded quickly enough when the nurses paged, whether your family would be comforted by my bedside manner and confident in my medical knowledge.

You gave me back my humanity, rescuing me from the endless streams of consults, frustrating logistics, and mountains of documentation that slowly erode even the most idealistic residents.

And in doing so, unknowingly, you have taken care of hundreds of patients, thousands of miles away from you, and from your personal battle of a lifetime.

Hillary Braun, MD Resident Physician, UCSF General Surgery

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Few enjoy overnight shifts. Time and space are confused - nobody should be awake or in the hospital. The natural order we desire is disturbed. Perhaps it makes sense then that so much seen after dark seems antithetical to that order.

On the ED board there was one name listed - SD. The presenting concern was abdominal pain. I thought nothing of it. The vast majority of patients we saw had various abdominal abnormalities.

If the attending knew what we were walking into, he did not show it. What awaited us was a woman, mid-forties, with three children huddled around her. She had one arm around a brown-haired boy to her right, the other around his shivering sister, and a sniffling toddler at her knees.

We did not record a patient history as much as bear witness to it. As the nurse held her hand, SD reported that for months her husband had been sexually abusing their children. The attending shut the door behind us and quietly asked her to recount what had happened, as much as she wished to, for each child and for herself. I will not go into the details here - suffice to say I heard a prime example of the annihilation of the natural order between parents and children.

She spoke slowly, and I scrambled to record every detail. As I wrote, the words barely grazed my consciousness; they simply zipped from synapse to synapse, ear to hand. Not until we returned to our computers did the moment materialize for me. The attending addressed me solemnly: “You can go home if you want. If you need to. But before you go, I expect a note for each of those children. They each deserve their own note.”

I did not go home that night until the shift was done. I wrote the notes. The children and their mother deserved them, as will all the patients I meet. Recording a patient’s history is our way of recording our society’s failures. Physicians cannot undo disruptions that have already happened, but we can protect and remember the survivors.

Ninad Bhat UCSF MS2

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“The Human Touch” The scream of the ambulance siren flooded me with fear, anticipation and excitement as my ambulance pulled up to the school. I jumped out with celerity and walked into the gym.

The wrestler we had been dispatched to help had landed the wrong way on his neck, and everyone there wondered whether this was only a sprain or something much worse. As carefully as we could, we lifted him onto the stretcher. As I carried my part of the stretcher, I trembled with fear that any wrong movement could exacerbate his injury. And there was something else bothering me too.

There was something about him I didn’t like. He was bigger than I expected. He was not easy to handle. He made me feel awkward. He was the kind of guy I would have avoided on the street.

He could have crushed me like a bug. All of this built up inside of me, until I found myself resisting him, avoiding his eyes, keeping him at a distance. I wasn’t letting him in.

While busying myself with irrelevances in the ambulance, I suddenly heard a strange noise and looked over to notice tears undulating down his cheeks. My heart sank within me at my selfishness, and a moment later I was at his side. His eyes focused on mine, and he sobbed out, “I’m really scared, man”. At that moment I felt something give and it seemed as if we were the only two in the ambulance. Almost involuntarily, I grabbed his hand and said, WWW.SFMMS.ORG

“I’m here for you”. And then it happened. He stopped crying, looked up at me, and smiled.

Life is unpredictable, it can be over in a second and we must make good use of it. That wrestler’s smile showed me who I am.

The comfort I gave him, although it lasted only a moment is something I strive to emulate every day. Time is a funny thing--we never realize its evanescent nature until dire circumstances arise. I am dedicated to compassionate patient care each day of my life as time marches on.

Nicholas Brownstone, M.D. Clinical Research Fellow, UCSF Department of Dermatology

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A shelter clinic dialectic Every Tuesday and Thursday night, first and second-year medical students practice clinical skills on people staying at San Francisco’s largest homeless shelter. During the inelegant medical exams, America’s contradictions are awkwardly laid bare: White and Black, rich and poor, housed and unhoused, able-bodied and disabled.

Doctor and patient.

T and I sat across from each other on one of those Camp Fire days last year when the air was grey and toxic. T was a woman in her 70’s with a shaved head and tan, weathered skin. She looked exhausted, her skinny shoulders heaving with each breath.

Unable to get a bed in the shelter, she had to sleep sitting in her wheelchair. You can’t lie down in the drop-in center, and she was scared to sleep outside after being robbed and assaulted. With severe heart failure and no place to lie down, T’s feet were swollen and covered in persistent wounds.

T spent decades working for the postal service before she suffered a work-related injury and was forced to retire. She scraped by on disability benefits until she was evicted from her home two years ago.

Our lives were unimaginably different. I was a young, ablebodied student-doctor. And T was an old, disabled laborer. I felt valued by society and entitled to a comfortable, professional-class life, but T had been forgotten, told that she was worthless and that she deserved nothing. She experienced cruelty and violence regularly on the street, and no one seemed to care, let alone help.

Our differences highlight a truth about the American experience: We are afforded precarious dignity only so long as we remain healthy, productive and competitive.

As a young student, I learned to fetishize competition and success, but I had never been forced to seriously reckon with the bitter, crushing violence dispensed to my most vulnerable neighbors.

The brutality T experienced humbled me. I reflected on all the help I had received and asked myself, “who will care for me when I become sick, disabled and old?”

We are all so fragile, and we all need help.

Henry Clay Carter Medical Student, UCSF

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In my second year of residency, I cared for a baby in the Neonatal Intensive Care Nursery with a severe germinal matrix hemorrhage (GMH). GMH is a common injury in premature babies born very early, during the sixth month of pregnancy. This condition can cause stroke and death in severe cases; survivors are high risk of neurological and psychological problems.

Despite progress in medical care, the rates of GMH have not changed in 20 years and no treatments exist. The family of my patient both loved her nascent life deeply and understood the gravity of her injury. They began our meeting by saying that they were not afraid of raising a child with disabilities. Still advocating for the best possible outcome, they asked, “What treatments are available?” I did not answer their question directly, but instead described supportive care. They responded politely but were clearly dissatisfied.

Returning the following day, they inquired about a clinical trial or experimental therapy. Saddened, I replied that there were none.

Finally, it became clear the baby would not survive. The mother decided to donate her daughter’s body to science, hoping to help other families avoid her agony.

Unbeknownst to the mother, I am also a scientist. During my PhD work, I studied blood vessels in the adult mouse brain with some success. Research on human illness is harder. Affected tissue is elusive, and animal models often do not accurately reflect disease. This patient and her family focused my career trajectory. I am now a fellow in neonatology, caring for the smallest and sickest patients. Additionally, I am working with a neuropathologist who envisioned a cure for this condition and collected brain tissue from babies who died with GMH. Through every experiment, I think of the brave family who honored the life of their child by fighting the status quo. In the future, I hope the spirit of our patients and some clever science conspire to change the course of brain development for vulnerable baby in the nursery.

Elizabeth Crouch, MD/PhD Neonatology Fellow

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The mood changed She reminded me of my own mother and wasn’t even my patient. Her son was, but as a pediatrician, you are often tied to everyone involved in a child’s care.

Everything about the situation hit like a ton of bricks. She was an African-American mother with three children, two sons – one who was admitted for potential osteomyelitis of the hip and an eldest daughter whose motherly skills were already arising at the ripe age of 11.

A single mother, she was caring for three children while simultaneously dealing with the sudden illness of a relative. I arrived on wards and immediately formed a sisterly bond with her, understanding how distressing this situation could be.

During the day, everything was light. Our patient was improving with IV antibiotics. We were all on the same page. However, at night, it was a different story.

My week of ward days felt the overtone from nights, in which I heard stories of my patient’s mother being “absent” during nightshift – leaving the daughter to care for her two siblings. She learned to order food for her brothers, process and synthesize updates on her brother’s condition, and inform staff on the whereabouts of her mother. continued next page

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The SFMMS 2020 Medical Trainee Essay Contest I thought of my own mom, who balanced a busy career with two children always at her side and how hard this could be. This brought memories of the lack of understanding from those who were not in our position, so when social services became offered as a solution, I immediately recalled how hard it can be to trust the healthcare system when there’s a history of many reasons not to.

After explaining the reality of the situation and why we needed to talk to her before involving external agencies to fellow staff, I felt sick to my stomach.

After switching to nights, the mood switched along with the sun setting. When she returned in the morning, I waited for her to return, to explain to her what happened, and why child protective services was even mentioned - ashamed that I had let it get this far.

Denise Powell, MD UCSF Pediatrics Residency, PGY-1 Pediatric Leaders Advancing Health Equity (PLUS) Program

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Suzanne She arrived to my general neurology clinic with fiery red hair.

In the midst of my busy clinic, I had to pause to absorb her new look. Her vivacious personality perfectly poured out from her hair into her fluorescent orange jacket. She was bubbly as always, even after a 100 day hospital stay - nothing could defeat this woman’s spirit, not even a global attack onto her brain.

I recall first meeting Susanne (name changed for anonymity) two months prior when I joined the neurology wards service as a new resident. I was eager to start the day, show my team that intern year had trained me well as I aimed to efficiently consolidate data for rounds and fluidly get through my plans for the day. But looking at Susanne, just as I did in clinic, I had to pause. I had read her chart the night before: “psychosis,” “I want to die,” “blurry vision,” “memory loss,” “5 minute generalized tonic-clonic seizure,” “husband worried,” “severe drug eruption from phenytoin.”

This is what I was prepared to see when entering her room. I had all intentions to evaluate her hallucinations, her memory, her rash; she and her husband had other plans. In fact, she was interestingly nurturing as she realized I was new to the team, and asked very appropriate questions, “so what about my steroid taper?” I was most captured by her determination to overcome this diagnosis of “presumed autoimmune encephalitis.” Her “brain on fire” surely accompanied a spirited soul. Susanne had gone from having a prolonged intubated state for refractory seizures just 65 days ago to a severe reaction from the drug used to treat them in the midst of developing psychosis on steroids, and yet she was ready to get back to her life that now seemed like a century away.

Susanne gave me hope, whether it be for myself, my other patient not snapping out of catatonia, my friend struggling from ending a difficult relationship, or my mother who recently suffered a severe fall, really, for all those who had been feeling defeated. We, too, will get through the challenges that lie ahead and recover to a new self. Not just because there are resources or treatments that will guide us, but because inside we all have that flame of tenacity that arises in times of need. I’m sure dying your hair fiery red helps.

Sonam Dilwali, MD, PhD UCSF Neurology, PGY-2

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The knocking was loud, frantic, and desperate. I sensed panic even before I opened the door. A young woman stood there, tearful eyes darting frantically back and forth as if expecting someone else.

I recognized her because we admitted her daughter the previous day with a respiratory infection. “Where’s your father?” she asked.

“He went to town to see a patient” I replied.

The emotions zipped through her face so fast that I nearly missed them. I saw disappointment, disbelief, dread, and surrender before she finally sank down, her knees now unable to support her. “Baby took a turn for the worse” she whispered, as if saying it any louder would lend power to her words, “and I need ‘doctor’ to come quickly”, she concluded, sounding defeated. Somehow, I could tell that she knew: ‘doctor’ was not coming, nothing could be done for her little girl now, and “baby” was going to die, no matter how much she wished it not.

I returned to the hospital with her, knowing full well that my one year of medical school had not prepared me for this. At bedside, “baby”, skin dusky and lips blue, was struggling to breathe. We stood close, afraid to touch yet soon after, she went still. Her mother’s wails cut through the quiet hospital as I stood there helplessly, feeling useless. The agony of this moment was not lost on me, neither has the look of horror on that mother’s face as it dawned on her that her daughter was surely going to die lost its chilling effect.

Years later, I find myself constantly drawn to Global Health and still reflect on the circumstances that made such a tragedy possible, including the problem of patient demand far exceeding physician supply, the unaffordability of healthcare when all cost is out of pocket and the lack of medical infrastructure. At times, I’m told I don’t have to go overseas to make an impact and I desperately want to find the words to adequately express how devastating it is for the above scenario to be the norm and not the exception.

Chidinma Enyinna Nephrology Fellow, UCSF

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Providers face an onslaught of people suffering. In a single ER shift, I might see a patient on hospice, a victim of violent domestic abuse, a teenager’s intentional overdose, and a dozen other patients whose physical, social, and psychological suffering has become commonplace to me. There are days when I compartmentalize fully, and my patient interactions feel wholly mundane.

But some encounters unexpectedly penetrate my hard-earned defense mechanisms, and it's not always clear why.

There is an older man who comes to our ER most days. He is homeless, has ethanol use disorder, and nearly always presents somewhere on the altered spectrum between head injured, intoxicated, and withdrawing. He has the same name as a famous poet, whose writing my father introduced me to when I was in high school. I had always wanted to tell this man that he shared a name with this poet, but he had never been lucid enough to receive this information. I’d stapled his head, admonished him for harassing me and our nurses, and asked him what month it was countless times, but I’d never had much casual conversation with him.

One day, his nurse approached me to say that he might be sober enough for discharge, but not yet withdrawing. I walked into his room, where he was seated on the edge of his bed, breathing hard.

“How are you feeling?” I asked him.

“Ready to go,” he replied.

“Say, did you know that you have the same name as a famous poet?”

He looked up and made eye contact with me. “Yeah,” he said.

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“He writes such beautiful poems!” I said.

“He does!”

We only spoke for a few moments more on this topic, but I was briefly transported to a world in which this patient was not drinking daily, falling down, and lying in the street until EMS picked him up. In this world, he was not yelling at nurses, or having his head stapled in the ethical gray area of implied consent, but was sitting somewhere—I imagine him sober, I imagine him indoors—reading a poem.

Grace Taylor Emergency Medicine PGY-3, UCSF/SFGH.

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How do I reconcile with myself following these moments? I try my best to hold onto the image in my head, so that I may remember them. Tomorrow, there will be another moment that passes too quickly, but I will cherish it, knowing that it is a privilege as a physician.

First day of clerkship, I walk into the ED to meet up with my resident and there’s a frail, elderly woman in the bay, barely holding on, with my resident by the room asking the son about resuscitation efforts regarding his mother. With the son’s decision, we let the moment pass, and we call time of death. I felt impartial, even removed until the son kissed her on the cheek goodbye. Up to this moment, I seemed to have suppressed my humanity in lieu of being a provider. This was my first observed death. Our team spent 30 minutes with the family thereafter and I saw my team speak honestly and empathetically; there was tact to simply being a human being.

Second week, “Code Blue in 9 ICU,” we run down and we’re relieved that it’s not someone on our list. However, I’m advised to stay and help by my resident, “It’s important for you to see this.”

Gloves on, I’m next to perform chest compressions. I’m hoping for ROSC anxiously before my turn. I’m the third person to go; I’m up.

I am focused on the depth and rate of my compressions, but all I feel is the sternum and the ribs that crack beneath my hands. I see his face, a young man. I’m covered in sweat, exhausted and I end my turn with no effect. I help out a second time, it’s the 7th round of compressions. Everyone looks at each other, and we hear the wife asking us to stop.

It’s time. I’m lost. They all went back to what they were doing, and I took the long way back to the resident room.

William M. Kwon, DDS MS3, UCSF School of Medicine PGY-3, Oral & Maxillofacial Surgery, UCSF

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When I first met her, I didn’t know she was dying. She was lying in bed, gasping for air, and I started to look around for help. She held up a hand to reassure me. Between ragged breaths, she told me she was okay. This was not her first admission. Her lungs had been ravaged, first by cancer, then by pneumonia, then by multiple emboli. She already knew the answer, but at the end of my brief interview, she asked me, “What’s wrong with me? Why does this keep happening?” I could see in her eyes that she was hoping for an answer other than the one she knew. I gave her the only honest answer I could give. She looked away, dejected, still gasping.

Despite an unholy alliance with chemotherapy and radiation, the cancer had come back, in her lungs as well as in her liver and bones. Palliation was the best we had to offer her. When I saw her WWW.SFMMS.ORG

the next morning, she told me she wanted to live, asked us to cure her. I opened my mouth, but she understood and told me the words that I had meant to say. “You’re trying your best.”

The next day would be the last day I’d see her. Her breathing was a little better. She asked me to keep smiling when I talked to her, like on the day I had first met her, before I knew that she was dying, when I had still thought that we would be making her problems go away. Keep smiling. “That’s the kindest thing you can do for me now.”

The intern talked her through her illness. The explanations were graceful, while I sat in silence, trying to smile. She understood. She remained on a ventilator while she waited for her loved ones. Later, I received a message. “She passed around 4 AM. She was comfortable throughout the night. The family was grateful for your help.”

I remember her face on our last day together, quiet resolution and calm acceptance in the face of inevitability, something I’ll have to learn.

Jinwoo Lee, Ph.D. Medical Student, UCSF

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The crisp air of October embraced New England with a sense of promise, the start of a new school year, and excitement for the coming holiday season. Along a street of red-brick townhouses, Mr. L. joined his two daughters in cheering for his wife, a runner in the Cambridge Half Marathon. As he held up their homemade sign, he cheered his wife’s name – and watched as she suddenly collapsed. EMS started CPR immediately, hoping to regain the pulse she had lost.

In the ICU, I received notice of a 36-year-old female runner who had suffered a cardiac arrest. After four defibrillation shocks, EMS had achieved return of spontaneous circulation; she was now being cooled.

Following her arrival, I sat down with the patient’s husband, a man in his mid-30’s, pinches of salt dusting his peppery black hair.

Lines of worry traversed his forehead, held his mouth taut with concern. Those lines would deepen considerably over the next few days. “Do you think she’ll wake up?” he asked, clasping his hands in a gesture of hope and prayer. “I really wish I knew the answer to that question,” I responded, “we just have to wait and see.”

And so he waited at his wife’s bedside, leaving the hospital only to visit his daughters, aged six and eight, who were staying with their grandparents. After a few days, he came to me. “I need help explaining what’s going on to my girls,” he said, “I don’t know how to do this on my own.” Engaging social workers, we did our best to walk Mr. L. through foreign and overwhelming territory.

His wife never woke up. Her daughters wanted to say goodbye – and after we camouflaged as many lines and tubes as possible, they did.

Every October, I think of Mr. L and his daughters, who suffered a tremendous loss, yet learned to create their “new normal” together.

As the leaves burst with red and gold, I hope that the cozy blanket of Fall wraps around their family with memories of a treasured past and quiet love and support for the coming year.

Julia A. Maheshwari, MD, PGY-5 Fellow, UCSF Pulmonary & Critical Care

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The SFMMS 2020 Medical Trainee Essay Contest During a preclinical inpatient preceptorship, I met a man with AIDS who was so desperately ill that he started seizing during our interview, and I had to run for help. When I came back to the hospital the following week, I saw that Mr. P wasn’t on my preceptor’s list anymore.

“What happened to him?”

My preceptor didn’t know. We tried to look him up in the records, but his surname was common, and I couldn’t remember his first name. I had used his initials in my patient writeup, but I couldn’t for the life of me recall what came after that first letter. I was faced with my own clinical blankness.

I had sat with this man and listened while he cried. The story he told me of constant and indescribable pain in his bones had nothing to do with the admitting diagnosis of esophageal candidiasis, but that was the story that mattered to him. After his seizure, I stayed with him while stat head CTs were ordered, because I couldn’t leave him alone, curled up as he was and moaning, “oh my god, oh my god, oh my god”.

I’ve often been told that medicine is a front-row seat to life, death, and everything in between. But Mr. P taught me that the hospital is also an interstitial space, a place of brief contact. And even if I remembered his name, Mr. P would still haunt me – swept up in the workings of the hospital and swept out again, probably to the corner of 55th and Telegraph Ave., where he’d come from.

In the course of my future career as a physician, I’ll meet many patients, with more names than I will ever be able to hold on to.

This fact fills me with awe as well as heaviness. I’ll never know what happened to Mr. P or how he felt about our encounter. I just hope that he felt recognized as a person, when we were face-toface, and not completely alone.

Maybe all we can do is make our contact resonate in that moment we are together.

Sharada Narayan (she/her/hers) MS 2019, MD 2022 UC Berkeley - UCSF Joint Medical Program

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The perpetually darkened room in the ICU was your home when I met you. The room was right in front of the doctor’s station, the placement denoting the severity of your illness. You had a stuffed bunny, with the curly soft fur that you always tucked under your arm. You would pout until you were assured of Bunny’s presence.

But then you got worse. You spent more hours sleeping and would look up with half-opened eyes when I prodded you both morning and evening.

Your prognosis depended on which group of people were in charge. The oncologists were always sunny – just add one more drug to your long list. You would pull through. Our team remained on the other side of that spectrum, persistently worried. We were the ones sitting at that nearby doctor’s station, listening as your alarms beeped with increasing frequency, stepping into the room to discuss the minute details of your care with the nurses and your family.

More equipment, lines, and tubes surrounded your bed, keeping vigil. Each organ system was allowed to rest; we had machines to outsource the work. Yet you were still alive.

One morning I went into your room first. You earned the right to be first. Your numbers kept creeping higher, a child winning the race on field day. And you looked at me. Your eyes were fully open, a clear, bright blue-gray that does not exist past toddlerhood. I knew it was your last day.

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I smoothed your covers. I gently touched your stomach so that I could later write “swollen, massively distended.” It seemed important to document all of the details. Maybe it would help? I was following the ritual of being a doctor; examination and documentation. I could not walk into rounds and state it is your last day.

I needed proof. I couldn’t just tell all the professionals that you had said your goodbye. It was a moment between us that, like love, is inexplicable to outsiders.

Quietly and solemnly, I walked to the door and could feel the gathering tears. I made sure to slide the curtain fully. That no slit of light could reach your eyes. That you wouldn’t see me in the hall. I clenched my jaw, tightened my throat so that my next exhale wouldn’t come out as a scream.

Rachel Ochotny, MD Pediatric Cardiology Fellow

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“We went for a smoke break. The patient and I, I mean. And her partner, he came. Just there, outside. You know, where the hospital opens into the street? Where the busses fly by, and people mill around the steps… She only had one cigarette. Her partner, he ran a few blocks to grab one from a friend… The resident, she, um, said we should go. For a smoke break, I mean.”

“Jimmy! Where the f*** are you, Jimmy?!” She shouted, pacing along the umber-painted fence, the iron boundary within which I begged her to stay. He’d been gone for 5 minutes now, and she refused to sit in the wheelchair we’d brought. Her slippers – black and once trimmed with soft wispy fur – now were sprinkled with the ash and dirt of the street. I asked her again to sit, to wait. She ignored me, looking anxiously, fearfully, into the eyes of every man running beyond the gates.

“Babe! Babe, I got ‘em! And I got you a Pepsi, too – the regular kind. You know you guys don’t sell any soda in this whole hospital?!” He beams as he says it, proud of his gift and still a touch out of breath. Jimmy bends to his side as he reaches deep into his low-hanging pockets, and with a flick, passes Sammie the lone lit cigarette. He turns her chair to the shade while she adjusts her sunglasses, the light still painfully bright as years of alcohol make their way out.

“Do I look pregnant yet?! I can’t let anyone see a pregnant lady smoking!” A smirk erupts – a cocktail of dread and hope – as Jimmy rests his street-worn hands on her robed abdomen. He says, “Babe, I saw Chuck around the corner! He says congratulations!” “Ahhh, you saw Chuck?! Remember that time he saved your dumb a**?”

Laughter mixes with the halo of smoke gathering over their heads.

Bzzzz. “Come in!” echoes through the static of the intercom. We roll past the resident as she leans back in her chair. “I always love a smoke break with my patients.”

Ekaterina Protsenko MD Candidate, 2021

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Ms. R’s prematurely-greying hair and overall physical frailty were superseded by a vivacious and kind demeanor that was universally infectious. She had an exquisite and eclectic taste in music, and when walking past her room you could with equal likelihood find her singing along to The Beatles or Tupac. While I initially knew only her diagnosis of alcoholic cirrhosis and desperate need of liver transplant, I later learned her long history in an abusive marriage involving manipulation with drugs and threats to her WWW.SFMMS.ORG

children. As she finally fled to California, her cirrhosis decompensated — despite her optimism, her body could not endure without transplantation. As the transplant committee began, I was hopeful that her compelling story would indicate an obvious decision. However, the surgeons were concerned about missed appointments, and once, months prior, a nurse noted concern of lapsed sobriety, which Ms. R vehemently denied. The committee narrowly decided Ms. R needed another month to prove her commitment before they could approve her transplant.

The music’s abrupt stop indicated the seriousness of the impending conversation. Despite our attempts to interject hope for future approval, we lacked certainty she would survive. The focus narrowed to her need for an invasive test: she insisted on avoiding such procedures given the uncertain prognosis, so her last days could be spent with her children. However, as we elucidated that a transplant was impossible without the procedure, Ms. R’s reliably sunny attitude finally broke. As she wept, I couldn’t help but to weep with her. She agreed to the test, but I wasn’t convinced we were in the right. I felt defeated: the-powers-that-be would not allow us to save Ms. R’s life, and forced us into an unwinnable situation, with Ms. R caught in the middle.

As I walked out of her room in moral and emotional distress, I heard a familiar tune on her stereo, a melody that still evokes this amalgam of sorrow and exasperation, alongside a tinge of Ms. R’s signature optimism. Her now-cracking voice hung over Paul Simon’s in dissonant harmony: “God bless you please, Mrs. Robinson, heaven holds a place for those who pray, heyheyhey.”

Carson Quinn 4th year Med student

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The Patient Beyond the Curtain “Is this a hospital or a prison?” I heard my roommate shout from beyond the dividing curtain as I lay in my hospital bed. During my fourth year of medical school, I was briefly hospitalized for a condition called rhabdomyolysis. Although I had already completed many months working on the wards in various clinical sites, it was not until I was a patient myself that I met Mr. B, who transformed my views on patient-centered care.

Having spent a few days sharing a room with Mr. B, I witnessed first-hand the various events leading to what many of his providers would refer to as his “outburst” for the duration of his stay. Mr. B was recovering from spine surgery. Therefore, his mobility was severely restricted, requiring a nurse to assist with nearly every movement. Each day was spent with a series of providers marching into the room, inadvertently reminding Mr. B of his lost autonomy.

“I need to take your blood,” one nurse instructed to him. Moments later, a physical therapist dropped by, “Sir, I need you to try sitting up for me”. Just as Mr. B sat down after his physical therapy session to rest, his doctor chimed in, “I know you want to go home, but you can’t leave until we feel that it’s safe”, unaware that Mr. B’s wife was unable to travel to the hospital and he desperately wished to see her.

Soon after my admission, I was back to performing my clinical duties. One morning, I was frantically running between rooms to gather information for my attending. I entered my first patient’s room and walked over to her bed in the darkness that one can only truly appreciate during 6 AM pre-rounding. I began to gently wake the patient and almost instinctually blurted out, “Excuse me ma’am I need you to…” before catching myself. I paused for a moment.

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“Ma’am, I’m so sorry to bother you this early in the morning. Can I have your permission to listen to your lungs? I just want to make sure the fluid that was building up is gone.”

Vid Reddy MD UCSF Candidate, Class of 2021

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During my first week as a doctor, I opened a door in the emergency department of the county hospital to reveal an emaciated woman pinned to a bed. She moaned through a spit mask while the machinery around her screamed a cacophony of concerns in beeps and chirps. Her heart rate was too high. Her oxygenation was too low. I stepped in and introduced myself.

"Goddammit!" she cried.

I pressed on her belly.

“Goddammit!”

I placed my stethoscope on her chest.

"Goddammit! Could you get me some cranberry juice?"

I pulled up her gown to reveal thin, wasting legs.

"Goddammit! Goddammit!"

I skimmed old medical records, using other doctors’ notes to tell me what she could not. She had AIDS. She had no housing. She was using methamphetamine and she was not taking her antiretrovirals and she had metastatic Kaposi sarcoma. Even I knew this was beyond our fixing. I asked her to sit forward so I could listen to her lungs.

"Goddammit! Can I have some cranberry juice?"

I left the room. I walked swiftly to the bathroom. I sat down on the floor and I cried.

In the morning, she was gone: transferred to the intensive care unit. In five days, she was gone again. She had died.

When I was in kindergarten, my family inherited an old Steinway & Sons piano. I remember playing notes and hearing only thuds. But days later, a man came to our house and sat down at the bench. I watched him work: pressing the keys, listening in silence, mumbling to himself, and fiddling with the instrument’s internals.

With time, every key produced a full-bodied note.

When my patient died, I thought of that man again, massaging the piano’s arthritic strings until each note rang true. I thought of how I might do things differently. I would bring her the cranberry juice. I would remove her spit mask. I would put a straw in the juice box and place the straw to her lips, and if she took even a single sip, it would sound to me like a melody.

Gabriela Reed, MD Internal Medicine, PGY-1

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You were an old bear from a distant wild who must have wandered into our hospital by mistake. You’d been teaching a group of cubs how to hunt when you collapsed on the forest floor. Your fur was a hoary beard; your limbs, like tree trunks. You didn’t think before you spoke, and it got you into trouble. But your heart was good. Clogged, calcified too.

Together, we dusted off your catalogue of stories: some comic, some wistful, each rugged like you. You wanted my address, always hollering how a buddy caught a “boatload o’ tuna,” and you’d ship me a case. One day, I asked you to look at me while the others examined a vein in your neck.

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The SFMMS 2020 Medical Trainee Essay Contest I laughed and felt the roughness of your paw in my hand.

You told us hunting season was starting. You’d go and come right back. Wouldn’t ramble that golden, boundless brush; just sit in the bed of the truck. I knew better.

“It’s safer to do it now,” I warned. “Wouldn’t want anything to happen out there.”

We joked how anesthesia would be like hibernation. You bared an anxious smile.

“Just make sure I wake back up.”

And you did. But something was wrong. For such a thick belly, you had a thin heart. Blood swelled up from you like a summer river, red and thick with salmon to catch. We couldn’t take care of you here, so you left. When you came back, I envisioned a weathered bear restored triumphantly to its den.

But the bear was gone.

We had skinned its fur, shaved grizzled beard to pale skin. Severed its able paws, leaving blue, dying digits that hold neither rifle nor rod. Sapped its burly strength, binding it to the bed of a truck for every hunting season to come.

I introduced myself to the man left behind.

“Hey, remember me? You called me ugly.”

Some days, he doesn’t know me. His muzzle hangs slack. Glossy eyes stare past me. But today, he snarls like a bear.

“That’s right; pig ugly!”

Drew Robinett MS3

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The Boy Who Wasn’t Sometimes the harbingers of a poor prognosis help you brace yourself – prematurity, genetics, maternal substance use. Other times you are utterly blindsided by the abrupt end of a healthy pregnancy. I met my patient after his sacred mother-infant connection was suddenly severed; in-utero after his placenta unexpectedly split from its life-source, then ex-utero, as he was rushed to the NICU and his mother, separately, to Recovery.

When I met him he wasn’t imposing. He took up little space and demanded little. We made no eye contact, exchanged no words.

I lifted his cool, blue arm and watched gravity return it indifferently to the bed. He lay absurdly dwarfed in a box amid gigantic machinery, his miniature face barely visible through a thicket of wires and tubes. Nurses, doctors and family gathered to gaze upon him like the tiny king in a twisted Nativity scene. We quietly contemplated this fragile light bulb whose filament fizzled before he could illuminate.

I approached his parents to explain that his electroencephalogram was silent because his meticulously constructed neural networks had been liquidated. He would never walk, talk, open his eyes, or breathe independently. My best attempts at professional compartmentalization were useless. My tears welled, my voice faltered. His mother quietly reflected, “You hear about these things, but never think they will happen to you.”

It didn’t take long for him to die. The twenty minutes I spent with him ended up being a large portion of his 72-hour life.

A few nights later, my son awoke with a fever and vomited. That same day he tripped and got a bloody nose. “Don’t worry,” I comforted him, “tomorrow’s a new day.” I clung to him tightly, knowing that tomorrow is only ever a wish, not a promise.

Jeffrey Russ, MD, PhD UCSF Child Neurology

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Medicine Has No Borders She leaned in, and in the softest voice whispered in my ear that she and her oldest son were undocumented. This was her first time in a doctor’s office. She had always avoided hospitals because she was afraid that she would be deported and separated from her children.

Although she had come in to our clinic that day because her youngest son had been having asthma attacks, much of our conversation centered around her lack of documentation. Her fear that she would be unable to care for the medical needs of her children was palpable. I listened to her, reassured her, and did my best to help her navigate her first encounter with the healthcare system.

At the end of our appointment I walked her out to the parking lot, and she turned and enveloped me in her arms. We embraced for almost a full minute in complete silence. In that moment we were fully present, connected by our common guardianship of her biggest secret and deepest fears.

Although almost four years have passed, our encounter is still etched into my memory. Whenever I think back to that day, I am reminded of the incredible sacrifices that parents make for their children. For this family, living without documentation meant a constant fear of separation. As the daughter of an immigrant parent myself, I have become increasingly aware of the privilege that my mother’s green card affords my family. Unlike millions of individuals in our country, I know that my family will not be taken away from me.

Remembering moments like these keeps me grounded in my motivations for pursuing a career in medicine. Becoming a physician requires more than just mastery of clinical skills, and the practice of medicine is inherently intertwined with the complexity of our patients’ lives. Throughout my training it has become increasingly clear to me that improving the health of my patients requires me to advocate for systems-level changes outside of the exam room. Medicine does not exist in a silo, and neither can we as advocates for our patients and for more equitable healthcare systems.

Christina Schmidt, MS2, UCSF

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Lost and Found I breathe deeply before knocking, allowing a single moment of vulnerability before carefully resetting my smile. My next patient is loved and feared in our Alzheimer’s clinic. Eileen had been known for her passion and fire in health, and now she could tip from laughter to anger at a moment’s notice.

Today, I feel too delicate for the banter that normally keeps me on my toes. In an identical exam room hours before, I had sat shivering in the paper gown of a patient and learned that I may never run again. Now, I struggle to re-assume the role of provider as I grapple with the loss of a foundational piece of my identity.

Today, Eileen is also mourning. She pulls out a photo of a painting from years ago, when she worked in intricate detail and expressed her deepest emotions on canvas. With a fragility that matches my own, Eileen tells me of an art studio that has fallen into disrepair. In Eileen’s loss, I see my own reflected back a thousand-fold.

In the ensuing months, I call dozens of art teachers until I find someone to help Eileen reopen her studio. She paints with wide, unsteady brushstrokes, often forgetting where she began, but she creates. My first steps off crutches are weak and shaky, and I don’t run, but I discover new ways to move. During her weekly infusions, we flip through new paintings that reconnect Eileen to an WWW.SFMMS.ORG

identity once forgotten. Together we grieve what we lost, but we also marvel at what we still can do.

In death as in life, Eileen remains a constant reminder to contextualize my patients’ pain within our common human struggle: to integrate new challenges into our identities and move forward with dignity. Our time together did not alter the course of her ultimately fatal disease, but in uncovering Eileen’s vibrant history, we found an opportunity for healing and gratitude at the end of a full life. Illness bends but does not break the most fundamental pieces of our humanity—they lie just below the surface, waiting to be rediscovered.

Hope Schwartz, UCSF Class of 2023 / MS1

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Existing in Chaos There was chaos ensuing around us, the buzz of people getting in and out of the train, but I was trying to convey to her that I was here, and I was listening.

A research project aiming to understand substance use by street-based adolescents brought me to Mumbai, India some summers ago. Geeta, like almost all the girls I met, said yes when I asked her if she had ever had sex for money. Geeta, like almost all the boys and girls I met, said she had started sniffing glue—easy to find and cheap—when she was under 10 years old, and more recently in her teenage years, started to move on to “brown sugar”, a dirty mixture of heroin. Geeta, at the end of my 30-minute probe into her life, asked me if I knew where she could go to check if she was pregnant.

In that moment, I felt both hopeless and useless. Hopeless because there were countless Geetas who had stories just like hers.

Useless because I had no idea where the nearest free clinic was or if there even was one.

A month later, I was making my way to the awning under the train station. I heard someone yell “Didi! Didi,” which in Hindi means sister. I turned around to see who was yelling and who they were yelling at. Down the train tracks I saw Geeta running towards me, waving excitedly. She caught me up on her life. Good news: her family that she had run away from accepted her back into the home. Bad news: she was pregnant. Whose baby? Likely a “client’s.”

I think about Geeta a lot. The experiences that we had been brought up on—the ones that we like to think make us who we are—could not have been more different. So what was it about our first meeting that allowed her to feel comfortable to speak her truths to a complete stranger? And maybe the answer is as simple as that she was allowed the space to simply speak, to exist, and to be.

Aishwarya Thakur MD Candidate | UCSF Class of 2021

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Humbling Reminders from a Patient I’ve always been cautious, wary even of interacting of veterans given my multiple experiences of microaggressions or hearing the all too familiar question, “Are you Vietnamese?” Now, as a secondyear medical student I have learned the terms transference and countertransference, and that we all bring our lived experiences, our biases, into our clinical encounters. I have realized if anything, that our biases, which can often be shaped by personal experiences, may become more amplified in a clinical setting, and more nuanced because of inherent power dynamics between provider and patient.

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My first VA patient was Mr. A, a Marine who hailed from Kentucky, but had spent most of his life in Ohio. Mr. A had been admitted for an elective left knee replacement that had become infected

by MRSA, suffered renal injury from gadolinium from an MRI, and eventually became wheelchair bound from his medical sequelae.

Going from regularly hiking, fishing, and living independently, at fifteen years, he was now the longest resident at the VA. To those who had cared for him throughout his medical stay, he was a reminder of the failures of medicine.

In his room, he asked our preceptor, “You’re going to make the transfer to Ohio happen, right, doc?” With him requiring aroundthe-clock medical attention, our preceptor gently reminded Mr. A that they would try and consider that possibility, as my co-medical student I looked at each other, knowing that Mr. A’s wish may just have been that, a wish.

We said our goodbyes and well-wishes shortly after, leaving with Mr. A’s reminder of medicine’s capacity to show us the humanity in others. While Mr. A’s medical progression may have been not uncommon before today’s advancements, today he might have been considered the victim of multiple medical errors. Today in 21st century medicine, I find myself constantly learning about astounding new therapies, but sometimes forgetful of the not so distant past where medicine failed patients. Humbled, I wonder how things will be, and what patients will look like twenty years from now when I am a physician for whom medicine may treat but not cure.

Michelle Tong, MD Candidate UCSF l 2022

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7 Days Day 1: Mr. H laid in bed, moaning in pain. The left side of his face was overtaken by a parotid tumor. He looked imposing and frail. I introduced myself as the medical student. He sighed in annoyance.

“May I ask you a few questions?”

He flicked his hand at me. I took that as a yes.

He spoke in a gurgled slur. I couldn’t understand a word. This was going to be a pretty trick.

Day 2: Morning “Good morning Mr. H. How’s your pain today?”

He glared at me.

“Still bad?”

His eyes said: Obviously.

Day 2: Afternoon “How are you?”

He looked resigned. He spoke. I didn’t understand.

“Can you repeat that?”

He glared. Spoke again. I understood a little.

Day 3: “I hear you couldn’t sleep last night.”

No glare today. He nodded and sighed.

“The pain?”

He stated, “It’s still bad and worse in my chest. Any news?”

“Nothing yet. We’re going to order some more imaging.”

I started his physical exam.

“You’re strong for a girl,” he stated.

I glared this time. He smiled. I smiled.

Day 4: “Mr. H needs sedation for the MRI,” I told my intern.

She looked surprised. “Was that in his chart?”

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The SFMMS 2020 Medical Trainee Essay Contest Day 5: I had a day off. I watched television in bed and ate PB&Js. I wondered if Mr. H was able to sleep that night.

Day 6: I walked into Mr. H’s room with my residents and attending.

“Where the hell were you?” He looked upset.

“I had a day off.”

He looked at me for a moment and asked, “You get some rest?”

“Yes, and you?”

“No. I had my MRI. Find anything?”

I looked to my attending. She nodded at me.

“Mr. H, I have some difficult news.”

Day 7: I consulted palliative care and prepared Mr. H’s discharge. As we said goodbye, he told me he trusted me. I choked up.

He shook my hand. “Stay strong,” he smiled.

His grip eased but didn’t falter. We were a team. I wonder if he knows how much that meant to me.

Niki Vora MD/MS candidate, UC Berkeley – UCSF Joint Medical Program

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He had brought us one of his hand-written essays—a two-page description about obscure thought transfer. Upon further questioning, he explained the mechanics of telepathy and noted that while he had this ability to communicate non-verbally, not many others did. He was convinced that technology is our future, and that even though society currently stigmatizes telepathy, thought transfer would become the norm within this century.

It was nearing the end of his second month at the hospital.

He had been admitted after dropping out of a court-mandated behavioral counseling program, and he also had nowhere else to go. He talked about his experience with schizoaffective disorder, the first episode of which had him thinking aliens were coming to invade the city, and how the medications made the voices he heard in the hum of the air conditioner disappear. He also spoke of substance-induced remote viewing episodes that allowed him to see the confluence of the past, present, and future.

Throughout our conversation, he was confident in his reasoning and convinced by his narrative. His untucked blue plaid shirt fit the image of a self-described “undisciplined scholar.” Sure, he hadn’t gone to college, but he had done his research. He had read books, papers, and articles about telepathy, and was aware of Elon Musk’s efforts to connect the brain to artificial intelligence. The lack of schooling also didn’t dampen his insight into society.

“If I were a billionaire and I told you these things, you’d think I’m just eccentric. But because I’m homeless, I’m considered crazy.”

His statement gave me pause. How do we define what is normal, if not by the consensus of society? And how do the labels we give our patients change who they are and the trajectories of their lives? I can only imagine the frustration and loneliness he’s experienced from his illness, and this interaction illustrated the importance of looking inside the experiences of others to meet them where they’re at. It reminded me to see beyond the condition and find the human, recognizing the universal desire for connection and understanding.

Sarah Watanaskul MS2 | UCSF School of Medicine

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“Patient is a poor historian.”

My chest tightened at the incriminating label as I checked the chart: JW, 35-year old Asian male. I glanced up to see him sitting in the hallway, amidst patients yelling and gurneys whizzing by.

Despite the hectic rhythm around us, he had told me through the Cantonese interpreter on speakerphone that he had numbness and weakness in his left hand. He thought that he could “shake off” the numbness, but then unexpectedly dropped a knife at the restaurant he works. When his cup of tea fell from his left hand, he decided to come to the hospital for the first time since moving to the US. I coached with my Cantonese echo, “Squeeze my hands as hard as you can!” And repeated my commands when his hands clutched mine with a faint difference between his right and left. I didn’t want to believe my exam, imagining it would be incredulous for a healthy young patient to have a stroke. But with no other leading diagnosis, I asked for help from my consultants and ordered a scan of his head.

Reading the consultant’s note, I wondered what had earned Josh this label and their recommendation: “defer imaging, patient safe for discharge.” It seemed that we had met different patients.

As the scan of JW’s head emerged, the radiologist called to detail a subtle stroke. I felt relieved that his symptoms could be explained, and that a worse stroke could be prevented with our care now, but the idea of a near-miss terrified me. JW’s diagnosis was possible but not very probable, and this uncertainty had been dismissed with labeling him a “poor historian.”

When patients don’t provide a linear story that fits our paradigms of disease, it’s up to us as their caretakers to listen to them and to the narratives that they have built. Listening requires more than hearing the spoken words; it means decoding them and making some sense of their worlds. In a medical culture encouraging us to create simplified versions of complex problems, listening deeply is our key to bridging gaps.

Sojung Yi UCSF-ZSFG Emergency Medicine Resident

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HOME Tap, Tap. Was that a 3+? Or a 4+?

Or are reflexes graded out of 5?

I couldn’t remember.

You whispered something, But I could barely hear you over all the machines.

I leaned in close, careful not to graze you with my White coat that had been in too many patient rooms and Not enough laundry rooms.

“I want to go home.”

I nervously tried to explain that you had a bad infection in your brain.

You had been here for 3 months already.

Even longer than I had.

I had read dozens of notes.

Home was not on any of the problem lists.

“No, I want to go home.”

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You pointed at the ceiling.

I look up, confused, As if expecting to find an answer in the tiles.

Reflexively I asked, “Oh, you mean…to heaven?”

You nodded.

A week later, New rotation, new scrubs, Old insecurities.

How much amniotic fluid was normal again?

I smiled anxiously at the pixelated baby on the monitor.

A rapid response Echoed over the intercom.

I almost dropped the ultrasound probe.

I already knew, But I checked anyway.

You finally got to go home.

Micha Y. Zheng, MPH, MS MD 2020 Candidate, UC Berkeley-UCSF Joint Medical Program

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Whenever I hear the harsh voice of self-doubt, I think back to my first patient. The folder on the clinic room door read, “64-yearold man with presbycusis.” I paused for one soft run-through of my tuning fork tests. Two years into medical school and there I was.

I had barely entered the room before a roaring barrage of words came thundering back. My patient was livid after waiting “damn near a year” for a “non-doctor” treating “something that doesn’t need fixing.” I instinctively pivoted to ask for the “time-out” available during our standardized patient exercises – but this was no dress rehearsal. My career had started, but the premiere seemed to be heading for a flop. I looked out the window for inspiration or, perhaps, an escape route. An American flag inaudibly billowed in the parking lot, practically taunting me with freedom.

“Have you ever heard about Reagan’s hearing difficulties?” I practically whispered. He looked puzzled, but intrigued. “Nearing the 1984 election, President Reagan had begun to notice a decline in his hearing,” I began, settling on the tan stool in front of him. “He sent for the best otologist in the United States: Dr. John House (no relation to Gregory). Alone in the Oval Office with the leader of the free world, Reagan had one question for Dr. House: ‘What are we going to do about my hearing, doc?’ House ran Reagan through a battery of tests and at the end of the exam, he had only one treatment to recommend: a hearing aid." I paused. "Well, you can imagine his apprehension at this proposition.” A silent grin broke across my patient’s face, who had to lean in to catch every word. “With only a moment’s pause, President Reagan chuckled and said, ‘OK, let’s do it!’ Hearing aid sales went up by more than 20% that year.”

The buzzing fluorescent lights were deafening. My patient snorted, grunted, and then suddenly began to laugh. He looked me up and down one last time before sticking out his hand.

“Well doc, if it’s good enough for Reagan, it’s good enough for me.”

Michael Zobel MD UCSF Surgery Resident

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Special Section: Medical Disaster Readiness in San Francisco

BEING CREW, NOT PASSENGERS Improving Medical Disaster Preparedness and Response in San Francisco

Scott J. Campbell MD, MPH During World War II, German U-boats were sinking British merchant ships in the frigid North Atlantic, and sailors waiting for rescue were perishing at alarming rates. Surprisingly, the survival rate among young, presumably fit sailors was much lower than among older seamen. A well-known educator at the time, Kurt Hahn, was called upon to fix the problem. He quickly identified the issue as a “lack of confidence in the victims,” rather than any lack of skill or equipment. He established a program of rugged challenges to help young recruits develop the internal fortitude, confidence and cooperative skills necessary to survive both physical and intellectual struggles.

Named "Outward Bound," after the nautical term that refers to the moment a ship leaves the safety of its home port bound for the open ocean, Hahn's program demonstrated the benefits of both individual achievement and team-building skills in a young group of sailors as they learned they possessed not only "far more than they knew", but the necessity of truly relying upon those comrades around them when their very survival was at stake.

A couple months ago, seventeen physician leaders from Sichuan Province traveled to San Francisco to learn about earthquake preparedness. Sichuan tragically suffered over 90,000 deaths and 375,000 injuries during a devastating earthquake in 2008, and the delegation spent a day at Kaiser San Francisco in dialogue with emergency medicine leaders from across the city, county and state.

Through their well rehearsed parallel systems of “treating the injured, restoring the acute care grid and preventing communicable disease outbreaks”, one thing became abundantly clear at the completion of the day’s discussions: our medical colleagues in China have fully woven “readiness” into their everyday lives as health care providers.

Every day in San Francisco, over 1,000 patients visit our hospital emergency departments, an increase of 40% since 2008 with ED visits in the city growing at 3 times the rate of population. During that same decade, there has been no significant net increase in medical surgical acute care beds across the same system. These daily supply and demand miss-matches have obvious consequences: from patient being boarded to the cobbling together of non-optimal ED treatment locations to increased leaving without being seen to rising ambulance diversion. In fact some months our ED “grid” is effectively closed to incoming ambulances 1 out of every 6 days. ED congestion is bad for everyone: it delays care, it tests our patients’ confidence in the health care system and most importantly it undermines our emergency responsiveness during an major incident or casualty event.

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Moreover, we have learned from local experts such as Dr. Chris Colwell at Zuckerberg San Francisco General Hospital and Trauma Center that these mass casualty events push our acute care grids to provide capacity in often unplanned fashions. For example, despite rigorous pre-hospital system planning and preparedness, most victims will often not arrive to a hospital

by EMS and in fact, many will self triage to the closest urgent care facility or use their phone “find the nearest hospital”. That hospital is often not the designated Level 1 trauma center but a smaller hospital(s), which then becomes a default trauma center, and sometimes for many days if the Level 1 trauma center is saturated. And once at an ED, patient EMRs are not likely to be constructed fast enough, and issues such as family assistance and reconnection as well as optimal media lines of communication often become major system stressors.

To better address the challenges of “readiness”, we all may need to wade into what may be unfamiliar territory: 1. Better communicate horizontally with our specialty colleagues within and across our communities. At the SF Emergency Physicians Association, we have just established a back channel “bat phone” hotline list with 2 ED physician providers from every hospital in the city to be used on a “break-the-glass,” major incident basis only.

We encourage other subspecialties to do the same.

2. Visualize extreme scenarios and “have a bougie” (as we say in rapid sequence intubation) plan in place. Where do the extra ventilators, fracture fixation hardware or dialysis machines live at your institution or nearby?

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3. Build mental patient check lists of how we would facilitate the process of “reverse patient triage” and rapidly, safely emptying our hospitals of 20% of their patients (Immediate Bed Availability).

4. Brush up on those “rusty” skills sitting just outside our comfort zones which could be called upon in and MCI such as minor suturing, splinting or performing CPR. By demonstrating to the rest of our friends and colleagues in the San Francisco and Marin County health care communities “what it is we do best,” there is no question that we can champion a broad-based solutions approach to “readiness” just like our colleagues in Sichuan have done. Like Kurt Hahn and his sailors in the North Atlantic, we at the SFMS know that “we are crew, not passengers”. Our friends, our families and the very patients we serve each day are depending on us.

Scott Campbell MD, MPH serves as Co-President of the San Francisco Emergency Physicians Association, which was founded in 1987 and has helped lead successful public-private initiatives such as the Sobering, Medical Respite, and Dore Psychiatric centers. SFEPA aims to inform policy at the intersection of emergency medicine and public health. Scott is a practicing ED physician at Kaiser San Francisco Medical Center.

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Special Section: Medical Disaster Readiness in San Francisco

TRULY EFFECTIVE DISASTER PREPAREDNESS: Will We Be Ready Next Time?

Christopher Colwell, MD April 20th, 1999 started like a very normal Tuesday for me, just like the disaster situation you will face will start as a normal day for you. Now that we know it will happen, and have had enough events that qualify as disasters that require a medical response to teach us some important lessons, we should discuss what it will look like. Or rather, what it should look like. Since we know it will happen, how are we preparing?

A disaster, as defined by the Centers for Disease Control and Prevention (CDC), is a serious disruption of the functioning of society causing widespread human, material, or environmental losses that exceed the local capacity to respond. Essentially, when the need overwhelms the resources available to respond to a particular situation. While it could be argued we face this in emergency medicine every day, we are talking about an event that results in mass casualties that overwhelm our capacity to respond. It may be an earthquake, or a mass shooting, an explosion or a bus accident, an intentional event or an accident. It really does not matter. What matters is how prepared we are to respond, and once we recognize we are in a disaster situation, how we distribute resources in a way that best serves our community.

Unlike what we do every day, which is direct all available resources to everyone, the sickest first, we will need to determine the best use of available resources with the objective of the good of the many over the good of the few. What exactly that means for us here in San Francisco should be part of the discussion we are having now, but certainly goes beyond the scope of this article. Suffice it to say some difficult decisions will need to be made that go well beyond the decisions we make as a matter of routine every day, and some will not get the resources that might get in a non-disaster situation. That may be the most difficult issue you will face. Are you ready to ration care?

My experience as the physician at the scene of the Columbine High School shootings in 1999 and in the Emergency Department at Denver Health for the Colorado Theater shootings in 2012 taught me some important lessons on disaster management that I believe we can use as we prepare for the 22

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next disaster here in San Francisco.

Many of the issues we faced in Colorado were experienced at other mass casualty events throughout the country including Oklahoma City, New York, Orlando, and Las Vegas. While this is by no means an exhaustive list, here are some of the lessons I took away from the Colorado events that may help inform our planning for the next event we experience here.

Communication will be critical.

This includes from the scene to the hospitals but also between the hospitals as well. Which hospitals have been overwhelmed and which still have capacity as an event progresses can inform destination and transport method decisions. How we are using available resources and exploring ways to better share them will come down to our ability to communicate with each other during the event. Cell phones, an important component of our communication now, may not be available as coverage may be overwhelmed or in some circumstances limited by law enforcement. My experience would suggest that while we have made some strides in our inter-hospital communications, there are also some opportunities in this area.

Knowing the closest centers will be overwhelmed, and not necessarily with the most critical patients, can help focus efforts on creating capacity in areas less likely to be dealing with large numbers. We also know that medical centers, particularly those closest to an event, can be targets as well. What happens if critical centers become incapacitated? We have some impressive resources that can assist in re-supplying centers or in creating triage locations and patient-care facilities.

We will need to better understand what those resources are and how to access them, even during “off � hours, in order to best utilize them at a critical time. There are also a number of potential alternative care sites, here in the City and nearby as well, that could be very useful when capacity at medical centers becomes limited. We may need to expand our current considerations for how and under what circumstances we might access and use these sites.

Distribution of patients can be an important issue and will almost certainly need to be approached differently than the way it is normally done. Simply going to the nearest center or WWW.SFMMS.ORG

a specialty center with all those needing or wanting care will result in simply displacing the disaster from the scene to that hospital. In situations that involve traumatic injuries in the City, the most critical patients should be taken to San Francisco General when possible, but the other hospitals will all need to be prepared to see trauma patients that they are not currently used to seeing. The emergency physicians, surgeons, and other specialists that staff the non-trauma centers are certainly capable of taking care of more significant trauma when necessary and should have a plan for how to do this. An experienced provider at or near the scene assisting with triage can be very helpful in determining which injuries can be reasonable cared for at non-trauma centers in a disaster situation.

There are a number of different triage tools available.

Which tool we use is far less important than the ability to use terminology that we all understand. What a green (minor), yellow (delayed), red (immediate), or black (expectant or deceased) looks like can vary a little depending on the scene and evaluator, but we should all have an idea of what each category means and where they would go in our facility. Minor and delayed patients will likely make up the large majority of the victims. Minor patients will ideally not get into the emergency department (ED). They will need a place to go, perhaps even at a site away from the hospital, that does have an experienced provider available that can reassess these patients understanding that triage is a dynamic process and patients initially assigned to one group may change over time and need to be placed in another. Tracking where patients go will be challenging, but needs to be done.

We should not separate families unless it is absolutely necessary. This will mean that hospitals that don’t typically see pediatrics will need to manage kids, and pediatric hospitals will need to manage adults. Destination should be determined by the more critically injured or ill family member. Only if both an adult and a pediatric patient (less than age 8) from the same family are critically injured or ill should we consider separating them.

Each hospital involved, and particularly the ED, will quickly become chaotic. There will be many people, and pieces of equipment as well, that will arrive. Roles and responsibilities will need to be assigned and should be determined in advance.

Vests with very visible colors will need to be available to clearly identify critical staff. Setting up each hospital’s incident command should be seamless as it will be exercised in advance.

Disaster exercises need to be designed to identify gaps. A “successful” exercise will not push us to be better prepared.

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We will need to take care of ourselves so we can take care of our patients. This means providing resources for the staff as well as our patients. Food will need to be available 24/7.

Some staff will need to be sent home so they will be available to relieve others as fatigue sets in. It also means providing resources for staff after the event is over. We must be very careful not to underestimate the impact that managing a major event can have on healthcare workers, even those used to regular traumatic events.

Successful management of a significant event will require emptying out the ED to every extent possible so there are open beds to manage new patients coming in. A dermatologist may not be comfortable managing major trauma, but could potentially take ED patients with rashes to an area separate from the ED to open up those beds. There will be roles for everyone, but they will need to be arranged in advance to every extent possible and may not be located in the ED. The media will need to be involved and people experienced in media relations available to help navigate this potentially impactful component of disaster events. The media can fill an important and helpful role in interacting with the public and getting critical information out to the community, but will need to be skillfully engaged. Their effect can be detrimental if their role in not appreciated.

We are only scratching the surface here. We may not know when or what it will look like, but we do know a disaster will come. We can be better prepared. Our community deserves nothing less.

Dr. Colwell is the Chief of Emergency Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco’s only Level I trauma center, and is also a Professor and Vice Chair in the Department of Emergency Medicine at UCSF School of Medicine.

He completed his undergraduate work at the University of Michigan and then went to medical school at Dartmouth Medical School, graduating in 1992. He completed his residency in Emergency Medicine at Denver General and has been Medical Director of the Denver Paramedic Division, Denver 911 System and Denver Fire Department, Chief of Emergency Medicine at Denver Health in 2009. He was the physician at the scene for the Columbine High School shootings and treated victims of the Aurora Theater shooting in the Emergency Department. His academic interests including publications and national speaking have focused on trauma and EMS issues in addition to Disaster Planning and MCI management.

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Special Section: Medical Disaster Readiness in San Francisco

A SALVE FOR THE CONFLAGRATION ERA Ian Mclachlan, MD, MPH This isn’t the first time that fire has challenged the very existence of American cities. In fact, at the turn of the last century, as America surged towards urbanization, it appeared our cities could never survive the scourge of flames that kept reducing them to ashes. Fire damages in Chicago 1871 totaled $871 million, Baltimore in 1904 were $250 million, and fire damages soared to $359 million after San Francisco’s 1906 earthquake*.

The solution was to professionalize volunteer fire brigades, to mainstream them into routine city management, to regulate building codes, and to create new financial systems of property insurance to underwrite these efforts. An “invisible screen of safety” protecting American cities was the phoenix that rose from these ashes. 1 The history of fires in California has similarly and significantly contributed to the country’s resilience. In 1970’s Southern California there were 773 wildfires occurring at the same before fire departments learned to unify their responses and extinguish the conflagration. This federally funded effort became the incident command system (ICS) which today is the backbone of every FEMA response, uniting local police, fire, public health and hospitals2. This organizational structure is scalable to a disaster of any size. And in hospitals we use hospital ICS (HICS) help solve every problem always the same way. In our “All Hazards Model” model we either evacuate patients or surge to receive more.

Today, the dystopian imagination has decidedly increased, and so should our hospital responses. Historically, the disaster response understandably was very focused on terrorism after 9/11. The constant clip of mass shootings sadly validating the importance of this paradigm. But in an era of climate change the number of casualties can be considerably more numerous.

If only out of necessity, it makes sense that our land of fires and earthquakes may invent yet another contribution to the country.

September 19th SFMMS gathered to welcome a contingency of Chinese disaster health experts. This was an enormously generous effort by physicians who blocked their busy schedules and found time to contemplate the logarithmic proportion of human suffering measured in the magnitudes (M) of Richter scales. We 24

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considered, what if a Sichuan Province-type earthquake occurred in San Francisco? Moments later the Mandarin interpreter would translate the sentiment, and the audience’s eyes would sink.

Centralization vs decentralization:

We found countless similarities between the Bay Area and Sichuan Province, but there were some marked differences as well. Universally a disaster response is centralized. The command structure must be clear. The actions must be definitive and swift. But across California each county designs their health department org chart in their own image, decides their own priorities to address local hazards and vulnerabilities. Our state health officer receives her priorities from the counties, not the other way around as some other states function. So when a regional disaster happens, like a large fire or earthquake, nine distinct bay area counties must find ways to work together. During the SFMMS conference both speakers and audience discussed if such a system could meet the urgency of a disaster when time is muscle, time is blood loss, and every second counts. How often would communication miss? Wouldn’t differing situational awareness’s conflict? Would people die? Could bay area hospitals surge to care for fire victims from across Northern California? And would outlying hospitals be able to care for Bay Area residents after an earthquake?

I was eager to learn how Sichuan province coordinated efforts in 2008 when an 8.0 M earthquake laid many thousands of people to rest. But when asked about the physician voice and physician leadership during the earthquake; hands that once waved furiously to share long philosophies now busied themselves holding teacups. The question did not resonate. I suspect their structure does not vitally depend on lateral collaboration as ours does during a disaster. The great advantage of our decentralized system is its ability to present many different solutions, and allow for many voices. But a cacophony of too many voices is not the San Francisco bay area dilemma.

To some degree our voice (and resilience) is diminished by regionalization of trauma. In a city of nearly one million people WWW.SFMMS.ORG

including day commuters, we all share only one trauma center3.

Boston, despite having a similar population, maintains eight level one trauma hospitals.4, 5 How safe is our city if it lacks redundancy? During the Boston bombing in 2013, 260 were injured, 20 of them critically injured and only 3 people were killed. The trauma hospitals of Boston ensured that every person who found emergency services survived4. That variability fuels many more questions.

The physician voice is also diminished by the structure of HICS. When the Kaiser Santa Rosa hospital evacuated amidst flames in 2017, CalFire had recommended the hospital “shelter in place” instead. Who bears the weight of that decision? The FEMA HICS organizational chart recommends the hospital chief operating officer decides. At the Santa Rosa hospital, the chief of the ED working in the hospital at 1am saw patients choking of smoke and urged evacuation despite CalFire’s concerns the roads at that time could become unsafe6. Physicians are a small fraction of the HICS command structure7. Consequentially, the clinician voice is proportionately decreased, especially during a disaster.

Lastly the communal physician voice is muted if we think of this as only an issue of trauma. Paris deployed 35 psychiatrists within hours of the attack that night8. Evacuating a hospital in the middle of the night, during a fire, and without medical error, is best accomplished with help from all of us. Resources largely determine the standard of care during a disaster9. It follows that some of the ethical dilemmas that occur during a disaster pitting resources against morbidity, the good of the individual versus society may be attenuated by the coordinated effort of many physicians working together. FEMA demands we are self-sufficient for 72 hours until federal assistance becomes available. The only help we may have until then is our disaster plan, and each other.

I must confess, there was a second ambition to hosting the Sichuan Province discussion about disasters; to spark the conversation locally. But during the final wrap up, we worried the smoldering conversation did not catch fire. We considered things might remain unchanged despite a shared concern: In this conflagration era, there is a need for innovation, especially led by physicians, to strengthen the coordination of our voices, skills and hospitals, reinforcing an ‘invisible safety net’ for our region.

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Douglass Ian Mclachlan, MD, MPH, is a senior emergency physician at Kaiser Permanente San Francisco

References 1. Scott Gabriel Knowles. The Disaster Experts. U Penn Press July 2, 2012.

2. Federal Emergency Management Administration. IS-100.C: introduction to the Incident Command System, ICS 100 3. 2019 Medical Surge Assessment Gap Analysis Report: prepared for the SF Dept of Public Health, Public Health Emergency Preparedness and Response Branch.

4. Atul Gawande. Why Boston’s hospitals were ready. The New Yorker. April 17, 2013 5. https://en.wikipedia.org/wiki/List_of_trauma_centers_in_ Massachusetts 6. Magana J, Medeiros S, Weil J, et al. Last Stand in Santa Rosa.

EM:RAP podcast. September 2019.

7. https://www.calhospitalprepare.org/hics , Physician roles at the hospital in a disaster 8. Hirsch M, Carli P, Nizard R, et al. The medical response to multisite terrorist attacks in Paris. Lancet. 2015;386:25352538.

9. IOM (Institute of Medicine). 2012. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response.

Washington, DC: The National Academies Press.

*= I suspect these are 2012 dollars. But the book references another resource not available to me before the deadline for this article.

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Advocacy and Education

SAN FRANCISCO HOPES TO IMPROVE CARE

For People With Mental Illness Living On Streets An interview with Anton Nigusse Bland, MD, San Francisco’s Director of Mental Health Reform San Francisco Mayor London Breed has promised to tackle her city’s homelessness crisis, a vexing situation involving drug abuse and mental illness that is compounded by the city’s high housing costs. Breed has asked Dr. Anton Nigusse Bland, most recently the medical director for psychiatric emergency services at Zuckerberg San Francisco General Hospital, to help solve the problem.

In March, she appointed him to the newly created position of director of mental health reform. His main role is to help the city improve its mental health and addiction treatment for people experiencing homelessness.

“I had the opportunity being there on the front lines, providing services directly to clients, to better understand and appreciate when a person has that combination of homelessness, mental illness and substance abuse,” said Nigusse Bland. He has worked in several Bay Area county mental health systems, first as an

Brian Krans

integrated care psychiatrist with Alameda Health System, then as chief of psychiatry for Contra Costa County.

The mayor backed a new state law, SB-1045, which establishes pilot programs to expand the use of conservatorship — a controversial practice that allows the city to take people with mental illness or substance abuse issues off the streets without their consent and put them into treatment.

To identify the people in greatest need of services, city employees used data on the 18,000 residents in need of immediate shelter. They identified about 3,700 who were experiencing what Nigusse Bland calls the “trifecta” of homelessness, mental illness and substance use. Many of them have repeatedly visited ERs or been jailed multiple times in the past year. Of those 3,700 people, 237 were identified as immediate priorities. Nigusse Bland said the key is coordinating care to get them into housing and services they may not know are available.

San Francisco is the only jurisdiction so far to create such a conservatorship pilot program, though the law also allows Los Angeles and San Diego counties to do so. San Francisco officials also recently reached an agreement on how to allocate mental health funding for those with the most urgent needs. Their plan includes a 24-hour service center and an outreach team.

Nigusse Bland sat down last month with California Healthline at the San Francisco Department of Public Health in the city’s Civic Center, which has long been a hub of homelessness and open-air drug use, to talk about the daunting task facing him. His comments have been edited for space and clarity.

Q: What were some of your first steps when you took this job?

We had a couple of challenges ahead of us, one of which was being clear about who is affected by homelessness, mental illness and substance abuse and finding the root cause of why they’re having this experience right now. In this population, care coordination works, and you have to be very thoughtful about deploying evidence-based practices to get those services to those individuals.

One of the overwhelming assumptions about this group of individuals is that they’re all getting high on crystal meth, but we were surprised to learn that 95% of these people have an alcoholrelated problem. The good thing is that there are many things we can do about alcohol.

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Q: What services will be available to the 237 people you identified as having the most urgent needs?

Those individuals will receive an advanced care coordination team coupled with street responders, mental health specialists, a psychiatrist, and caseworkers who are actively reaching out to these people in the community. If they are found in an emergency setting, we will go to that setting and help navigate them to a safe place, which might be a substance use treatment program, a mental health residential program or directly into housing.

Q: Allowing city officials to hold people against their will is controversial. What do you think about using conservatorship to treat people with mental illness or substance abuse disorders?

We have to be very thoughtful in the balance between autonomy and restoring a person’s dignity and health. It’s inhumane to allow someone to suffer on the streets with serious mental illness and substance abuse when there are alternatives available to them. In many of those cases, those individuals who are so severely affected may not even understand what’s happening to them at that moment. They’re struggling.

Through conservatorship, we have an opportunity to help restore that person’s capacity. I see it as an opportunity. In some cases, it can be the right thing to do to help that person get back on track.

Q: How will you get people the services they need given historically limited funding?

Our mayor has made a significant investment by adding over 200 new behavioral health beds into our pipeline with plans to add over 800 new beds. We have commitments to increase the number of our intensive case managers, especially in mental health services for individuals with complex mental health and substance abuse issues. We’ve made a commitment to reduce intensive case managers’ workloads to be able to meet the needs of these clients. We want to make sure the ones most severely affected are getting into housing and get the support to stay in housing.

Q: How will you gauge success?

We should see changes in people experiencing homelessness, the amount of time they spend in jail and the emergency room, and their engagement in some kind of meaningful activity. There are a couple of things that I think are going to make an impact, one of which is our Drug Sobering Center for those suffering the consequences of methamphetamine use. If someone appears confused, is having difficulty keeping their clothes on or yelling at someone, there’s a safe place that’s not jail, that’s not the emergency room, where they can recover and get counseling. And, if they’re ready, they can go into a treatment program as a next step.

That person doesn’t have to spend another night on the street and has the opportunity to get into services rather than having a jail record. And there’s the indirect impact of our emergency departments likely experiencing less crowding.

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Q: What else should people know about this work?

Thirty-five percent of those 3,700 individuals in that trifecta are black and/or African American, a group that represents only 5% of San Francisco’s population, so they are disproportionately represented in the most vulnerable among us. We want to see an equitable San Francisco so everyone has a fair shot at wellness and recovery.

Sometimes that first opportunity isn’t successful and you might have to engage again to get that person on the right track, but what we know is that with every opportunity, they can make progress. It might be incremental, and it’s on their own timeline, but they can get better.

Courtesy of California Healthline, from the California Health Care Foundation.

Seeking Surgeons and Specialists to volunteer with Operation Access Operation Access (OA) is seeking surgeons and specialists who want to volunteer locally to help individuals who lack health insurance, are low-income, and require an outpatient procedure.

For the last twenty six years, OA has been organizing medical volunteers and arranging surgical and specialty care in nine counties of the Bay Area. OA’s program in San Francisco and Marin has been growing and various participating hospitals have generously agreed to donate charity care that is performed through Operation Access.

Clients are referred by community clinics and OA provides hands-on case management and interpreters to make it easy to volunteer and for patients to arrive to their appointments fully prepared.

High demand specialties include gastroenterology, general surgery, gynecology, orthopedics, podiatry, urology and vascular.

For more information, consult www.operationaccess. org. If you are interested in becoming involved as a volunteer, please contact San Francisco Program Manager, Kealey Clemens, at (415) 733-0055 or Marin Program Manager, Elise Hilsinger, at (415) 733-0079.

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Advocacy and Education

HERE'S HOW TO FIGHT ADDICTION. TRUST ME, I'M IN RECOVERY — But does the government have the guts?

Paul H. Earley, MD, DFASAM Regardless of race, income, gender, or profession, addiction is a complex medical disease that can affect anyone.

Take, for example, a young doctor I watched fall into its clutches. Like most college students, he experimented with alcohol. When his post-college experimentation expanded to cocaine and opioids, his judgment left him, but his false confidence — fueled by his training in neurophysiology — did not. As he moved into medical school and then residency, he found himself caught between a drive to acquire the skills of his profession and the incessant hunger of his illness.

But with addiction, the end result is quite predictable. His accelerating substance use disorder caused him to lose himself, his job, and eventually his freedom. He would have lost his medical license, too, if he had not received a sustained tapering course of addiction care and ongoing support by family, friends, and others on the same journey of recovery.

The result of proper treatment was nothing short of a miracle.

This physician found a life filled with joy and an amazing new medical specialty, treating others who have been diagnosed with substance use disorder (SUD).

But I didn't see that man in my office. I saw him in the mirror. My story underscores the fact that recovery is possible — if the right treatment and support is provided at the right times.

Unfortunately, our nation's response to the addiction and overdose crisis is inadequate. In 2017, nearly 21 million Americans needed treatment for SUD, but only 4 million reported receiving any form of SUD treatment or ancillary services.

During the same year, over 70,000 Americans lost their lives due to a drug overdose. Two-thirds of those deaths involved opioids. Despite preliminary signs that drug overdoses may be starting to ebb, new reports show that some states are actually seeing an increase in their overdose death rates.

The statistics are grim, but there is hope. We know what needs to be done to save lives. Thanks to a growing body of scientific research, there is a roadmap to recovery. Now it is up to Con28

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gress to follow it.

Teach Addiction Medicine Few Americans with SUD have access to high quality, evidencebased addiction treatment.

According to the 2017 final report of the President's Commission on Combating Drug Addiction and the Opioid Crisis, there were roughly 4,400 certified addiction physician specialists actively practicing across the country, but based on a 2009 estimate — well before the surge in overdose deaths hit record levels— the U.S. needed at least 6,000 of those specialists to meet the demand for treatment. Put simply, the addiction specialty treatment workforce is catastrophically insufficient to address addiction.

Stigma and misunderstanding about addiction— particularly within the medical community — compounds the problem.

According to a recent survey of healthcare professionals in Massachusetts, only one in four had ever received any type of addiction medicine training during medical education, while more than half of the emergency medicine, family medicine, and internal medicine providers (falsely) believed that opioid use disorder (OUD) is not treatable. Addiction is a complex disease, not a moral failing. We need many more in the medical community to understand this.

Congress can be part of the solution by passing legislation and funding programs that promote education and training in addiction medicine and incentivize more medical students and professionals to serve in high-need areas.

Standardize Addiction Medicine

Like other medical specialties, addiction medicine is based on a broad and ever-growing body of scientific research.

Patients need to feel confident that their healthcare providers can deliver personalized, evidence-based care. This includes offering access to affordable addiction medications, when appropriate, that are proven to save lives. When crafting policy, Congress should lead with science and encourage the adoption of standards and research-validated guidelines for treating Americans with addiction.

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Cover Addiction Medicine Finally, Congress must help remove the barriers that prevent people with SUD — including people who are incarcerated -from accessing and affording care that could save their lives and make our communities safer. Today's healthcare system provides insufficient support for the coordination of behavioral, social, and psychological services that patients often need in addition to medication. And there is a particularly urgent need to reform payment policies so that more Americans who are incarcerated can access evidence-based medical care.

Research estimates that 65 percent of individuals in prisons or jails meet the clinical criteria for SUD and that these individuals are 129 times more likely to die from drug overdose within the first two weeks after release, as compared to the general population.

The road to recovery is never easy — I know this from experience. I also know that it's possible. We must give a roadmap for this journey to all Americans struggling with addiction. Together, we can build a prevention and treatment infrastructure and a more compassionate society that will end this crisis — and we need Congress to help finish the job.

Paul H. Earley, MD, DFASAM, based in Atlanta, is the president of the American Society of Addiction Medicine and has been an addiction medicine physician for 30 years. An original version of this piece appeared on MedPage Today, September 30, 2019.

Protect access and control health care costs for CA patients; Oppose the so-called “Fairness for Injured Patients Act” Late last year, wealthy out-of-state trial attorneys filed an initiative for the November 2020 ballot that would substantially raise health care costs for all Californians, reduce access and exploit patients for profit. While most reporting to date has focused on the proposed changes to California’s existing law—the Medical Injury Compensation Reform Act (MICRA)—this misguided initiative would effectively eliminate California's medical lawsuit limits to create new financial windfalls for California's trial lawyers.

Proponents of this measure must collect 623,212 valid signatures, which must be verified no later than June 25, 2020. Recent reports show that they’re on track to meet those numbers and qualify for the November ballot, which is why we need your commitment to oppose this dangerous initiative now more than ever.

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In 2014, our coalition fought and handily defeated Proposition 46, clearly saying NO to changes in MICRA that would have quadrupled the cap on non-economic damages.

This measure goes far beyond what Proposition 46 would have done and the cost to taxpayers would be substantially greater. As recently noted by the independent Legislative Analyst Office, the "Fairness for Injured Patients Act" will cost California taxpayers tens of millions "to high hundreds of millions of dollars annually" in health care costs.

Proposition 46 taught us the power of a strong coalition, and this time around it will be even more important.

To learn more about the new initiative, please visit protectmicra.org.

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Advocacy and Education

CONGRESS NEEDS TO ACT AGAINST VAPING EPIDEMIC Senator Dianne Feinstein From the San Francisco Chronicle, January 16, 2020. Note: Senator Dianne Feinstein's father was a longtime member of the San Francisco Medical Society.

According to research published last year in the New England Journal of Medicine, 35% of all high school seniors had vaped over the previous year. That’s nearly double the 18% who were vaping just two years ago, an incredible increase over such a short period. At the same time, the number of youth who smoke traditional cigarettes continues to decline.

Two reasons for this trend are the easy access to vaping products and the prevalence of flavored vaping products like root beer float, cotton candy and gummy bear that appeal to children.

San Francisco has already moved to ban e-cigarettes, and the state is also contemplating a flavor ban. But to curb youth vaping nationwide, these issues must be addressed by Congress.

Vaping Epidemic

The most commonly used brand among minors, Juul, has the same amount of nicotine in one cartridge as 20 cigarettes.

And there is scant evidence to suggest that smokers end their nicotine addiction by switching from cigarettes. Despite the rapid spread of these devices and the recent spike in deaths and illness attributed to their use, there is a shocking lack of regulation on the use and distribution of e-cigarettes. Manufacturers of these devices aren’t subject to the same safety standards as other tobacco products, and that needs to change.

I led a group of senators last year in introducing a bill to require online sales of e-cigarettes to meet the same requirements as traditional cigarettes, including age verification at time of purchase and delivery.

Studies show that one of the easiest ways for underage users to purchase e-cigarettes is online where there is no proactive verification that buyers meet age verification requirements.

This bipartisan bill would put in place regulations identical to those faced by online tobacco retailors. A companion to this bill has passed the House, and it should be voted on in the Senate without delay.

Flavored vaping products

Another similarity to regular cigarettes is the effort to market them directly to kids - in this case, through the use of mint, candy, fruit, or chocolate flavored products. One survey by the Food and Drug Administration and the National Institutes for Health found 80% of youth who vape do so because they like the flavors, and 81% had a flavored e-cigarette the first time they tried it.

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The Trump administration recently announced a partial ban on flavors, but it doesn’t go far enough to prevent underage vaping. The administration’s ban applies solely to disposable cartridges, exempting menthol and tobacco flavored cartridges along with vaping “tank” devices that can be refilled. While Juul and other cartridge products are the most popular with children right now, this partial ban will only shift underage users to the exempted flavors and refillable devices not covered by the ban.

If we’re going to stop underage vaping, we have to get rid of all flavored vaping products, regardless of the method used to inhale it. Several states have already moved to enact temporary bans on the sale of all flavored e-cigarettes. The city of San Francisco - the home of Juul - has banned the sale of e-cigarettes altogether and a statewide ban on all flavored tobacco products, to include traditional tobacco, has been proposed.

Congress can take further action by enacting a similar ban on all flavored vaping products nationwide.

My colleague Sen. Dick Durbin, D-Ill., has introduced a bill in the Senate that would put in place such a ban. I’m proud to cosponsor it. It’s time we prohibit these flavors nationally as we did with flavored traditional cigarettes, and we should vote on that bill immediately.

Lung illness

In addition to a youth vaping epidemic, we’ve now seen a mysterious lung illness leave more than 2,500 people sick and 55 dead. It seems this illness is connected to illicit THC products, but we simply do not know enough to rule out other sources like legally sold e-cigarettes. That’s because anyone can currently manufacture and sell vaping devices, and put whatever they want in the cartridges or tanks, without having to prove they won’t harm users. That’s all the more reason to subject these devices to an FDA approval process before they’re sold.

We shouldn’t take a trial-and-error approach with the health of so many Americans in the balance.

We have faced the menace of addictive, nicotine-based products with serious health risks before, and the decrease in tobacco use, especially by children, is one of the top public health successes of the past half century. We should respond with the same rigorous regulations before more children are addicted and more Americans fall ill or die from vaping.

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COMMUNITY MEDICAL NEWS Kaiser Permanente

Chinese Hospital

Maria Ansari, MD

Sam Kao, MD

Kaiser Permanente is dedicated to providing the highest quality care to our members. The ongoing educational programs that we offer our physicians affords them opportunities increase their skills and competence in today’s dynamic health care environment.

Our Medical Center is home to a robust Graduate Medical Education (GME) program which includes two residency programs and five fellowships for almost 75 post graduates.

We also have a Continuing Medical Education (CME) program which strives to affect change in physician practices based on demonstrated need. Each year, we offer 500-600 CME hours to physicians from 25 clinical departments, spanning primary care, surgical, and specialty care. Many Kaiser Permanente physicians find they are able meet their CME requirements without ever having to leave campus, which translates to better access and continuity for patients.

Our approach at Kaiser Permanente San Francisco is noteworthy because it seeks to identify quality gaps and opportunities for improvement and then address those with targeted interventions that will ultimately lead to improved outcomes.

Examples include a Northern California region-wide tobacco cessation effort, which resulted in an 11.4 percent quit rate for our members in San Francisco since Jan 2019, and a program to improve blood conservation, which resulted in the Medical Center using 1000 fewer units of blood.

Whenever possible, lecture-based learning has been replaced with more interactive, engaging formats, such as case-based discussion involving actual patients, simulation, experiential learning, and skills workshops that encourage collaboration at all levels.

The offerings are designed to be relevant to practicing physicians so that they are can implement those learnings with the next patient they see.

Fostering an environment in which physicians, allied clinicians, and students are enthusiastic and committed to ongoing education is consistent with Kaiser Permanente’s commitment to continuous improvement and innovation.

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Greetings from Chinese Hospital! As the newly installed Chief of Staff of the Chinese Hospital Medical Staff, I am pleased to re-introduce our Staff to the greater San Francisco medical community. It has been a rather lengthy hiatus in our written participation with the Medical Society, but we have maintained our connections through our individual member involvement.

Dr. Gordon Fung’s long and ongoing contributions through his deft and steady leadership as the Editor of this fine journal is a prime example. We all recognize the hours of unrecognized excellence in the articles we read, issue after issue. We have also seen a steady run of Presidents of the Medical Society from our staff. Most recently we’ve seen Dr. Lawrence Cheung, Dr. Roger Eng, and Dr. Man-Kit Leung take their turn at the helm of our Society. Needless to say, their contributions extend back further, and continue long after, their more visible turn, in multiple committees and Board positions, as well as at the CMA and AMA level.

We are grateful for their generosity with their time and efforts.

Since we last contributed to the SFMMS journal, Chinese Hospital unveiled the new seismically modern patient tower in April 2016. We have since seen some of the friction between management, health plans and physicians that many of our local hospitals and medical communities have experienced over the years.

In my over two decades of practice, I’ve come to understand that although we are all fundamentally optimistic by nature, there is no guarantee that things get better. Instead, the only guarantee is that no matter how good or bad, that things will always change.

This has been reflected in healthcare, near and far, and more broadly in our national dialog, our national experience.

Ultimately, we all endeavor to do our best, for our patients and our communities, day in and day out, hoping our efforts may affect positive change. Sometimes we’re more successful.

Sometimes less. From our founding in 1925 to today, Chinese Hospital’s mission continues to be a community-owned non-forprofit, existing primarily to deliver quality health care in a cost effective way, responsive to the community's ethnic and cultural uniqueness, providing access to health care to all socioeconomic levels. As Chief of Staff of we thank the entire Bay area medical community for your support, your wisdom, as we endeavor to continue our mission serving the San Francisco community. We wish you all good health and much joys in the New Year!

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19th annual UCSF CME Conference

DEVELOPMENTAL DISABILITIES: UPDATE FOR HEALTH PROFESSIONALS March 5 & 6, 2020 Golden Gateway Holiday Inn, San Francisco Lucy Crain, MD, FAAP I’m pleased to invite you as fellow members of Chapter I, NCAAP, to the 19th annual continuing medical education conference on Developmental Disabilities on March 5 & 6, 2020. SUCSF Professor of Nursing Geri Collins-Bride is conference co-chairperson, and Dr. John Takayama, past Chapter I president is a valued member of our Community Planning & Advisory Committee (CPAC). (This year’s conference will be located at a new venue, as noted above.)

The content of each year’s conference varies according to suggestions from our CPAC and feedback from previous year’s attendees. We always have topics on autism and the breadth of developmental disabilities across the lifespan. The 2020 conference will feature topics on policy and advocacy by the AAP’s own Mark Del Monte, as well as California based advocates and experts on diagnosis, treatment and referral of children and adults with autism, cerebral palsy and those lacking verbal abilities. Updates on the importance of language and augmentative communication resources will be addressed. Another topic of special interest and importance to health professionals is that of dangerous off- label “cure-alls” for autism and other disabilities found on the internet. Special presentations on sexual molestation/abuse as well as psychopharmacology and mental health issues and their special challenges for children and youth with DD should be beneficial to anyone caring for individuals with developmental disabilities. Pediatricians especially will find of special interest the topics on cerebral palsy and appropriately helping your patients benefit from the special services and therapies provided by California Children’s Services (CCS). A variety of other topics include dental care, estate planning for individuals with DD, and featured expert self -advocates highlight means to help individuals with DD toward self- determination and productive employment. I hope to see you there!

Early bird registration, information, content details, and conference brochure can be found at Cme.ucsf.edu or call 415-4765808

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Saint Francis Memorial Hospital Expands Behavioral Health Unit to Support Community Need Additional beds could serve up to 40 more at-risk patients each month Dignity Health Saint Francis Memorial Hospital has expanded its inpatient behavioral health unit to care for up to 40 more patients struggling with severe mental health disorders each month.

The expansion opens six additional beds for acute psychiatric care, increasing total beds from 24 to 30, and making Saint Francis’ behavioral health unit one of the largest for acute psychiatric care in the City.

“To address our mental health crisis and help the people in our city who are truly struggling on our streets, we need all of our community partners to step up and provide more care,” said Mayor London N. Breed. “These new beds at Saint Francis are a good first step, and we all need to be committed to continuing to do more. Working together, we can make a difference for our most vulnerable residents and for our city.”

In order to best serve patients in the unit, staffing will increase proportionately, including an additional social worker to help link patients with community resources or post-acute care after discharge.

“We’re being proactive to respond to a need we’re seeing every day,” said Jennifer Leong, MD, medical director of the Saint Francis Behavioral Health Unit. “We want to surround more at-risk patients with appropriate care and link them to services they might not be able to access on their own.”

“GLIDE and Saint Francis have complementary missions, and we’ve been longtime partners in taking care of the most at-risk members of our community,” said Kenneth Kim, PsyD, director of behavioral health services for GLIDE. “We applaud the decision

by Saint Francis to expand care for this population.”

Funding for the expansion comes from the Saint Francis Foundation and the hospital’s annual community benefit commitment.

Saint Francis currently provides more than $7 million per year in unreimbursed mental health services.

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SAN FRANCISCO MARIN MEDICINE JANUARY/FEBRUARY 2020

WWW.SFMMS.ORG

WWW.SFMMS.ORG

JANUARY/FEBRUARY 2020

SAN FRANCISCO MARIN MEDICINE

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CLASSIFIED ADS SAN FRANCISCO

MARIN MEDICAL SOCIETY

UPCOMING EVENTS CMA Webinar: Model Medical Staff Bylaws-Help for California Physicians Tuesday, March 3, 2020, 12:15-1:15pm Medical staff bylaws can be complicated, detailed and potentially dangerous for physicians and their patients. Medical staffs should not be rushed or pressured into adopting bylaws that limit physician rights or divert medical staff authority. This webinar will provide you with tools necessary to support effective medical staff operations and self-governance. Medical staff attorney Libby Snelson explains how physicians and medical staff - and the professionals who assist them - can put the CMA Model Medical Staff Bylaws to work. For more information or to register, visit http://bit.ly/38bN3uV.

Winding Down Your Practice Wednesday, March 4, 2020, 6:00-8:00pm | Commissary at The Presidio, 101 Montgomery Street, San Francisco

Effectively transitioning your practice for your patients, staff and family requires careful planning and sufficient time to accomplish. Join SFMMS and practice management expert Debra Phairas for a seminar to learn creative strategies to help you accomplish your goals, including: bringing in an associate, recruiting, selling the practice, or closing the practice. We will also cover the latest information on valuation methodology for selling, divorce, or estate planning purposes. The cost is $89 for members and $129 for nonmembers; spouses/significant others are encouraged to attend at no additional charge.

Dinner is provided and is generously supported by Mechanics Bank. For more information or to register, visit www.sfmms. org/events.aspx.

Reducing Practice Management Hypertension Wednesday, March 25, 2020, 6:00-8:00pm | Osha Thai, 4 Embarcadero Center, San Francisco Wednesday, April 1, 2020, 6:00-8:00pm | Piatti, 625 Redwood Highway, Mill Valley

Physicians and managers today are feeling the stress of many aspects of running the practice and this can lead to many forms of Practice Management Hypertension. Join SFMMS and practice management expert Debra Phairas for this free workshop that will provide tips to lower your blood pressure and resultant anxiety to successfully navigate the business side of the practice.

Topics covered include hypertension related to the EMR, health care reform, cash flow, malpractice, personnel and labor law, Medicare fraud and abuse, OSHA/HIPAA compliance, mergers, acquisitions, foundations and practice integration, IPA/health plan interaction, and physician/manager burnout. Dinner is provided. The event is generously sponsored by the Cooperative of American Physicians. For more information or to register, visit www.sfmms.org/events.aspx.

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SAN FRANCISCO MARIN MEDICINE JANUARY/FEBRUARY 2020

Psychotherapy Office for Sublease in San Francisco Medical Office Building on 909 Hyde Street. Some view. Air conditioned.

Parking available. Contact Stuart Pickel, M.D. at 415-385-3367 or spickel@ix.netcom.com for further information.

Plastic Surgery Practice For Sale - Modesto, CA. Revenue $1.4 million on 4 doctor days. Cosmetic (breast, body, facial, hair transplant, stem cell) and otolaryngology services in accredited surgical suite that is included in the transaction. High referral rate from both patients and other doctors. Third-party appraisal available. Photos available. Offered at only $519,000. Contact Medical Practices USA for more information.

925-820-6758. email: gary@medicalpracticesUSA.com www.MedicalPracticesUSA.com

Internal Medicine Practice For Sale - Napa County. Concierge medical practice with revenues averaging $600,000 seeing 8 - 10 patients per day. Seller's net income is near the 90-percentile for IM. Long established in the area, moved to newly renovated 1440 sq. ft. location in 2015; great proximity to hospital. EMR in place. Photos and third-party appraisal available. Offered at only $497,000. Contact Medical Practices USA for more information. 925-820 6758. email: gary@medicalpracticesUSA. com www.MedicalPracticesUSA.com.

Internal Medicine Practice For Sale - Fresno, CA. Revenue $1.4 million on 70 MD hours/week. Perfect for two doctors to take over. This practice is part of a five doctor group that includes a lab, Cardiac Ultrasound, Nuclear Cardiology Stress Testing, Gastroenterology Specialty Services, and Bone Densitometry. Offered at $493,000. Contact Medical Practices USA for more information. 925-820-6758. email: gary@medicalpracticesUSA.com www.MedicalPracticesUSA.com

Internal Medicine Practice For Sale - Northern CA Wine Country.

Concierge medical practice with revenues averaging $600,000 seeing 8 - 10 patients per day. Seller’s net income is near the 90-percentile for IM. Long established in the area, moved to newly renovated 1440 sq. ft. location in 2015; great proximity to hospital. EMR in place. Photos and third party appraisal available. Offered at only $350,000. Contact Medical Practices USA for more information. 925-820-6758. email: gary@medicalpracticesUSA.com www.MedicalPracticesUSA.com

Plastic Surgery Practice For Sale - Modesto, CA. Revenue $1.4 million on 4 doctor days. Cosmetic (breast, body, facial, hair transplant, stem cell) and otolaryngology services in accredited surgical suite that is included in the transaction. High referral rate from both patients and other doctors. Third-party appraisal available. Photos available. Offered at only $519,000. Contact Medical Practices USA for more information.

925-820-6758. email: gary@medicalpracticesUSA.com www.MedicalPracticesUSA.com

Advertiser Index Clinic By the Bay . . . . . . . . . . . . . . . . . 21 Cooperative of American Physicians, Inc. . . . . . . . . . . . . . . . . . . . . Inside Back Cover CPMC. . . . . . . . . . . . . . . . . . . . . . . . . 19 MIEC. . . . . . . . . . . . . . Inside Front Cover Sutter Health NCH. . . . . . . . . . Back Cover Tracy Zweig Associates. . . . . . . . . . . . . 21 VitalTalk. . . . . . . . . . . . . . . . . . . . . . . 31

WWW.SFMMS.ORG

San Francisco Marin Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133

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San Dimas, CA Permit No. 410