San Francisco Marin Medicine, Vol. 94, No. 3, July/August/September

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

COVID Challenges Continue ADDICTION: The Shadow Epidemic San Francisco’s Incoming AMA President

Volume 94, Number 3 | JULY/AUGUST/SEPTEMBER 2021

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IN THIS ISSUE

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FEATURE ARTICLES

MONTHLY COLUMNS

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Membership Matters

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

SFMMS Interview: Jack Resneck, MD, AMA President-Elect Steve Heilig, MPH

11 Addiction Treatment in the COVID Era

David E. Smith, MD

12 The Intersection of Psychiatry and 12-Step Recovery

Jason Eric Schiffman, MD, MA, MBA 15 Trauma and Addiction

Keith Loring, MD

18 The X-Waiver Needs to Go

Mark Rosenberg, DO, MBA

22 The Unrepresented Patient: Caring for the Vulnerable

in Times of Crisis

Ruchika Mishra, PhD and Robert Fulbright, JD, MA 24 Making Sense of Wildfire Smoke

Ted Schettler, MD, MPH

26 Yes, Kids Can Safely Return to School—Even with COVID's Delta Variant on the Rise

Naveena Bobba, MD and Theodore Ruel, MD

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Executive Memo Conrad Amenta

COMMUNITY NEWS 39 Kaiser News Maria Ansari, MD

39 Chinese Hospital Sam Kao, MD

OF INTEREST 20 Physician Wellness Resources 30 SFMMS Book Review: "The Premonition: A Pandemic Story" by Michael Lewis

Michael Schrader, MD, PhD 44 Advertiser Index

28 A Budget for California's Future Good Health

Sandra R. Hernández, MD 31 My First Days at SFGH

Paul Volberding, MD

33 Safe Streets Have Emptied My Emergency Department—We Should Keep Them

Stephen Gamboa, MD

34 Clinic By the Bay: A Decade of Care for the Medically Underserved

Paul Turek, MD

Cover Art: “The Beginning of the End?”

by Cynthia Fletcher, cynthiafletcherart.com WWW.SFMMS.ORG

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

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MEMBERSHIP MATTERS SFDPH and Marin Issue COVID-19 Vaccination Updates As the COVID-19 delta variant is spreading in San Francisco and the Bay Area, the San Francisco Department of Public Health released a situational update with vaccine guidance for providers and patients. The Health Advisory includes resources for vaccine administrators, patients, and guidance on the supplemental vaccine dose in J&J recipients. The full document is published in this issue of the SFMMS journal and at https:// www.sfcdcp.org/wp-content/uploads/2021/08/Advisory-COVIDVaccination-Update-FINAL-2021.08.06.pdf For Marin, see in this journal and at: https://www.marinhhs. org/sites/default/files/files/public-health-updates/advisory_-_ covid-19_update_-_order_2021.07.29.pdf

ALERT: Counseling Patients on When to Get Vaccinated After a Covid-19 Illness The San Francisco Vaccine Call Center for Covid-19 helps arrange appointments for people who need vaccine and are having difficulty navigating the system or are uncertain about eligibility. It is important that primary physicians are aware of current recommendations regarding when vaccine can be given after a Covid illness. While originally, the CDC suggested patients could wait 90 days, this is no longer true. Patients should be vaccinated as soon as possible after they have met criteria for end of isolation (10 days since symptom onset, no fever in the last 24 hours and symptom improvement). The only individuals who should wait 90 days are those who received monoclonal antibodies or convalescent plasma as a treatment during their illness. For more information see: https://www. cdc.gov/vaccines/covid-19/clinical-considerations/covid19-vaccines-us.html#Administration Patients may call the Vaccine Call Center at 628-652-2700 Monday through Friday to obtain appointments for vaccine, or email us at sfvaxnow.sfdph.org. Health care personnel that have questions about testing, isolation and quarantine, and vaccination are welcome to call the Clinical Consult Line at 628-652-2830.

A Message From SFMMS’ Political Action Committee: Support Governor Gavin Newsom by Voting No on the Republican Recall on September 14

On September 14, Californians will vote on whether to recall Governor Newsom and replace him as Governor of California.

The Board of Directors for the Political Action Committee of the San Francisco Marin Medical Society encourages physicians and members of our community in San Francisco and Marin Counties to vote no on the recall.

The recall election was triggered by Republicans seeking to replace the Governor despite his strong support for health care coverage and access, support for early childhood education, Cali2

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fornia’s strong economic performance and budget surplus, and a science-informed response to the coronavirus pandemic that has saved many lives. Early in his term, when addressing the California Medical Association, Governor Newsom referred to himself as “your health care Governor.”

“Governor Newsom was elected in 2018 with nearly 62 percent of the vote. If he is recalled, he will be replaced with a Republican candidate with a fraction of that support,” said Dr. Joseph Woo, Chair of the SFMMS PAC. “California will lose our momentum on issues related to health and health care, climate change, wildfire management, and more.”

The recall of Governor Newsom is opposed by key leaders throughout the state, including the California Labor Federation, the California Teachers Association, the Los Angeles Business Council, the Valley Industry & Commerce Association, the Sierra Club California, the California Environmental Justice Alliance, the California League of Conservation Voters, and The Sacramento Bee.

Working Together to Safely Reopen Schools Now!

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

Open Safe Consumption Sites (SFMMS Letter in the San Francisco Chronicle)

Regarding “Safe site obvious step to curb drug deaths” (Aug. 8): Heather Knight gets it sadly correct. Safe consumption sites are now endorsed by mainstream medical and public health groups, including the San Francisco Marin Medical Society and even the American Medical Association. A couple of years ago, a mock demonstration site was set up in the Tenderloin to show how they work. Coincidentally, the American Society of Addiction Medicine was meeting in a hotel just across the street.

Many addiction physicians there, some of whom were initially skeptical about such an intervention, toured the site and came out in favor of instituting them in this time of crisis, as such sites do not encourage use but actually can help get drug users to stop doing so.

This is indeed a sad replay of the prolonged struggle to legalize syringe exchange programs, now long shown to curtail both addiction and infectious diseases. It’s time our political leaders follow expert opinion and evidence some compassion as well in allowing and supporting safe consumption sites to open in our city and state.

– Monique Schaulis, MD, president, San Francisco Marin Medical Society

Registration for the 18th Annual Network of Ethnic Physician Organizations (NEPO) Summit is Live This year's summit will be virtual and cover topics critical to diverse physicians and patients including COVID-19, adverse childhood experiences (ACEs), health outcome disparities in the Asian American and Pacific Islander communities and WWW.SFMMS.ORG

more. See: https://www.phcdocs.org/News/registration-for-the-18th-annualnetwork-of-ethnic-physician-organizations-nepo-summit-is-live

CMA Updates Return-to-Work FAQ with Information on New Vaccination Mandate As COVID-19 cases continue to rise across California, Governor Gavin Newsom took action last week to require all state workers and workers in health care and high-risk congregate settings to either show proof of full vaccination or be tested at least once per week. To help physicians understand these new requirements as they relate to health care, CMA has updated its return-to-work FAQ— Returning to the Physical Workplace: Legal parameters and considerations for employers.

Financial Support for Covid Vaccination in Your Practice

CalVaxGrant, a new state program to increase COVID-19 vaccination rates, has expanded its scope and extended the application cycle to reach more Californians. In addition to physicians and medical practices*, independent pharmacies can now apply to receive up to $55,000 in support of their vaccination efforts.

Eligible providers can be reimbursed for related expenses incurred since November 2020 and through November 2021, including staffing and training (most common expenses), technology, infrastructure, supplies and equipment, and administrative overhead.

The application cycle has been extended until Friday, September 10, 2021, at 11:59 p.m. PT and is first come, first served. CMA encourages physicians to apply early to capitalize on this grant funding. For more information: https://www.phcdocs.org/News/calvaxgrant-provides-physician-practices-up-to-55000-for-covid-19-vaccine-administration

Local Support: SFMMS Community Service Foundation Nominations Welcome

The San Francisco Marin Medical Society Community Service Foundation (SFMMS CSF) was founded to serve as a conduit for funds to and from patrons and community organizations. Over the years, the SFMMS CSF has helped to address issues ranging from medical ethics to organ donor shortages by providing tax-deductible donations.

SFMMS' Executive Committee reviews nominations from SFMMS members and awards small grants. Recent grantees have included Operation Access, the San Francisco Free Clinic, the San Francisco Marin Food Bank, NovatoSpirit, the San Rafael Canal Alliance, and more. The SFMMS CSF is proud to support organizations dedicated to serving vulnerable populations in San Francisco and Marin Counties.

For information on the SFMMS CSF or new potential grantee nominations, please contact Steve Heilig at: heilig@sfmms.org.

November will bring the 2021 election of San Francisco Marin Medical Society officers, committee members and delegate representatives.

This year, the slate of candidates’ biographies will be posted online for your consideration. By mid-September, the 2021 candidate biographies and statements of interest of the nominees for Board Officers, Board Directors, SFMMS House of Delegates to CMA, Nominations Committee, CMA Young Physicians Section, and AMA Delegation will be posted online and available for viewing by visiting our website at: http://www.sfmms.org/ advocacy/leadership-opportunities, or by scanning the QR code below from your smartphone.

Please note, online voting for all eligible members will open at 5pm on October 19th. All votes must be cast by 5 p.m. on November 2nd, 2021. Please stay tuned for more details on the full slate of candidates and how to cast your electronic vote. For questions, contact Ian Knox, Director of Operations & Governance at iknox@sfmms.org.

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July/August/September 2021 Volume 94, Number 2 Editor Gordon L. Fung, MD, PhD, FACC, FACP Managing Editor Steve Heilig, MPH Production Maureen Erwin EDITORIAL BOARD Editor Gordon L. Fung, MD, PhD, FACC, FACP Tonie Brayer, MD Linda Clever, MD Anne Cummings, MD Irina DeFischer, MD Shieva Khayam-Bashi, MD John Maa, MD David Pating, MD SFMMS OFFICERS President Monique Schaulis, MD, MPH President-elect Michael C. Schrader, MD, PhD, FACP Secretary Dennis Song, MD, DDS Treasurer Heyman Oo, MD, MPH Immediate Past President Brian Grady, MD SFMMS STAFF Executive Director Conrad Amenta Associate Executive Director, Public Health and Education Steve Heilig, MPH Director of Operations and Governance Ian Knox Director of Engagement Molly Baldridge, MPH Staff Associate Ashley Coskey 2021 SFMMS BOARD OF DIRECTORS Edward Alfrey, MD Ayanna Bennett, MD Julie Bokser, MD Keith Chamberlin, MD Anne Cummings, MD Nida F. Degesys, MD Manal Elkarra, MD Beth Griffiths, MD Robert A. Harvey, MD Harrison Hines, MD Zarah Iqbal, MD Michael K. Kwok, MD Jason R. Nau, MD Sarita Satpathy, MD Kristen Swann, MD Kenneth Tai, MD Melanie Thompson, DO Winnie Tong, MD Matthew D. Willis, MD, MPH Joseph W. Woo, MD Andrea Yeung, MD

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

HANG IN THERE, EVERYONE "As we move into our second Covid autumn, we must harness those moments of beauty that give us the fortitude to carry on."

When I started writing this column in June, it was with optimism. As I wrote, “We have made it mid- way through the year! So much positive change is happening in our communities.

The days are longer. Mass vaccination is over. We’ve brought our middle schoolers into the vaccinated bubble and they are now able to re-stretch their wings. As are the rest of us...”

For a few weeks at work, I didn’t wear an N95 or a face shield, just a surgical mask. I felt so physically and emotionally liberated. My patients could actually hear and see me. I went almost six weeks without seeing patients with Covid. As I look back at those innocent words from June, July seems so much more complex, and I feel foreboding about August. After seeing a downtrend for months, we are so clearly headed in the wrong direction. In the last few days, we’ve reinstituted mandatory eye protection on the job; I’m back to screaming through my N95 and face shield so my patients can hear me.

And perhaps most disconcertingly, the feeling of being truly protected by the vaccine is waning. I have taken to telling ER patients that I’m not too proud to beg them to get vaccinated.

Rarely, it works. In the meantime, I read climate horror stories from around the world. Record breaking heat, drought, floods, and smoke. We’re not even close to done with Covid but climate change won’t wait. The annual fire season promises to be severe.

I’ve already started repetitively checking the Air Quality Index.

My kids asked me recently, “Will we have another orange day when the sun doesn’t rise?” Urgent environmental action is imperative but we are distracted by a multitude of crises. Melancholy seems a fitting emotion for these grey summer days.

And yet, I know I am fortunate. I can breathe. I am housed and have a good job. The fog protects me from the scorching temperatures nearby. I can expect that my children will attend school in the fall. On my last dawn bike ride to work, I saw baby coyotes and a barn owl in Golden Gate Park. I felt a small rush of joy as I pedaled past and saw the flash of wings passing close. As we move into our second Covid autumn, we must harness those moments of beauty that give us the fortitude to carry on.

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

FROM THE EDITORS – As Dr. Schaulis notes above, these are trying times. We hope all our members and readers are doing well enough. In this edition of our journal, you can find fodder for thought and action on many fronts. With substance abuse spiking along with COVID, faculty from the recent SFMMS Addiction conference present leading-edge perspectives. San Francisco’s first AMA president-elect in decades indicates that the medical profession’s largest association will be in good hands. Our “wellness” activities are open to all of you to help get through challenges. Schools can reopen, thanks in part to medical leadership, including locally. Our state’s proposed health budget looks, yes, healthy. Our first installment of local pioneering AIDS physician Paul Volberding’s memoir reminds us that we have been through very big challenges here before.

And there’s more; we hope you learn from and enjoy this issue.

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EXECUTIVE MEMO Conrad Amenta, SFMMS Executive Director

We Convened a Group of Private Practice Physicians in San Francisco and Marin.

HERE’S WHAT THEY TOLD US. The COVID-19 pandemic has been exacerbating existing pressures on the economic sustainability of small and solo physician practices. In the past year, we’ve witnessed an acceleration of early retirements among physicians and continued consolidation in the physician workforce. The scope of these effects, and the likelihood of future physicians to choose private practice, remains poorly understood, however.

To improve our understanding of how private practice has been affected by the COVID-19 pandemic, in July 2021, SFMMS brought together for a facilitated discussion a group of physician members who practice in private, small, or solo practice settings in San Francisco and Marin counties. The objective of the discussion was to identify ‘pain points’ in their practice, to inform the work of the Society to support our small and solo physician members, and to better understand how the COVID-19 pandemic continues to affect physicians in our community and the future of medical practice.

The information we collected during the discussion will be combined with the results of an online member survey and will lead to the creation of a public report, which will draw attention to the challenges experienced by physicians who own or practice in a small or solo medical practice and support the deliberations of the SFMMS Board of Directors.

In dialogue with our members, SFMMS has already identified several issues in categories including community, revenue, hiring, the physician pipeline, and the availability of tools and resources. In many cases, these issues predated the pandemic, but have been exacerbated and accelerated by it. For example, reductions in overall patient volume and the high costs of over-

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head, combined with the challenge of hiring essential support staff, have for some time inhibited the sustainability of some private practices. COVID-19 has further reduced patient volumes, increased costs as practices expanded their telehealth capabilities, and made hiring more challenging than ever.

Many of these issues can be at least partially addressed by the medical society placing an increased emphasis on convening and connecting members who practice in small and solo physician practices so that they can network, share resources, bolster their referral networks, and recommend candidates for key support positions. SFMMS can also convene residents training at UCSF residency programs and connect them to members who are practicing in small and solo practice models to convey the trade-offs and benefits of the mode of practice. We’ll endeavour to deliver on these key supports.

Small and solo providers in private practice are an essential component of the medical community in San Francisco and Marin counties, but they’re facing unprecedented challenges to their business model, and these challenges are accelerating consolidation in the physician workforce. Consolidation, over time, can lead to reduced access to care and diversity of care models, especially among the most underserved and underrepresented patient populations. That’s why we take so seriously the mission to support our small and solo physician practices as we emerge from the pandemic.

Conrad Amenta

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SFMMS INTERVIEW: JACK RESNECK, MD, AMA President-Elect Steve Heilig, MPH Next year, dermatologist Jack Resneck, MD will become the first AMA president from San Francisco since the 1960s. He is a graduate of UCSF and practices there, where he is vice-chair of his department, and has been President of the California Society for Dermatology and Dermatologic Surgery, board chair of the AMA and chair of their Council on Legislation as well. He has an appointment in UCSF’s Philip R. Lee Institute for Health Policy Studies, and here shares some of his background and interests, how his clinical practice informs his advocacy work, and how the AMA is addressing its “reputational lag” in the modern era.

– Steve Heilig, MPH and then spent a little time working in Washington, DC. I loved working on big issues that could affect lots of patients and physicians, but I realized I was missing that special one-on-one connection of the patient/physician relationship. I feel like I’ve been incredibly lucky to end up with a career that lets me serve both as a physician taking care of individual patients—and also working at the policy level in organized medicine to make it easier for all of us to care for our patients.

How did you choose your specialty?

That was a last-minute choice. I had already filled out my applications for residencies in internal medicine. But a lastminute dermatology rotation in fourth year convinced me to follow the family footsteps and return to dermatology.

Congratulations on becoming the AMA president elect – the first from San Francisco in decades and the first ever from UCSF. Thanks! It’s exciting to be in this role as a Californian and UCSF physician, and also the first dermatologist in about a hundred years.

To start, where are you from?

I grew up in Shreveport, Louisiana. My father is a physician who did his residency training at UCSF, so we had a three-year detour to the Bay Area when I was a little kid. Subsequently, we returned to Louisiana where I lived until leaving for college at Brown University. I came to UCSF for medical school after a brief time working in DC, and I stayed here for internship, residency, fellowship, and then joined the faculty.

Do you recall first making your decision to go into medicine?

I don’t remember a particular moment; growing up in a medical family and watching my dad love his career as a physician working in a small practice clearly had an impact. As a kid, you often think you want to do something different from your parents, but I fortunately recognized at some point that medicine was pretty cool. I was a policy major as an undergraduate WWW.SFMMS.ORG

What was your first exposure to, or awareness of, the AMA? As a medical student, I wasn’t yet very aware of everything the AMA does for physicians and our patients. I suspect I held many assumptions based on “reputational lag” from several decades ago. When I was a resident at UCSF, I was chosen by my specialty society to be part of the AMA Resident and Fellows Section, with very little knowledge of what to expect. Once I arrived, I kind of fell in love with the whole process. Many physicians aren’t aware that AMA policy is set by a large House of Delegates, with physicians representing state medical associations, national specialty societies, federal health services, and others. The policymaking process is incredibly democratic. It begins with resolutions that originate from physicians, and the ensuing testimony and debates are science and evidence-based.

I quickly realized as a resident witnessing this process that policy was being set by people who cared and showed up to do the work. So I kept showing up and building relationships with colleagues, including the fantastic delegation from the California Medical Association. I kept witnessing the difference that individual physicians could make bringing great policy ideas, and the impact that AMA could ultimately have carrying out those policies. The process can actually be quite nimble—I remember one meeting where a group of medical students brought a resolution to ask AMA to help their colleagues under DACA program protections facing a risk of deportation, and almost immediately, the AMA was engaged nationally on the issue. It’s not uncommon to see small groups of people show up and convince colleagues of issues they care about and watch a large and fortunately influential organization make a positive difference. continued on page 8

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You’ve worked and published a fair bit yourself on health policy issues; what have been some of your own interests?

I’ve long been very interested in improving access to care, and it’s great to be so involved with the AMA in an era where that has been a big priority. Some of my recent work has related to telemedicine, digital health, and augmented intelligence—both the tremendous upsides when implemented well, and the risks if done poorly. I’ve pushed for expanded coverage so patients can use virtual tools to connect with their physicians, especially in the wake of the pandemic, but I’ve also studied the poor quality of care from some of the corporate, direct-to-consumer internet telehealth sites.

I’ve also published illustrating the enormous burden of prior authorization on physicians and patients—prior auth has grown so far beyond its original intent of focusing on new, high-cost tests and treatments. Instead, many of us now find ourselves even having to fight with insurers over generic medications, or refills when a patient is already stable on a therapy. I’ve also worked on the problems with the current quality and cost measurement and reporting systems. While we all firmly believe in quality improvement, the measurement ecosystem right now isn’t focused on a narrow set of goals that matter to physicians and patients, and has become too burdensome.

I’ve been very interested in learnings from healthcare delivery during the COVID-19 pandemic. We’ve witnessed serious health inequities that have long existed but were laid bare for all to see by the pandemic as communities experienced different risks, different outcomes, and varying access to vaccines and care.

I’m proud that AMA has created a Center for Health Equity with ambitious plans to dismantle structural racism in healthcare and embed equity and racial justice throughout the organization.

I’m also passionate about medical education, and the AMA has been investing for several years in reimagining physician training and lifelong learning. This has included grants to several California medical schools that are part of a consortium we convene regularly to share new ideas and best practices.

There continues to be a big shift of physicians into large systems instead of solo or smaller groups. What can the AMA do to help physicians stay in control of such decisions that impact patient care?

We want to preserve the viability of all practice venues as options for physicians. We have to continue to fight the burdens that get in the way of what brought us all to this profession – caring for our patients. And some of those burdens fall particularly hard on smaller, independent practices that haven’t received the resources they need to invest in electronic health records, quality reporting, and many other accumulating requirements. We undertook some survey work a few years back and basically learned that for every one hour of patient care, physicians are saddled with about two hours of administrative work on computers or phones.

That has to change—we have to get physicians back spending time doing what they love and what they are best at.

The flat payments from Medicare and other insurers have been part of the problem. Another thing the COVID pandemic has unmasked is the incredible financial fragility of many small practices. The AMA worked with Congress to secure billions in

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funding for private practices, but sadly, we know many may not survive the pandemic.

I mentioned prior auth earlier. This is incredibly frustrating for me and for most of my colleagues around the country. We still can’t see in our EHR systems which prescriptions are on formulary or seamlessly file a prior auth request electronically.

My patients and I continue to be frustrated every time a prescription for a generic topical cream that has been around since the 1960s gets rejected, or a refill triggers a new PA requirement after a patient has found an effective treatment and is doing well.

And part of the lengthy appeal process often involves debating the merits of a treatment on the phone with someone who isn’t a physician and has never heard of the disease we are treating.

Physicians want to be good stewards of resources, but this maddening process has to change, and the AMA is fighting for that change at the national and state levels.

You mentioned a “reputational lag” with respect to the AMA. We’ve seen the AMA attacked from both the left and right, going back to the Medicare debate in the 1960s and the ACA a decade ago. I think the most common perception locally is that the AMA has been too representative in policy, with respect to diversity and women in the profession, and issues like those. How do you see the AMA’s evolution on such issues?

Obviously, we have members with a wide diversity of political and other perspectives. As a large advocacy organization, we strive for nonpartisan approaches when possible to solve the most urgent pain points that patients and physicians feel. It’s our job to work with anybody who will sit down with us to make medicine better and improve public health. That being said, times have changed and certainly our policies have evolved. The House of Delegates meetings are clearly evidence of that, and I think that most physicians from our area would be pretty excited to see what the AMA has done, and is doing, to advance clinical practice and address inequities in the system. We fought efforts to tear the ACA down as it was clear that would limit access for so many patients. We’re keeping science at the forefront in the midst of the pandemic, speaking out on social determinants of health, and treating gun violence as a public health crisis. Many physicians aren’t aware of our litigation center, and the dozens of court cases we’re involved with at any given time. We sued the FDA, for example, for failing to follow their own policies to remove menthol from cigarettes, long used by the tobacco industry to particularly target Black youth, with devastating results.

We were one of the leading voices in the courts when the federal government tried to change the Title X program to gag physician speech, restricting doctors from even counseling patients about all their reproductive health options. I already mentioned our efforts to preserve DACA protections, and we have been involved in litigation to protect LGBTQ patients, and particularly our trans community, from abhorrent discrimination. So, there’s a lot going on, and our struggle always is to communicate to the profession everything we are doing.

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There has been some heated debate at the AMA about racism and inequality in healthcare, and even a dust-up at JAMA. How is AMA now confronting these divisive issues?

I’m incredibly proud of the work that our Center for Health Equity is doing. Of course, we’re not surprised that our plan to advance health equity and racial justice across our work at the AMA has been controversial to some. But it’s based on policy our House of Delegates has adopted over the past few years, and also it’s rooted in science and evidence about the impact of inequities in medicine and society and what we can do and need to do to address them—improving the health of individuals and communities, and building alliances with historically marginalized physicians and other stakeholders. We need to push upstream to address social determinants of health and the root causes of these inequities, and to ensure that future innovations (such as AI) are implemented in ways that reduce rather than exacerbate health inequities.

We have a huge problem with drug abuse and addiction, worsened during the pandemic. How is AMA addressing that now? I was impressed and maybe surprised to see the AMA endorse at least the trial of safe injections sites, ahead of even the CMA on this.

Yes, substance abuse disorders have clearly been an ongoing “second pandemic.” Certainly, we are a source of education for physicians around the country, with prescribing patterns changing for the better. We have pushed insurers and the government to provide coverage for evidence-based pain management alternatives, and to increase broader access to medication assisted treatment for substance use disorders. We have called for better access to SUD treatment in prisons and jails, and for expanded harm-reduction policies such as naloxone access and needle and syringe-exchange programs. Unfortunately, we’ve seen big increases in the use of fentanyl and other synthetic opiates around the country, magnified during this pandemic, and we need to look harder at these issues and work collaboratively at the state level to address them.

Healthcare costs remain a huge issue, including pharma and other contributors – how is the AMA addressing the problem?

I have testified in front of Congress on the serious issue of drug pricing. Of course we physicians are excited about new treatments that help our patients, and we expect that they will be more costly at first—but when we see such medications continue to double or quadruple in price many years after their introduction, that impacts our patients’ ability to access those drugs. And we’ve seen even generics that used to be affordable, skyrocket in price. This requires a multi-pronged approach.

As physicians we witness this problem every day when working with a patient to consider treatment options. We want to be responsible stewards of resources, but the supply chain has so little transparency between the manufacturers, the PBMs, and the insurers, that it’s very difficult to know the cost of anything we are prescribing. Patients are always surprised that my EHR doesn’t tell me what’s on their formulary, what the prices are, or what the patient’s share of cost will be. Instead, the patient gets a big surprise upon arriving at the pharmacy, learning they need a WWW.SFMMS.ORG

prior authorization, or that the drug isn’t on their formulary and will cost a tremendous amount. This is a market failure and there is a lack of competition. We need supply chain pricing transparency, accurate real-time pharmacy benefit data at the point of care, legislation to combat anti-competitive behavior and price gouging, and more biosimilars.

Our public health system has long been noted to be chronically underfunded and disjointed, and the pandemic has highlighted that. How is AMA working with that, and are you working with the American Public Health Association and others on preparedness, prevention, and other public health needs?

Yes, we have been working with colleagues in public health on a number of shared goals. We have to push our work upstream to address social determinants and other drivers of public health, such as housing insecurity, food insecurity, transportation insecurity, and other barriers that impact individuals and communities. Years of underinvestment have left us, in some cases, with an overburdened public health workforce that was challenged to confront a pandemic of this scale. And we have seen public health officials become the target of misunderstanding, political attacks, and even threats of violence that are completely unacceptable.

We consistently bring science and evidence to issues that are too often politicized. Physicians are playing important roles online and in social media to be credible sources for information rooted in science and evidence.

When do you actually take office as AMA president?

I will be inaugurated in June, 2022. It’s a three-year cycle from president-elect to president and then immediate past-president.

What happens to your own clinical practice during this time?

Well, it’s obviously got to shrink a bit, but it’s also very important to me to continue to see patients. When I am testifying before Congress or in other venues about the challenges we physicians and our patients are facing, being able to speak from personal experience about an interaction I had with a patient or an argument with a health insurer makes me more effective as an advocate. And I think it also keeps me grounded in the joys and challenges of being a physician, the obstacles and burdens we face every day. But mainly I really love providing care and want it to continue being a big part of my life.

American Medical Association calls for public, private sectors to mandate vaccines AUG. 24 The American Medical Association urged the public and private sectors to mandate COVID-19 vaccinations, saying the move is key to getting control of the pandemic. The call comes one day after the Food and Drug Administration fully approved the Pfizer vaccine, a step that is expected to lead more companies to pull the trigger on mandating vaccination for their employees. The AMA, the country's leading doctors group, is seeking to speed that process along.

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Special Section: From the SFMMS Addiction Conference

ADDICTION TREATMENT IN THE COVID ERA David E. Smith, MD On June 18, 2021, the annual David E. Smith Symposium convened online, sponsored by the San Francisco Marin Medical Society. Held annually since 1968, the conference serves as a platform to raise awareness about developments in the treatment of addiction and substance use disorders. Throughout its history, the conference has brought knowledge about addiction medicine to West Coast practitioners. This year’s theme was “Addiction Treatment in the Covid Era.” My collaboration with the San Francisco Medical Society goes back more than 50 years, beginning soon after I founded the Haight Ashbury Free Clinic during the Summer of Love in 1967.

My malpractice carrier refused to cover the clinic’s operations, serving youth who migrated to San Francisco. The San Francisco Medical Society stepped in to insure us so we could continue.

The Haight Ashbury Free Clinic’s successor, HealthRight360, still provides medical, dental, and behavioral health services to 40,000 people annually in 11 California counties.

Today, San Francisco is the epicenter for a nationwide drug crisis: in 2020, 80 lives were lost to fentanyl overdose for every 100,000 people in the city. The National Institute for Drug Abuse (NIDA) has labeled this phenomenon “deaths of despair.” Contributing to this, street drugs, including methamphetamine and Xanax, are often laced with fentanyl to boost their effect.

Substance use disorder strains the medical resources of every specialty, as it leads to a variety of problems, such as methamphetamine psychosis, overdoses requiring emergency care, and endocarditis resulting from injecting drugs.

This year, Symposium presenters covered changes to the rules governing buprenorphine, a mixed agonist-antagonist that represents a major advance in the options for the medical treatment of addictive disorders. Buprenorphine, a Schedule 3 drug, offers more access than methadone, a Schedule 2 drug which is only available in a limited number of federal- and stateapproved opiate treatment programs. Still, a recent study in ASAMs Journal of Addiction Medicine found that only 13 percent of residents felt qualified to treat opiate addiction when the patients entered the medical system.

Furthermore, 89 percent of those residents said they believe that Drug Enforcement Agency (DEA) restrictions and training requirements compromised their ability to use these medicines.

To administer buprenorphine for this purpose, physicians must apply to the DEA for a waiver (the “X waiver”) and take a training

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course. To improve the medical response, HHS is relaxing the X waiver requirements, in the hopes that doing so will reduce some of the impediments to physician responses to the opiate crisis.

Regina LaBelle, acting director of the Office of National Drug Control Policy, said, “Addiction treatment should be a routine part of healthcare, and this new guideline will make access to quality treatment for opioid use disorders more accessible. The guideline is an important step forward in our efforts to bend the curve of the overdose and addiction epidemic.”

Some of our other faculty have summary essays in this issue of the SFMMS journal, wherein you can read of some of the latest concepts in addiction etiology, treatment, and recovery. The half-day online conference was very well-received and is posted in full on the SFMMS website, www.sfmms.org .

My co-chair Steve Heilig of the SFMMS and I thank the San Francisco Marin Medical Society for hosting this year’s conference. Presenting the latest guidelines and scientific advances—free of charge—to the San Francisco medical community and frontline health care workers is consistent with the original motto of the Haight Ashbury Free Clinic, “Health care is a right, not a privilege.”

David E. Smith, MD is a 54-year SFMMS member; Founder, Haight Ashbury Free Clinics; Past-president of the California Society of Addiction Medicine and the American Society of Addiction Medicine; and one of the most highly-awarded UCSF faculty members for his leadership, teaching, research and more.

References

Shuey B. et al, “Evaluation of Resident Physicians' Knowledge of and Attitudes Towards Prescribing Buprenorphine for Patients With Opioid Use Disorder.” J Addiction Med Volume 15, Number 3, May/June 2021.

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Special Section: From the SFMMS Addiction Conference

THE INTERSECTION OF PSYCHIATRY AND 12-STEP RECOVERY Jason Eric Schiffman, MD, MA, MBA Until the founding of Alcoholics Anonymous in 1935, there were essentially no standardized treatments for addiction, and it is likely that few, if any, individuals with addictive disorders prior to that time substantially recovered from the condition. Historically, the field of medicine had little interest in addiction, and for many years after its inception, Alcoholics Anonymous and the numerous other 12-step programs derived from it remained the only standardized interventions for addictive disorders. As a consequence, 12-step based approaches have been a mainstay of addiction treatment and to this day remain one of the most commonly utilized interventions for addictive disorders worldwide.

Because 12-step programs are a non-clinical, communitybased intervention that developed outside of the healthcare field, integrating their use with treatment within the healthcare system has presented some challenges. Three points of intersection in which these challenges are most evident are as follows: 1) discomfort in some factions of the 12-step community with the use of psychotropic medications (particularly opioid agonist/partial agonist maintenance therapy for opioid use disorder),

2) the historical and continuing exclusion of addiction treat ment centers from regulation by state medical boards and the corporate practice of medicine laws governing the rest of the healthcare industry, and

3) the fact that 12-step programs claim to achieve their efficacy through a spiritual mechanism.

This third point, which is the focus of this article, has often caused discomfort among physicians who find themselves in the difficult position of defending a treatment recommendation for which there is good empirical evidence but for which the purported mechanism of efficacy is outside the biological model of illness. In the modern healthcare system, prescription of a purportedly spiritual intervention is unlikely to be well received in any other field of medicine, so it should not be surprising that physicians have struggled with finding a way to recommend and explain 12-step based interventions to their patients with addictive disorders.

A series of recent studies have both supported 12-step interventions as effective1 and shed some light on the mechanisms through which this efficacy is mediated2. The studies evaluated the following six potential mediators of Alcoholics Anonymous efficacy: • spirituality • social abstinence self-efficacy (i.e., confidence in one’s ability to remain abstinent when confronted with high-risk social drinking situations) 12

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• negative affect abstinence self-efficacy (i.e., confidence in one’s ability to remain abstinent when experiencing • depression/anxiety) • depression symptoms • negative social networks (i.e., removing heavy drinkers from the social network) • positive social networks (i.e., adding abstainers/recovering individuals into the social network).

What was found was that the primary mediators of 12-step efficacy were facilitation of changes in social networks and increases in social and negative affect abstinence self-efficacy.

Spirituality did mediate some benefit, particularly among individuals with more severe symptoms, but this benefit was minor compared to social and self-efficacy mediators.3 The fact that spirituality appears to be a minor contributor to 12-step efficacy, despite what 12-step groups say about themselves, is useful in helping the physician recommending 12-step participation explain the recommendation by reference to social and psychological mechanisms rather than spiritual mechanisms.

Nonetheless, given the emphasis 12-step approaches place on spirituality and the fact that spirituality appears to mediate at least some of 12-step’s efficacy, it would be useful to have an explanation for what this mechanism is that uses a psychological rather than spiritual framework that was thus consistent with the biopsychosocial model used in modern medicine.

First, let’s summarize how 12-step interventions benefit individuals with addictive disorders according to Alcoholics Anonymous itself.

The following is from a section of the Alcoholic Anonymous literature entitled “How it Works”: (a) We were alcoholic and could not manage our own lives. (b) Probably no human power could have relieved our alcoholism. (c) God could and would if He were sought.

As stated above, Alcoholics Anonymous believes neither the alcoholic nor other people have the power to relieve addiction, and that 12-step interventions work via facilitation of “conscious contact” with a higher power. It is then the higher power that alleviates the addiction through removal of the individual’s obsession to use the substance or behavior to which they are addicted. The 12 steps are meant to accomplish this connection through removal of ego-related blocks between the individual and their higher power. This is depicted in the following schematic.

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Cognitive neuroscience and psychology provide a useful framework for understanding the underlying mechanisms and etiology of addictive disorders. What becomes an addictive disorder typically begins as the non-addictive use of a euphorigenic substance or behavior as a means to manage chronic dysphoric feelings. The repeated use, especially when it is providing both euphoria and relief from dysphoria, hyperactivates the reward pathway. Eventually, the degree of reward-mediated drive (termed “incentive salience”) associated with cues of the substance or behavior becomes so strong that the use cannot be reliably inhibited by the prefrontal cortex.

Both the addictive process and the process underlying the chronic dysphoric feelings for which the addictive substance or behavior was initially a solution, can be understood as manifestations of a particular type of learning fundamental to how human (and likely other animal) brains encode information about the world. The primary mechanism through which previously gained knowledge is used to understand the present and make predictions about the future is the creation and application of templates. A general description of this process is as follows: • Experiences which are either common or associated with intense emotion (or both) result in the creation of an associated template in the mind of the individual.

• The template retains the core features of the original experience but with the specific elements replaced with general categories.

• The template retains the core thoughts, feelings, and behaviors associated with the original experience, particularly as they relate to the individual’s ability to function or survive.

• When the individual encounters similar scenarios in the future, the template is activated and applied to the present situation, imbuing it with the knowledge, feelings, and behaviors contained in the template.

For example, if you are attacked by a bear and survive, your brain forms a template of the event which helps protect you in the future, not just from another attack by the original bear but from bear attacks in general.

When experiences are either very distressing or very rewarding, the templates formed from them contain powerful feelings and are often easily triggered. This is the basis for both addiction and for the chronic states of depression and anxiety that are so often its precursor.

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As depicted in the schematics below, both traumatic and hedonic (rewarding) experiences create templates which may then become the basis for chronic problematic emotions and behaviors. The extent to which these emotional states and behaviors become dysfunctional is dependent upon how easily the templates to which they belong are triggered which in turn depends on how distressing or rewarding the original events were. Thus, individuals who experience many or severely distressing events, particularly during development, are vulnerable to developing chronic feelings of anxiety and depression.

When these individuals discover a euphorigenic substance or behavior that ameliorates their chronic dysphoria, they are apt to chronically repeat its use and are thus vulnerable to developing hedonic templates associated with the powerful cravings which characterize addiction.

How might we use the concept of trauma templates and hedonic templates to explain why “conscious contact with a higher power” as described by Alcoholics Anonymous may help those with addictive disorders? A clue may be found in the unofficial advice sometimes given at 12-step meetings that your higher power can be anything you choose; it just can’t be you and it has to be loving.

Secure attachment is the bedrock of psychological and emotional wellbeing. This is particularly true of attachment with important adults when we are children, which becomes the basis for our attachment templates later in life. Unlike most other animals, human children are essentially incapable of surviving on their own for the first decade of life and evolution has thus fashioned children’s cognitive/emotional system to prioritize establishing and maintaining secure attachment to stable parent figures above all else. The emotional manifestations of this system are that secure attachment results in rewarding feelings of self-worth, validity, lovability, and peacefulness and continued on page 14

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Special Section: From the SFMMS Addiction Conference lack of secure attachment results in feelings of anxiety, shame, and emptiness and a drive to determine what we need to change about ourselves in order to become loveable.

By positing the existence of a “higher power” and developing a practice of making “conscious contact” with it, it is likely that 12-step participants who are benefitting from the spiritual aspect of the program are doing so by inducing an experience of secure attachment with a loving authority.

While this article has focused narrowly on the mechanism by which the spiritual aspect of 12-step interventions may benefit individuals with addictive disorders, the methodology employed here of using a psychological framework to understand a spiritual experience may be useful in understanding how other spiritual practices mediate emotional benefits to their practitioners.

When a template is triggered, the thoughts and feelings associated with it are experienced as being about what is happening in the present moment even though their origin is something that happened in the past. For example, if you ask a person who was mauled by a dog when they were young what they are afraid of when they are in the presence of a dog now, they will point to the animal in front of them. Strong templates have low activation thresholds, i.e., are easily triggered, and for individuals in whom these exist, the present moment may be consistently flooded with the intense anxiety and shame or intense cravings derived from past experiences. The ability to exit these templates by entering into a state of secure attachment with a loving authority may be a particularly useful skill for managing dysphoric feelings and cravings and is likely how a “conscious connection” with a higher power benefits individuals with addictive disorders.

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Jason Eric Schiffman, MD, MA, MBA is a psychiatrist and board-certified addiction medicine specialist. He is the founder and Director of the UCLA Dual Diagnosis Program and Camden Center, a mental health and addiction treatment program in Los Angeles and the San Francisco Bay Area.

References 1. Kelly JF, Humphreys K, Ferri M. (2020). Alcoholics Anonymous and other 12-step programs for alcohol use disorder.

Cochrane Database Syst Rev. 2020 Mar 11;3(3):CD012880. doi: 10.1002/14651858.CD012880.pub2. PMID: 32159228; PMCID: PMC7065341.

2. Kelly JF. Is Alcoholics Anonymous religious, spiritual, neither? Findings from 25 years of mechanisms of behavior change research. Addiction. 2017;112(6):929-936. doi:10.1111/add.13590 3. Kelly JF, Hoeppner B, Stout RL, Pagano M. Determining the relative importance of the mechanisms of behavior change within Alcoholics Anonymous: a multiple mediator analysis.

Addiction. 2012;107(2):289–99.

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TRAUMA AND ADDICTION Keith Loring, MD

“Every human has a true authentic self. Trauma is the disconnection from it and healing is the reconnection with it” – Gabor Maté, MD

As Carl Jung said, “Until you make the unconscious conscious, it will direct your life and you will call it fate.” Deep within each of us is our center, our authentic self, the essential part of us that is perfectly whole and unbroken, that holds all the wisdom, energy and intuition necessary to heal our earliest and deepest wounds to restore wholeness throughout our system and to create a life of awareness, connection and joy.

Addiction is a response to trauma, specifically early childhood trauma. In order to understand addiction, we need to understand the nature of trauma and its impact on human development. Seen through this lens, fully trauma informed, we are able to see those suffering addiction for what happened to them rather than what’s wrong with them. When we address what happened rather than what’s “wrong,” we see our patients for their possibility, not as victims.

We are then able to offer solutions rather than solace. We meet them where they are, not where we think they should be. We become collaborators in their healing process, and we stop the fool’s errand of trying to fix them. That’s their job, not ours.

For most of the 25 years I practiced emergency medicine, I saw addiction as an unsolvable problem to be mitigated, or at best, be managed. Patients suffering addiction were often the most difficult. They were manipulative drug-seekers, or they were intoxicated, combative disruptors of the emergency department, who got in the way of taking care of those who were truly suffering. I became adept at catching drug-seekers early in their game and finding the most efficient ways of detoxing intoxicated patients and discharging them as soon as possible in order to minimize their impact on the operations of the ED. In essence, I was loaded to the brim with compassion and understanding – NOT! Not for my patients and not for myself. What I wasn’t willing to see in them, I was unwilling to see in myself— my own suffering.

About 15 years into my emergency medicine career, while holding leadership positions in two local emergency departments and their hospital medical staffs, at the San Francisco Emergency Physician’s Association and the (then) San FranWWW.SFMMS.ORG

cisco Medical Society, and as a regional medical director for a large multi-contract emergency medicine partnership, my primary coping mechanism—an insatiable appetite for the circuit party scene— collided in spectacular fashion with the rest of my life. I was addicted to taking on those many roles and responsibilities in a desperate attempt to prove my self-worth. And I had become addicted to the dance parties and the drugs that fueled them as the only way to cope with the overwhelming and ever-growing pain on the inside.

That was the darkest and most transformational period in my life. My inner narcissist mounted a valiant effort to save face but failed. With him no longer in the lead, I got my life back, and began to recover my true self. Along the way, I have become well acquainted with the nature of human trauma, the colorful ways in which it is expressed, and the possibility that exists in every one of us, to move through and past our trauma, to discover that within our deepest suffering lies our greatest source of wisdom and compassion.

Coping with the Trauma Within Trauma is not what happens to us, it is what happens on the inside as a result of what happens. The inner experience is the key. Trauma is anything that changes us in a way that makes our future responses to the world more limited, that causes a constriction. It interferes with our natural process of growth and development. We come out of trauma more limited than when we go in—limited self-awareness, limited flexibility in our future responses, limited capacity to self-regulate. We become disconnected from our body and our self. We are more likely to override our gut feelings, which are essential for survival. We are less able to stay in the present moment.

As infants and children, our inner experience is highly dependent on how well we are seen, heard and held by our adult caregivers. The difference between becoming traumatized and building resiliency depends entirely on the adult caregiving continued on page 16

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Special Section: From the SFMMS Addiction Conference environment in which we were held—or not. The more secure, attuned and compassionate the holding, the greater the likelihood that we will grow and develop into fully self-assured, fully self-regulated and compassionate adult human beings. The more problematic and insecure the holding, the more our natural process of development is impeded and the more we divert our energy toward automatic and instinctual ways of coping that work very well in the moment but become increasingly maladaptive later in life.

In other words, as children we don’t get traumatized because of our hurt, we get traumatized because we are alone with our hurt. That hurt can be from something as obvious and overt as emotional, physical or sexual abuse and it can be from something much less obvious such as having a depressed parent who is emotionally unavailable. Alone with our hurt, while completely vulnerable and helpless, our most evolved human response, reaching out for help, is not available. We cannot run away. And we cannot put up a fight. We are left with our most primitive survival responses, embedded in our reptilian brain— we are left to either freeze or fold, our defense mechanisms of last resort.

These are completely automatic and largely unconscious reactions. We learn to tune out, withdraw, distract, numb, repress or depress our feelings in response to stress. We become defended against vulnerability, which is essential for human connection. We disconnect from ourselves and from the world around us. We adopt shame-based beliefs, that we are not worthy, not loveable, or worse. As children, when bad things happen to us, we automatically believe it is because there is something wrong with us. There is no middle ground or nuance available to us. It’s too overwhelming to acknowledge the truth—that our caregivers are too overwhelmed and are incapable of keeping us safe and nurturing us the way we need.

It is far less overwhelming to take on shame than experience the full emotional impact of realizing we are not safe or safely held.

Faced with existential crisis, we default to shame. It is never a conscious choice, but it is a brilliant survival strategy. In this way we stay attached to the adults in our world and survive, but it is at the cost of our authenticity.

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Addiction: A Self-Defeating Solution Among the strategies we adopt to cope with this predicament is the process of addiction. Addictive behavior is aimed at alleviating the suffering of being stuck in a lonely and dangerous place, full of anxiety and shame. This strategy too is never a choice; it’s automatic and unconscious. However, it is always only a temporary solution that over time, like an overzealous fire hose, can cause a lot of collateral damage and eventually becomes its own source of suffering. And despite the mounting damage and suffering, you can’t give it up.

All the while, the pain of unresolved trauma remains undischarged, held in the body and buried deep within the psyche until we either die from our defense against it or we discover our inner capacity to consciously and courageously revisit, sit with and authentically discharge it, each of us in our own unique way, with willingness, curiosity and courage. The unresolved pain held within the entire mind-body system must be addressed.

The only way past it is through it. There is no other way. That, in a nutshell, is the process of recovery. It’s heroic work; the true hero’s journey, an inward journey that every human being has the capacity to undertake. Our job as physicians is to recognize that capacity in ourselves and therefore in others. Where we have compassion for ourselves, we automatically have compassion for those with whom we work.

Healing and Recovery From a neuropsychological perspective, the implication of understanding addiction as a response to trauma, as an unconsciously learned behavior, is profound. A person suffering addiction is no longer a victim of their genes fated with a diseased brain and broken psychology that are irreparable and at best manageable. The brain of a person suffering addiction is perfectly intact. It developed in response to its biopsychosocial and spiritual environment. It does perfectly well what it learned to do, with brilliance, tenacity and resilience. It’s just that the behaviors that these qualities serve are self-destructive, antisocial, and can eventually become anti-survival, pushing the brain and body past the point of no return.

The good news is that an intact brain is reprogrammable.

Adult human neuroplasticity allows for ongoing personal transformation and growth throughout one’s lifespan, provided there is safety. In the words of Stephen Porges, “Safety is not the absence of danger, it is the presence of connection.” The work of recovery from addiction—recovery from trauma—is the work of reconnection. When a human being is held in compassionate connection, their brain will re-tune and rewire, turning its intelligence, tenacity and resilience away from defense toward growth and restoration.

Consider this as we engage in relationship with our patients: Seek to understand them for what happened to them, not for what’s wrong with them. All wounding occurs in relationship; therefore, all healing must occur in a relationship that holds a person in a way they weren’t when they were wounded. What do we do to hold our patients in a way that they feel truly held, seen, heard and understood? Such that they sense from us that they are safe and worthy of healing? Such that they have full agency WWW.SFMMS.ORG

to look inward and tap into their inner resources for healing?

Our patients co-regulate with us—they take their inner cues of safety from us. When we see them for what is wrong with them, they sense it and see themselves as judged, as victims. When we are truly curious to see them for what happened, they will sense it and feel understood and seen for their possibility. So it’s our job to do our own deep work of self-discovery, to be self-aware, to show up fully self-regulated and present in order for them to learn how to do so as well. To do this we need to open our eyes, ears and hearts to a trauma informed view of all mental and bio-physical illness, a view that necessarily recognizes that the mind and the body are inseparable and that the source of healing comes from within.

From this perspective, difficult patients transform into human beings with amazing histories of challenge, difficulty, and survival. Each suffering in their own unique way and worthy of support and guidance toward healing. The vast armamentarium of tools we have at our disposal—the medicines we prescribe and the procedures we perform—become far more effective when we understand that the source of healing lies within those we serve.

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For a deeper dive into the topics of trauma, addiction, and healing I recommend the following: In The Realm of the Hungry Ghosts: Close Encounters with Addiction - Gabor Maté, MD

The Body Keeps the Score: Brain, Mind and Body in the Healing of Trauma - Bessel Van der Kolk, MD In An Unspoken Voice: How the Body Releases Trauma and Restores Goodness – Peter Levine

The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication and Self-Regulation Stephen Porges

Keith Loring, MD, is board certified in both emergency medicine and addiction medicine.

He practices addiction medicine at HealthRight360 and is a certified Compassionate Inquiry Practitioner, a fully trauma informed approach to counseling, recovery coaching and therapy developed by Gabor Maté, MD. https://compassionateinquiry.com/practitioners/ He has been a member of the SFMMS for many years, serving in various capacities and currently is an alternate delegate to the CMA HOD.

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Special Section: From the SFMMS Addiction Conference

The X-Waiver Needs to Go

BARRIERS TO MEDICATION-ASSISTED TREATMENT PREVENT EMERGENCY PHYSICIANS FROM SAVING MORE LIVES Mark Rosenberg, DO, MBA This past year was the deadliest year in U.S. history. While most people are understandably focused on COVID-19, many of our other healthcare challenges did not diminish and some have been getting much worse. We experienced a record-breaking year for drug overdose deaths in 2020 and a large proportion of those tragedies can be traced to opioids.

Today alone, about 130 people will not survive an opioid overdose. Safe and effective treatment options, such as buprenorphine administered through medication-assisted treatment (MAT), can be lifesaving when it is able to be used in the nation's emergency departments. This is especially important because more patients are relying on emergency physicians for care than ever before. However, barriers to medication-assisted treatment are preventing emergency departments from saving more lives.

Emergency physicians are often the best or only option for many patients, and we are at the center of solutions to many of the nation's biggest health challenges, especially the opioid crisis. Emergency departments are following the successful example of states like Colorado, which reduced prescribing of these medicines by 20% by prioritizing alternatives to opioids.

And across the country, a growing number of emergency physicians want to administer medication-assisted treatment as an early intervention that can help patients enter long-term treatment in their communities.

Extensive experience and data show that buprenorphine is one of the most effective treatments for people with opioid use disorder. This medication can cut the risk of overdose death in half. And patients started on buprenorphine in the emergency department are twice as likely to remain in treatment, which is a significant challenge for people struggling with addiction, particularly in communities with limited treatment options outside 18

of the emergency department.

Congressional action is critical to addressing the hurdles that block access to medicationassisted treatment in the emergency department.

A principal barrier is the "X-waiver." Prescribing clinicians must obtain an X-waiver, the mandatory but onerous certification that includes completion of eight to 24 hours of additional training. This requirement isn't necessary for any other prescribed medication.

Momentum is growing to address this barrier. This week, emergency physicians are in Washington, D.C. to advocate for the passage of the bipartisan Mainstreaming Addiction Treatment (MAT) Act (H.R. 1384/S. 445), legislation that removes this bureaucratic hurdle and would improve patient access to treatment for opioid use disorder by eliminating the X-waiver requirement for prescribing physicians.

The Biden administration took a step in the right direction earlier this year by loosening the burdensome training requirements for clinicians treating 30 or fewer patients. But the continued presence of the X-waiver perpetuates the stigma associated with these treatments, which also plays a role in preventing clinicians from prescribing buprenorphine to patients.

As a result, this treatment remains unnecessarily isolated from normal healthcare delivery. Another issue is that clinicians must still complete the registration process for the waiver through the Drug Enforcement Agency, which can take months—time that we cannot afford to take right now as CDC data show that we just experienced the largest annual increase in drug overdose deaths in at least a half-century.

The MAT Act treats buprenorphine like any other essential medication. The bill also calls for a national education campaign to encourage health professionals to better integrate substance

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abuse treatment into practice, provide training modules, and highlight available resources to improve the way we approach opioid emergencies.

Emergency physicians are leading efforts to improve the way we address the opioid epidemic across the country. Increasing patient access to care for opioid use disorder and reducing stigma around treating it in the emergency department are major priorities for us and other advocates. Beyond just legislation, evidencebased substance use disorder clinical practice guidelines, training courses for physicians, and advocacy for changes that improve physician training and patient care related to treating and preventing opioid misuse and overdose are all essential.

While there is much more to ending the opioid crisis

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than medication-assisted treatment, passing the MAT Act to encourage access to a vital treatment is an important step forward that we should take immediately. The sooner treatment is started, the easier it is to maintain and the more likely it is that a recovery plan can succeed.

Mark Rosenberg, DO, MBA, is the president of the American College of Emergency Physicians. This commentary originally appeared in Medpage Today in July.

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Physician Wellness

RESOURCE CORNER: RECENT WELLNESS EVENTS Women in Medicine Series In April SFMMS hosted our first Women in Medicine meeting of 2021, with a guided discussion from the book “Good Morning I Love You” by Dr. Shauna Shapiro. One member stated that being part of this group felt “like a good hug.” If you would like more information or to join, contact Director of Engagement, Molly Baldridge, at mbaldridge@sfmms.org.

Book Club Series

In February and May the SFMMS Book Club discussed and read "Together: The Healing Power of Human Connection in a Sometimes Lonely World" by Dr. Vivek Murthy and “God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine” by Dr. Victoria Sweet. For more information or to join the SFMMS Book Club, contact Director of Engagement, Molly Baldridge, at mbaldridge@sfmms.org.

Culinary Medicine Series

As part of SFMMS' Physician Wellness efforts, we hosted a virtual Culinary Medicine series during the spring of 2021 for our members. Great thanks to Dr. Marjorie Smith who spearheaded and facilitated the SFMMS Culinary Medicine series. Her efforts to nourish and sustain our members resulted in six engaging sessions. The final three sessions of this spring series began with “Healthy and Delicious Cooking'' for Families with Dr. Emma Steinberg, a Board-Certified Pediatrician and trained chef on May 6th. For her session, SFMMS members were encouraged to bring their children and family members virtually, so that they could cook along. Dr. Steinberg's session included a cooking demonstration, where attendees and their family members made easy, plant-forward, delicious recipes at home that were perfect for weeknights or busy schedules. On May 13th, Dr. Linda Shiue, Director of Culinary Medicine with Kaiser Permanente San Francisco, focused on demonstrating recipes to celebrate AAPI Heritage Month, from her book, “Spicebox Kitchen: Eat Well and Be Healthy with Globally Inspired, Vegetable-Forward Recipes.” During her session, she shared the culinary and medicinal power of spices through a cooking demonstration. Lastly, on June 10th, SFMMS Board Member, Dr. Anne Cummings and Chef Mark Novak focused on a summer recipe, demonstrating how to barbecue Salmon with Raspberry Buerre Blanc and Veggies. To watch recordings of these events or to learn more about the recipes and books provided to attendees, please visit the SFMMS Wellness Page at http://www.sfmms. org/get-help/physician-wellness. Stay tuned for our fall Culinary Medicine offering.

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SF Marin Nature & Wellness While we wait to get together in person, the SFMMS Wellness Committee wanted to share photos of SF and Marin nature to encourage you and your loved ones to get outside and nourish yourself by enjoying the beautiful places all around us!

Dr. Linda Hawes Clever, SFMMS Wellness Committee Member, Mill Valley Fire Trail with a friend, Grandpoppy, Mom, her grandchildren, and their dog “climbing and walking and noticing and pure JOY.”

Tuesday, August 17th 6:30 - 8pm: Join us for our third meeting of the SFMMS Book Club; we will be discussing "The Boy, the Mole, the Fox and the Horse" by Charlie Mackesy. Inspiration and hope in uncertain times in this beautiful book, following the tale of a curious boy, a greedy mole, a wary fox and a wise horse who find themselves together in sometimes difficult terrain, sharing their greatest fears and biggest discoveries about vulnerability, kindness, hope, friendship and love. The shared adventures and important conversations between the four friends are full of life lessons that have connected with readers of all ages.

Book Recommendations

Dr. Anne Cummings, SFMMS Board and Wellness Committee Member, Muir Woods.

Dr. Jessie Mahoney, SFMMS Wellness Committee Chair, Point Reyes.

“The Doctor Stories” by William Carlos Williams. He was/is one of America’s most renowned poets, who also happened to be a family practitioner for decades. A classic collection of fictional short stories, most recent edition is 2018 from New Directions publisher, with forward by Atul Gawande.

“The End of October” by Lawrence Wright, 2020. New thriller novel by great non-fiction Pulitzer-winning writer about a "mysterious killer virus."

“Internal Medicine: A Doctor’s Stories” by Terrence Holt. Non-fiction about medical training, esp. residency on the front lines.

“The Plague” by Albert Camus.

Classic novel by the Nobelist, in midst of a mysterious epidemic.

“The Barbary Plague: The BlackDeath in Victorian San Francisco” by Marilyn Chase, 2003. Local history classic about early SF. WWW.SFMMS.ORG

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THE UNREPRESENTED PATIENT:

Caring for the Vulnerable in Times of Crisis Ruchika Mishra, PhD and Robert Fulbright, JD, MA 2020 was an especially difficult year for hospitals across the country and internationally. A report published by the US Department of Health and Human Services in March 2021 outlined some of the challenges that hospitals have faced during the COVID – 19 pandemic1. Hospitals reported patients delaying or forgoing routine health care that led to worsening of medical conditions. Administrators predicted that widespread delayed care could result in higher hospitalization rates and need for more complex hospital care in the future. Administrators also voiced concern that the pandemic has led to greater mental and behavioral health needs among patients. They anticipated that the needs for mental and behavioral health services at their hospitals would continue to grow and reported concern about meeting these needs. Many hospitals raised concerns that the COVID-19 pandemic has exacerbated existing disparities in access to care and health outcomes. Many of these challenges are expected to have long term implications for health care delivery in acute care settings.

Over the last year, the Bioethics Program at Sutter Health’s CPMC has experienced a substantial increase in ethics consultation requests around decision-making for unrepresented patients in San Francisco. In 2020, unrepresented patient issues formed over 20 % of our ethics consultation requests. This was an 81% increase as compared to 2019. “Unrepresented patients” are individuals who are unable to make their own medical decisions and do not have a surrogate decision-maker. They do not have family, friends, or others who can make medical decisions for them when they cannot. These patients are usually among the most vulnerable members of our society. They live with challenging socio-economic situations and are often the victims of abuse, homelessness, mental health issues, and extreme poverty. During the COVID – 19 pandemic, we have seen a record number of patients arriving at our hospitals who are unidentified. Even when we were able to track down their identity, it was evident that they had no social support, exhibited low health literacy, had little to no regular medical care, and clearly no individual to speak to their wishes and values. When such patients arrive in our hospitals, the health care teams find themselves in a dilemma, facing patients who cannot make medical decisions 22

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and with no one other than the hospital team advocating on their behalf. In the absence of adequate representation, such patients are at risk of being either over-treated or undertreated.

C a l i fo r n i a l aw a l l o ws for a legal conservator to be appointed to make decisions on behalf of unrepresented patients. However, this process can take several months.

During the worst of the pandemic crisis, if a patient’s conservatorship application was accepted by the local public guardian office, the process could take more than nine months to complete. In many such situations, the medical team cannot wait for the appointment of a conservator. When a large number of unrepresented patients present to the hospital in a critically ill state or the patient’s medical needs require a more immediate response, the medical team is put in a quandary. This is especially true if the patient needs treatment that requires informed consent. The medical team may feel they cannot provide these treatments because there is no authorized individual to approve.

Hospitals need to dedicate extra attention when caring for an unrepresented patient. First, the medical team must carefully consider the assessment of the unrepresented patient’s decisional capacity. This assessment greatly impacts the patient’s hospital course. The determination that a patient lacks capacity limits their ability to guide the medical team with respect to treatment decisions. The Attending Physician has the ultimate responsibility to determine if the patient has decision-making capacity. In some cases, the Attending Physician may request opinions from consultants like Psychiatrists and Neuropsychologists to assist in assessment of a patient’s capacity. Second, the hospital must use appropriate resources to make reasonable efforts to locate friends, family, or other interested parties who may function as a surrogate. If no surrogate is found after a diligent search, the patient remains ‘unrepresented’ and the hospital has an obligation to act in the patient’s best interests and ensure that treatment decisions are made through a fair, just, and transparent process.

A few years ago, in response to this organizational ethics issue, our Bioethics Program developed a model decisionmaking policy for unrepresented patients at CPMC. This policy has since been standardized across several Sutter Health hosWWW.SFMMS.ORG

pitals in the Bay Area. Having this policy in place prior to the pandemic was extremely helpful as CPMC saw a surge in unrepresented patient cases in addition to the COVID – 19 spike. Their fragile place in the medical system and in our society was exacerbated by the evolving pandemic crisis. The extreme vulnerability of these patients emphasizes the importance of transparent decision-making processes at an organizational level. Our policy is rooted in the traditional role of hospital ethics committees as an advisory body while recognizing and preserving the primary responsibilities of the Attending Physician. It is important that the ethics consultation include an interdisciplinary discussion regarding the different aspects of the patient’s care that may have a bearing on treatment decision making. However, it should be noted that the ethics consultation service or hospital ethics committee does not serve as a decision-making body. It serves in an advisory role making non-binding recommendations to the Attending Physician, who is ultimately responsible for the unrepresented patient’s medical care. One of the tasks of the consultation service is to collect input from multiple sources; this creates a transparent process that ensures medical decisions for the vulnerable are made after thoughtful reflection and discussion with a collaborative team approach.

Our policy takes into account the various clinical circumstances in which treatment decisions must be made. It addresses three clinical scenarios, examining the need for intervention and the benefits and burdens the treatment presents. First, in the case of an emergency situation, the Attending Physician follows the Emergency Medical Treatment and Active Labor Act (EMTALA). EMTALA is a federal law that requires emergency departments provide medical treatments necessary to stabilize patients. This can be done on the basis of presumed consent.

Second, when it comes to routine non-emergent treatments, the Attending Physician may proceed with treatment as long as the benefits clearly outweigh the burdens and the patient is accepting of the medical treatment. If the patient is refusing treatment, the Attending Physician should request an ethics consultation, as per the policy. When a patient begins to refuse treatment, it raises questions about appropriateness of forced treatment, the larger goals of care, and whether the patient would be willing and able to adhere with necessary follow-up treatment, if needed. In such situations, an ethics consultation is valuable in assessing the need for the intervention in the larger context of the patient’s rights, needs, and the other contextual features of the patient’s care.

Third, if decisions need to be made regarding invasive treatments or withdrawal/withholding of life sustaining treatment, the policy requires an ethics consultation. Again, the goal of the policy is to ensure that decision-making for the unrepresented patient is a transparent process. The ethics consultation process includes a thorough review of the patient’s medical record, discussions with the Attending Physician, other consultants, the primary care provider, if available, and any contacts or patient representatives that may provide insight into the patient as a person. The process requires deliberation over the patient’s clinical condition, prognosis, any preferences if known, and ultimately, a thoughtful evaluation and interdisciplinary discussion WWW.SFMMS.ORG

of the patient’s best interests. It is often helpful to have a community representative on the ethics committee participate in such discussions. Recommendations are made to the Attending Physician regarding the ethical appropriateness of proceeding with invasive treatments or withdrawal/withholding of treatments determined to be medically non-beneficial and therefore, inappropriate. If there are any conflicts or unresolved issues, the hospital’s administrative resources can be utilized for appropriate delivery of care.

Our goal in describing the challenges of the unrepresented patient is to both highlight this issue that will continue to rise and to call attention to the problem only made worse by the pandemic. As more of these patients arrive in hospitals due to delayed medical care or neglect of their needs fueled by socioeconomic reasons and mental health concerns, it is essential that hospitals are prepared to care for the most vulnerable amongst us in a fair, just, and transparent manner. One of the ways to ensure this outcome is for hospitals to have a clear policy that addresses the process for caring for these patients under different medical situations. This not only protects these marginalized patients but also supports the physicians and healthcare teams in doing the right thing and delivering medically appropriate care.

Dr. Mishra is the Director and a bioethicist and Mr. Fulbright a bioethicist at the Sutter Health Program in Medicine and Human Values. For more information on the pioneering program, co-founded by the late Dr. Albert Jonsen and William Andereck, MD, see: Bioethics Services | Sutter Health

References 1. U.S. Department of Health and Human Services Office of Inspector General. March 2021. Hospitals Reported That the COVID-19 Pandemic Has Significantly Strained Health Care.

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MAKING SENSE OF WILDFIRE SMOKE Ted Schettler, MD, MPH Record-setting drought and heat in the West, driven in large part by climate change, set the stage for an early start to the 2021 wildfire season. By early July fires had engulfed more than twice the acreage that burned this time last year, the largest wildfire season recorded in California history. Although wildfires are natural features of this landscape, their increased intensity in prolonged seasons with more people living in the wildland-urban interface has deepened and widened their destructive impacts. Deaths and injuries to residents and firefighters, catastrophic property loss, socio-economic upheaval and forced displacement of people from their homes are the most wrenching, long-lasting consequences where the fires burn.

But health impacts extend far beyond, primarily due to hazardous smoke that spreads over vast regions, sometimes for many days or weeks.

Wildfire Smoke Characteristics

Wildfire smoke is physically and chemically complex. Its composition, formation, behavior, aging, and dispersion are influenced by the fuel mix, kind of fire, rate of fuel consumption, meteorological conditions, and landscape features.

The primary emissions from wildfires are coarse and fine particulate matter (PM), including aerosols; gases such as carbon monoxide, hydrogen cyanide, methane, nitrous oxide, nitrogen oxides, other volatile organic carbon compounds, including benzene, formaldehyde and acrolein; trace metals; polycyclic aromatic hydrocarbons (PAHs) and other toxicants. Some of the gases form secondary pollutants including organic aerosols and ozone when they photo-react in the atmosphere.

Particulate matter is typically divided into sub-types by size.

Particles less than 10 microns in diameter (PM10) are inhalable; those between 2.5-10 microns are largely confined to the upper airways. Smaller particles (< PM 2.5) can penetrate more deeply into lungs and ultrafine particles can pass into the general circulation. Wildfire-related PM 2.5 is often used as a metric of exposure but is only a surrogate for the complex mix of particles, gases, and hazardous air pollutants unique to each fire.

Health Effects of Wildfire Smoke

Well-established health effects of exposure to wildfire smoke range from eye and respiratory tract irritation to reduced lung function, bronchitis, pneumonia, exacerbation of asthma and COPD, and premature death—similar to impacts of urban PM. Even children without asthma show a decline in lung function.

A causal association between general particulate air pollution 24

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and cardiovascular morbidity and mortality is well established. Data linking wildfire smoke exposure to cardiovascular mortality and morbidity are mixed but most studies find increased risks of adverse cardiovascular events, especially among susceptible populations. Young and healthy people can also develop biological responses including systemic inflammation and vascular activation. Inconsistencies in study findings may be due to differences in exposure and outcome assessment methods, considerations of lag times, and variability in smoke composition. Very close to the fire, carbon monoxide concentrations can be high enough to be an acute health threat causing headache, weakness, dizziness, confusion, visual impairment, coma, and death.

In addition to impaired lung function, firefighters are at increased risk of several kinds of cancer, plausibly because of repetitive exposures to a variety of carcinogens associated with products of combustion. Cancer risk associated with exposure to wildfire smoke in the general population, however, is uncertain.

There is growing interest in learning more about what happens when smoke blankets communities sometimes for weeks at a time, since wildfire smoke waves, events lasting more than two days, have increased sharply in recent years. Birth outcomes, mental health, cognitive impacts, and cancer have not been sufficiently studied although some evidence shows an increased risk of low birth weight or preterm birth with wildfire smoke exposure during pregnancy.

Children, pregnant women, people with pre-existing respiratory disease and the elderly are especially vulnerable to smoke exposure and should take particular care to limit exposures to wildfire smoke.

Personal and Public Health Protection

Officials from the U.S. Environmental Protection Agency, U.S. Forest Service, Centers for Disease Control and Prevention, and California Air Resources Board have prepared Wildfire Smoke: A Guide for Public Health Officials, which contains a wealth of information useful to all stakeholders, including clinicians who will periodically be advising patients on best practices for minimizing smoke exposure and health risks. Another guide from the CDC summarizes recommendations succinctly for the general public. Health care professionals, health care systems, public health officials, city planners, schools and businesses should all be involved in implementing solutions to mitigate adverse impacts of wildfire smoke.

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Strategies for personal protection Stay indoors as much as possible: Reduce smoke exposure by staying indoors with doors and windows closed. Effectiveness in reducing exposure will depend on whether or not air conditioning that recirculates indoor air is available as well as the tightness of building construction. With windows and doors closed, particulate air pollution can be significantly reduced, although not by much in buildings that allow outdoor air to infiltrate easily. In warm weather, however, without air conditioning it may be difficult to stay in a closed-up house, requiring temporarily moving to a cooler location.

High-efficiency particulate air (HEPA) filter air cleaners that do not emit ozone can help reduce indoor particle levels dramatically. They should be matched to the size of the space where they are placed, which may require creating a “clean room” within a home closed off from the rest of the house where the air cleaner can work most efficiently. Most particulate air cleaners do not remove gases but some models are designed to accomplish that as well by adding an activated charcoal layer.

If necessary, a cheaper alternative to commercial HEPA air cleaning devices can be made by attaching a one-inch thick high efficiency furnace filter, available in hardware stores, to the back of a box fan so that air entering the fan is drawn through the filter. In a “clean room” these can significantly reduce particulate levels.

Reduce other sources of indoor air pollution during a smoke event such as tobacco smoking, using gas, propane and woodburning stoves and furnaces, spraying aerosol products, frying or broiling meat, burning candles and incense, and vacuuming, which can all increase particle levels.

In vehicles, people can reduce smoke levels by keeping the windows and vents closed, and, if available, operating air conditioning in “re-circulate” mode. However, in hot weather a car’s interior can heat up very quickly to dangerous levels with windows closed.

Reduce activity: Since exercise can dramatically increase respiratory minute volume, reducing physical activity will lower exposure to inhaled air pollutants and reduce health risks during a smoke event.

Respiratory protection with facial masks (respirators): Facial masks (respirators) should only be used after first implementing other more effective methods of smoke exposure reduction as much as possible. Appropriately-designed, properly-fitting facial masks can help to further reduce exposures, particularly when outdoor activity cannot be avoided. But masks should not be used as a reason to justify spending more time outdoors during smoke events by creating a false sense of security.

One-strap paper masks, surgical masks, or covering the mouth and nose with a bandana or handkerchief are not adequate protection from wildfire smoke. The N95, N100 (or P100) particulate filtering masks, sometimes called face piece respirators, are most appropriate for the general public. (N indicates not resistant to oil, P indicates oil proof; either is effective for particulate filtration.) N95 masks are rated to capture at least 95 percent of small particles and N or P100 to capture at least 99.97 percent. However, their performance depends on a snug WWW.SFMMS.ORG

fit to facial contours. Facial hair reduces their effectiveness. They are also very difficult to fit properly to children and do not provide adequate protection. Facial masks may also make breathing more difficult and resistance increases with respirator efficiency, which can make them uncomfortable and potentially hazardous to people with respiratory or cardiac disease.

Tightly-fitting respirators with purple HEPA filters offer a high degree of protection from particulates but may be less comfortable and more expensive than flexible masks. Most readily available masks generally do not filter gases but some models are constructed with an additional carbon layer that absorbs some gases. Tightly-fitting respirators with particulate and cartridge filters can also be effective for protection from particulates and certain gases.

All respirators can become clogged as filtered particulates build up and should be regularly replaced, particularly as breathing becomes more difficult with prolonged use.

Strategies for public health protection

Strategic public health interventions that complement and inform protective measures undertaken by individuals and families are critical components of the response to wildfire smoke events. They include public service announcements; sharing of recommendations for people of all ages, health status, and social circumstances; and providing “clean air” shelters. These interventions depend on anticipation, preparation, and building partnerships so that they can be implemented on short notice—perhaps as soon as tomorrow or next week. The 2021 fire season is off to an explosive start and may last longer than ever before.

Additional Resources:

Wildfire Smoke: A Guide for Public Health Officials. EPA. Available at: Wildfire Smoke: A Guide for Public Health Officials | AirNow.gov

Protecting Children from Wildfire Smoke and Ash. Fact sheets available at: Public: Protecting Children from Wildfire Smoke and Ash - PEHSU Cascio W. Wildland fire smoke and human health. Sci Total Environ. 2018; 624:586-595.

Reid C, Brauer M, Johnston F, Jerrett M, et al. Critical review of health impacts of wildfire smoke exposure. Environ Health Perspect. 2016; 124(9):1334-1343.

National Academy of Sciences. The Chemistry of Urban Wildfires. The Chemistry of Urban Wildfires A Virtual InformationGathering Workshop | National Academies

Ted Schettler, MD, MPH is Science Director, Science and Environmental Health Network and affiliated with Commonweal in Marin. He received his MD from Case-Western Reserve University and a master's degree in public health from the Harvard School of Public Health. He practiced medicine for many years in New England.

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YES, KIDS CAN SAFELY RETURN TO SCHOOL— Even with COVID's Delta Variant on the Rise

Naveena Bobba, MD and Theodore Ruel, MD As parents and caregivers across San Francisco prepare for their children to finally head back to school this August, they are undoubtedly feeling a mixture of emotions.

Of course, they must be grateful that schools are reopening in person because of the immeasurable social and educational benefits their children will receive. They, like all of us, are also assuredly hopeful for a return to normalcy.

But it’s also completely reasonable to feel concerned with the recent rise in COVID-19 cases.

The headlines each day tell us about how the highly infectious COVID delta variant has driven an increase in cases and hospitalizations across the nation, in California and here in the Bay Area. While it’s normal to feel these conflicting emotions, it’s also important to look at the data, science and facts surrounding school openings — as public health professionals have done from the beginning of this pandemic.

The data continue to show that schools can be safe places for our children to learn, socialize and play when the appropriate safety measures are taken. These measures include vaccinations for those who are eligible, universal indoor masking, frequent hand-washing, making sure staff and kids stay home when sick, and proper ventilation. For children under 12 who are not yet eligible for the vaccine, the good news is that serious forms of COVID are extremely rare. We have plenty of local case studies to back this data up.

In San Francisco, there were seven cases of COVID transmission in all schools with in-person learning among 48,000 students and teachers from September 2020 through June 2021, including the San Francisco Unified School District. All other cases reported at schools were related to community transmission outside of school. This includes the time period during the height of our winter surge. Moreover, there have been no verified outbreaks in San Francisco camps and learning hubs this summer.

The best way to protect our school communities is not to keep kids home — it’s to make sure that everyone in your household who is eligible gets vaccinated now. Despite recent news about breakthrough infections, vaccines are highly effective at preventing hospitalization and severe illness. The more adults and teens who are vaccinated, the more protection we offer to those who are not yet eligible for vaccines—including young school age children.

Anyone can go to sf.gov/get-vaccinated or call 628-652-2700 to book an appointment for a free vaccination. The good news for San Francisco is that we already have one of the highest 26

vaccination rates in the nation, with 77% of our eligible population fully vaccinated, including teenagers in middle and high school. We’re well on our way to giving our kids the community protection they need.

But we can still do better. As we carefully track and respond to the much more infectious delta variant, we need to be mindful that research shows current vaccines are still highly effective, even against this strain. In fact, vaccinated people are 10 times less likely to be hospitalized than those who haven’t yet gotten their jabs.

To date, there have been no COVID-19 related deaths in San Francisco among the vaccinated.

There should be no delay in returning to school. On this we are in agreement with the Centers of Disease Control and Prevention, the California Department of Public Health and county health officers all over the Bay Area. The evidence clearly shows that at this time, the benefits of in-person school—academic learning, social-emotional growth, social and health services, and many more—outweigh the risks of COVID-19, provided that schools have the proper, multi-layered safety measures in place.

Given the proven health and educational benefits of in-person learning, our priority must be to continue to work together to ensure a smooth transition back to school for all grades, at full capacity, when the school year begins in a few weeks. As health professionals, we are confident that schools can and should fully reopen for all grades—with safety measures in place. We urge school administrators, teachers, staff and families in San Francisco to work together to get vaccinated and to follow all the safety measures needed to stop COVID’s spread.

We look forward to a joyous return to school.

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Naveena Bobba, MD is deputy director of the San Francisco Department of Public Health.

Theodore Ruel, MD is chief of the Division of Pediatric Infectious Diseases and Global Health at UCSF Benioff Children’s Hospitals.

This piece originally appeared in the San Francisco Chronicle in July.

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SAN FRANCISCO

MARIN MEDICAL SOCIETY

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A BUDGET FOR CALIFORNIA’S FUTURE GOOD HEALTH Sandra R. Hernández, MD T h e COV I D - 1 9 p a n d e m i c reminds us that good health is the foundation of a prosperous society, and that far too many Californians suffer from preventable illnesses because of their skin color or the size of their paycheck. That’s why the ongoing process of reopening California must go hand in hand with investments in the longterm health of Californians.

By that measure, Governor Gavin Newsom and the state legislature earned high marks for the latest state budget. Overall, the fiscal year 2021–22 budget represents a historic level of investment in health that will pay dividends now and in the future.

There is cruel irony in the fact that the record-high tax revenues that make these public investments possible are the product of an economy that exhibits and exacerbates such extreme inequality. It is therefore both just and prudent for state leaders to channel California’s extraordinary budget surplus into programs that begin to bridge the state’s economic and health divide. The full list of the budget’s new health investments is too lengthy to include here. Instead, I’ll share five areas where the budget could transform California’s health care safety net in ways that will help many millions of our state’s residents.

Advancing Health Equity

The pandemic made racial and ethnic health inequities impossible to ignore. The budget provides new tools for the state to take on this monumental problem. It will fund a health equity data dashboard to enable California’s health and social service departments to align their activities and operate with increased transparency and accountability. It authorizes the Department of Managed Health Care to establish and enforce health equity and quality standards for licensed full-service and behavioral health plans. And it commits to allocations of $300 million per year beginning in 2022-23 to reduce health disparities and support a public health workforce.

The budget calls upon the Department of Consumer Affairs and the Department of Health Care Access and Information to work with licensing boards to collect data on race/ethnicity, languages spoken, gender identity, sexual orientation, and disability status of California’s health care professionals. This information can be used to guide the growth and diversity of the health care 28

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workforce, particularly in medically underserved and high-poverty areas.

Of course, it will take more than one budget cycle to alleviate generations of structural racism and transform care to uphold the dignity that each Californian deserves. Still, this year’s budget is an unprecedented move in that direction, especially if the new spending is combined with strengthened health equity standards and requirements for commercial Medi-Cal managed care plans, whose contracts are up for renewal.

Expanding Health Coverage

Our entire society pays a price when millions of workers and families are left out of the health care system. With this budget, the state takes a big step toward covering everyone by expanding Medi-Cal eligibility to Californians with low incomes age 50 and above regardless of immigration status. Many people covered by this policy have spent decades performing essential roles in California communities and contributing billions to the state economy. This builds on California’s previous expansions of eligibility for kids and young adults from low-income households, regardless of immigration status. Taken together, these policies make California the undeniable leader among states working to achieve universal coverage.

Strengthening Medi-Cal

Medi-Cal is the biggest player in California’s health care market and the best opportunity we have to lift the health of our state. And yet, for all its strengths, too many Californians with complex health needs experience the program as fragmented and difficult to navigate. Enter CalAIM, which is short for California Advancing and Innovating Medi-Cal. Its goal is to improve health outcomes for people with the greatest health burdens — like those experiencing homelessness — by adopting a “whole-person” approach to care.

After years of planning, the 2021–22 state budget serves as CalAIM’s official launching pad. It provides the authorization and resources for the Department of Health Care Services to implement CalAIM. Also, because effective care management for people with complex needs depends on the ability for providers to share information with each other, the budget also provides funding WWW.SFMMS.ORG

and a requirement that the state develop a framework to improve health data exchange across the state and a requirement that providers share their data. On that front, California has an opportunity to build on what other states have done to enable providers to see the whole picture, make coordinated and timely decisions, and save lives.

Increasing Access Through Telehealth

One bright spot of the past year was the rapid spread of telehealth care through the availability of video and phone visits.

The technology behind telehealth isn’t new, but it took a pandemic to unleash its potential. Community health centers became major adopters of telehealth to maintain their patients’ access to primary care and mental health care. Now with the pandemic receding, state policymakers had to figure out a policy for how Medi-Cal should reimburse these telehealth visits going forward.

The biggest question was what to do about phone visits, which have proven to be a lifeline — and the most convenient way for many Californians with low incomes to access care.

Fortunately, the governor and lawmakers agreed to extend coverage for both phone and video visits at the same rate as in-person visits for the next year. That change will give state lawmakers time to continue learning from the experiences of community health centers and to revisit the issue in the next budget.

Building the Health Workforce

There would be no health care system without an expansive health workforce. If that wasn’t clear before the pandemic, it should be extremely clear now. In 2019, the California Future Health Workforce Commission projected major shortages of professionals to meet demand for primary care, mental health, and other critical services over the next decade. The commission’s work exposed the fact that no state agency had been tasked with tracking how many health care workers were being trained or whether the training matched the state’s most pressing needs.

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The 2021–22 budget changes that. New funding will recast the Office of Statewide Health Planning and Development (OSHPD) as the Department of Health Care Access and Information, authorize it to play a more central role in health workforce planning, and develop a robust data system to better inform health workforce policy and funding decisions.

The budget also includes several new investments to address specific health workforce shortages, including new medical residency programs, more mental health providers for children and youth, more public health workers, and broader Medi-Cal reimbursement for services provided by community health workers.

With a record budget surplus and the biggest health emergency in over a century, now is the right time for smart strategic investments in California’s health care safety net. I applaud state leaders for making this down payment on a healthier future and a more just society.

Sandra R. Hernández, MD, is president and CEO of the California Health Care Foundation. Prior to joining CHCF, Sandra was CEO of The San Francisco Foundation, which she led for 16 years. She previously served as director of public health for the City and County of San Francisco. Sandra practiced at San Francisco General Hospital in the HIV/AIDS Clinic from 1984 to 2016 and was an assistant clinical professor at the UCSF School of Medicine. Sandra is a graduate of Yale University, the Tufts School of Medicine, and the certificate program for senior executives in state and local government at Harvard University’s John F. Kennedy School of Government.

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SFMMS BOOK REVIEW

THE PREMONITION: A PANDEMIC STORY

by Michael Lewis | WW Norton, May 2021 Michael Schrader, MD, PhD Michael Lewis has written an insightful new book about the Covid pandemic.

This book is about the heroism and the failures of the US response to the Covid-19 pandemic. Given the current resurgence of Covid-19 as the Delta variant this story is ongoing.

As in many of his previous works the narrative is related through the personal stories of the heroes of this ongoing crisis.

The heroes are physicians and scientists: Charity Dean, Carter Mecher, Richard Hatchet, Joe DeRisi (of UCSF). The narrative opens with the story of how a high school student’s science fair project became a seminal model for epidemiology. From then on things get ever more complicated and disturbing.

Lewis champions individual initiative and gumption over bureaucratic inertia. He characterizes the United States Centers for Disease Control and Prevention as inefficient and bureaucratic not in so many words but by repeated examples and descriptions of its failures to act decisively when the well-being of our citizens was at stake. He further points out that the CDC is not merely a United States institution but the preeminent institution of its kind in the world. Furthermore, the failings of the CDC predate the current crisis.

In typical Lewis style, he intersperses technical explanations with the personal narratives. He presents the science of epidemiology, R0 values, and logarithmic growth in simple metaphorical explanations. He returns to the technical aspects again and again, reinforcing through iteration.

Lewis addresses the political aspects of the pandemic response. He gives substantial credit to the administration of President George W. Bush. President Bush had read John Berry’s book, The Great Influenza, and had seen the potential threat.

Through his impetus a pandemic planning task force was created and generously funded.

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This created a level of expertise in the Federal government headed by Drs. Mecher and Hatchett. They refined the pandemic model that had its roots in the school science fair project. They revisited the data from the 1918 influenza pandemic and affirmed the age-old practice of social distancing, and then were able to get it adopted by the CDC as policy.

Lewis also focuses on the individual expertise and initiative of UCSF scientist Dr. Joe DeRisi. Dr. DeRisi pioneered a technology that identified the initial SARS virus in 2003. Dr. DeRisi was integral to the local response to Covid-19 and established a local lab that could DNA sequence SARSCoV2 samples to trace its origins.

Lewis emphasizes the human hubris, arrogance, ignorance, and complacency that have exacerbated the crisis at every decision point. The CDC has failed both healthcare workers and the American public. The heroes of this book are the officials of public health departments who have done their best to shepherd us through this crisis.

Lewis builds to the larger points of the historical politicization of the CDC following the Swine flu immunization fiasco of 1976 and the lack of power and funding of local public health officials. He criticizes the fragmented nature of American healthcare with its shortsighted profit-driven goals. The final lesson: This has happened before, this will happen again, and it is still happening.

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Dr. Schrader, an internist, is Chair of the SFMMS delegation to the CMA and PresidentElect of the SFMMS.

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MY FIRST DAYS AT SFGH Paul Volberding, MD

SFMMS is proud to have this exclusive preview excerpt from the work-in-progress autobiography of Dr. Volberding, a pioneer in the response to what became the AIDS pandemic and one of San Francisco’s—many would say the nation's— most renowned medical figures. This first excerpt details the start of his career and first encounters with a new, as yet unidentified pathogen.

July 1, 1981, was my first day as a University of California San Francisco faculty member, hired to begin a new division of medical oncology non-surgical cancer care in adults at San Francisco General Hospital. Although I’d spent as much time at the General as I was allowed by my fellowship program, I was then still in training, fully 10 years after finishing my college days in Chicago. Now, I would be charged with organizing and directing the care of cancer patients and educating the fellows, residents and students who would report to me. This all was, of course, a serious responsibility and an unheard-of career acceleration!

Most “division chiefs” had been faculty members for at least a decade before being given this position. I assume many of the chiefs I was joining looked quite askance at this new kid on the block and wondered how my boss, Merle Sande, had pulled this off without conducting a search!

I don’t recall the weather that first day, but July in San Francisco is typically cool and foggy in the morning—always a shocker to summer tourists in tee shirts and shorts. But I do remember being thrilled at the chance to launch a new career at a hospital I’d fallen in love with during my training and to provide cancer care to the typically very ill patients of a safety net hospital. Just as I’d transitioned from the last day of my fellowship to my new position, I knew I’d meet a newly minted first day oncology fellow that day immediately following residency training in internal medicine. Soon after checking out my new office (a windowless room about 8 feet square equipped with a used Steelcase desk that occupied most of the space) I met with my fellow, Ray Stricker, also excited to be launching an important new stage in his career. Ray had recently moved from New York where he’d finished his internal medicine residency at St. Luke’s-Roosevelt Hospital after medical school at Columbia.

As we did “rounds” that day, walking around the hospital wards to introduce ourselves to the house staff and the hospitalized patients we had been asked to help care for, we met a remarkable patient I’ll call Richard. As a doctor, one cares for so many patients; relatively few are so striking to be remembered years later. But I do vividly remember Richard even after 40 years as do Ray and Sue Carlisle, Richard’s intern at that time.

Sue would later have a long career at the General, eventually as the Associate UCSF Dean for the hospital. I remember Richard, his face and his disease with striking clarity and the immediate challenge his social situation represented for us as we cared for him. Richard was a 22-year-old man with an unbelievably WWW.SFMMS.ORG

rare cancer, Kaposi’s sarcoma, or KS. He was the case I’d heard rumors of the day before from my colleague John Klock.

On some very quick reading (a textbook as this was years before the internet and Google) I found that KS was known to occur in elderly Jewish men from the Mediterranean basin, and was a very slow growing cancer, often confined to the skin of the lower legs. As it was so slowly growing, KS in that population typically didn’t require treatment as the patients, often in their 80’s, would likely die sooner of a more serious disease. I had just been studying for my oncology qualifying exams that would certify me (for life!) as a medical oncologist and I’d completely skipped studying about KS. I was certain it wouldn’t be included in any questions. It wasn’t. But Richard’s disease was wildly different from those textbook descriptions, and he would clearly have been one of those morning report cases Molly and Chip had been encountering with Merle. My patient was originally from the deep South and had made it to San Francisco after realizing he was gay and not likely to fit in with his deeply religious family given “lifestyle”. He had no real friends and exchanged sex to survive, meeting many of his innumerable partners in bath houses and in the course of things experiencing numerous sexually transmitted infections, all treated at the City Clinic. By the time he was admitted to SFGH, Richard had lost an extreme amount of weight, had a haunted, gaunt expression and looked far too much like the concentration camp survivors I’d seen in my father’s World War II scrapbook I’d poured over for many hours as a child. Richard had smooth, purple, bruised-appearing KS tumors scattered over his entire body and face and totally encasing his thighs in a thick woody plaque. He was so weak he could barely sit unassisted. And none of this made any sense from what I’d read!

In addition to the “classical KS” in the elderly, there was a more aggressive type seen in sub-Saharan Africa, even affecting some children. Richard was not old, not Jewish, and definitely not an African child! In medical training, we are taught to expect incremental expansion of our knowledge regarding diseases we already knew. We expected to gradually learn more about hypertension, diabetes and the like and to gradually develop better treatments for them. Nothing was taught about the possibility of encountering absolutely new conditions and with no doubt this is why in retrospect so many of us missed those first cases of AIDS. Molly and Merle had seen those cases in morning report as continued on page 32

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a strange coincidence and I’d seen my lymphoma patient at the university as just a case of really bad luck. On July 1st 1981, my mental impression of Richard was that he was suffering from a rare and unfortunately hideously advanced cancer, nothing more except that his disease fit nothing that had been previously seen in medicine. I could not answer Richard’s questions about what he had or what to expect but even at first glance, I did not expect a good outcome.

From this first patient though—and repeated in countless times in the following years—we confronted the need to care for desperately ill persons with little in the way of support from what I called “traditional” families. My patient’s families were almost always at a distance and not uncommonly unaware that their son—my first patients were almost exclusively young men—were gay or that they had become ill. But my brand new, first-day oncology fellow Ray said that “maybe we’d seen something like this in New York.” Remember, this is before any public discussion of KS as a new condition in gay men; the very first, very brief story in the New York Times would not come out for three more days. Ray offered to call colleagues where he’d trained and they confirmed his recollection. In this case the telephone was our best social media and linked some of the very few of us as we began to deal with something absolutely new. Not yet frightening given the blinders we wore that kept us focused on what we’d learned rather than the reality in our faces. But the fear would soon follow. I’m leaving that last memory in place as a warning and reminder. It was fixed in my recollection, and I would have sworn it was true., but in recent conversations, Ray corrects me pointing out that he’d seen a case of KS as a medical student at Columbia and it was the “classical” variant in an elderly Jewish man! Memory is remarkably slippery and often biased so we remember events that best fit our own selfperception.

Things happened very quickly in mid-1981 as the medical response to this new world began. In early June, the Centers for Disease Control had published a short paper that proved of monumental significance. A young, Stanford-trained clinical immunologist at UCLA, Mike Gottlieb, had been informed by a community physician, Joel Weisman, of five cases he was seeing of gay men with a previously incredibly rare pneumonia caused by an organism called at the time, pneumocystis carinii. These

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cases were therefore called PCP, for pneumocystis carinii pneumonia. I’d actually seen one PCP case during my Utah days but in a desperately ill young woman who’d had a kidney transplantation and was on massive doses of immune inhibitors to prevent organ rejection. But the cases Mike investigated were young and previously in good health, and each case was a man who had sex with other men. Unlike many of the rest of us, Mike was willing to think outside the box and had a powerful new tool to help him. Monoclonal antibodies, engineered pure proteins that recognize other specific proteins and link to them physically, had only been developed six years earlier, in 1975. These antibodies were then used with another new tool called flow cytometry that had been developed in 1972. Together, this technology allowed immunologists like Mike Gottlieb to “tag” different cells in the immune system and count them separately in a rapid automated process instead of earlier primitive methods requiring counting individual cells through a microscope. He could count these cells in the blood enumerating the different populations of key components of the immune system that protect us from the incredible spectrum of microbes that they are prepared to kill.

In 1981, this technology was extremely rare even in the most advanced research universities. In all of UCSF there was only one flow cytometer—there are now many hundreds. When Mike examined the blood of the five cases of PCP at UCLA, he discovered that the expected proportions of the different types of cells that constitute a normal, healthy immune system were completely deranged. Normally cells called “helper cells” are more common than ones called “suppressor cells” but in these first-reported AIDS patients, helpers were greatly reduced. The immune system is extremely complex but it’s work requires delicate balances of the many different types of cells of which it is composed. Mike’s fundamental recognition of an underlying disturbance in the numbers of cells of the immune system leading to a serious disease was at the heart of AIDS and would drive our work for decades to come. What was causing this imbalance of cells would eventually lead us to HIV. (To be continued….)

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Safe Streets Have Emptied My Emergency Department—

WE SHOULD KEEP THEM Stephen Gamboa, MD I was at my church picnic in Golden Gate Park in April 2019 when I heard someone yelling for help. After that disconcerting incident, I began to pay attention to the daily stream of pedestrians, runners and bike riders injured by cars in my Emergency Department. Prior to the pandemic, JFK Drive in Golden Gate Park was a predictably dangerous place for people on foot and bikes. I cared for many park-goers who had been badly injured there. In fact, JFK Drive is designated by The City as a high-injury corridor, meaning that it was among the most dangerous streets in The City for pedestrians.

It’s no longer that way. After JFK Drive was closed to motor vehicle traffic in April 2020 to allow for more social distancing, I noticed something strange and wonderful: I haven’t seen a single patient in my ER due to a traffic collision on JFK. Because JFK Drive has remained car-free and safe for kids, we have prevented many serious injuries. Data supports my observations: In 2019, nine people reported injuries on JFK, some quite severe (notably, most injuries, including many I see in the ER, are never reported in official tallies). Since the road closed to cars, zero serious injuries have been reported.

I tell almost everyone that I see in my ER that the most dangerous thing they will do in San Francisco is cross the street, and the statistics bear that out. This is especially true for children: Motor vehicle crashes are the leading cause of death in young people ages one to 29 in California. As the father of two small children, this hits particularly close to home. This is a public health crisis. We must do better for our children.

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San Franciscans should take great pride in the leadership our city has demonstrated in its pandemic response. Working on the front lines in the ER and as part of the Department of Public Health’s COVID Response, I have seen how strong and proactive leadership can save many lives. Now it is time for our San Francisco city leaders to demonstrate the same proactive and evidenced-based approach to traffic safety in our city.

As an emergency physician and a father, I will always advocate for approaches that save lives. If we have an opportunity to make our city safer for children and other vulnerable people through maintaining car-free spaces and Slow Streets, we must take it.

Conversely, if JFK Drive is opened back up to motor vehicles, we will have to live with the knowledge that every injury or God forbid, fatality, that is suffered there was within our power to prevent and we chose not to do it. San Franciscans, especially children, deserve a permanently kid-safe and car-free JFK. Stephen Gamboa, MD, is a father of two, resident of the Richmond District and an emergency physician at Kaiser Medical Center, San Francisco.

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CLINIC BY THE BAY: A DECADE OF CARE FOR THE MEDICALLY UNDERSERVED Paul Turek, MD The Clinic by the Bay mission: To understand and serve, with dignity and respect, the health and wellness needs of the medically underserved in the San Francisco Bay Area. and cannot afford private insurance, a population that consistently “falls through the cracks” in our health care system. Our overarching goal is to improve access to comprehensive, quality healthcare while also providing meaningful opportunities for volunteerism and civic engagement. We now serve as a training and experience environment for medical students, interns, and residents from Kaiser, UCSF, and Sutter/CPMC. Architectural rendering of the renovated Alemany Hospital at 35 We engage 100 volunteers per Onondaga Street, San Francisco, CA. month, of which 30% of those volunteers have been active for more than two years. To date, these volunteers have provided more than 70,000 hours of serCaring Roots vice, valued at more than 5 million dollars.

I was first approached by Janet Reilly and Scott Hauge in 2007 to help develop the Clinic’s care model. Philosophically, the Clinic An Overgrowth of Care was based on a national system of clinics called Volunteers in But there’s more! We have now served nearly 5,000 comMedicine (VIM) that began back East and that was powered by munity members and oversaw 2,652 visits in 2020, with 90% volunteer retired doctors and other care providers. Given a blank of patients reporting better health and ability to work. For six slate for how we would structure our Clinic in San Francisco, in years, we have been a state-licensed community clinic and more addition to treating every patient with kindness, respect and recently we added mental health services and launched an innopatience (a tenant of the VIM clinics), I also suggested that provative health coaching program to provide personalized supviders have old-school, long visits and that they not be burdened port for patients with chronic conditions. In 2020, we began to with paperwork in attempt to reverse the trend in modern mediaddress food insecurity and supporting chronic disease managecine toward 12-minute visits chock loaded with documentation. ment through our food access and “food as medicine” programs.

An electronic medical record with scribes working alongside proIn essence, Clinic by the Bay seeks to reduce preventable emerviders would do just fine to restore that lovely provider-patient gency room visits, add to the capacity of the primary care safety relationship that drew us into medicine in the first place. net, and improve health outcomes among the working uninsured.

The Clinic opened in 2008 as a 501(c)(3) non-profit in the And all of this is driven by an incredible culture of volunteering.

Excelsior district after a needs-analysis was performed to idenAs highlighted in a Huffington Post blog in 2013, we are a clinic tify the best location for the population we serve. The Clinic’s that is “powered by pro bono.” This is one agile, evolving, modern opening was attended by several luminaries including Senator little clinic!

Diane Feinstein, Representative Jackie Speier and founder of the And with growth comes growing pains. After a decade in VIM clinics, Dr Jack McConnell. And it has simply taken off from our currently leased Excelsior location, we are running out of there. We care for patients in San Francisco and San Mateo counspace for our day-to-day operations. As we add patients, serties who are ineligible for Medi-Cal or government assistance vices and a growing cadre of volunteer specialists, including There is a little free-clinicthat-could, right here in the heart of San Francisco, that you should really know about. It provides free medical care to the working uninsured. In fact, it's the only free medical clinic in the Bay Area that is entirely dedicated to this medically undeserved population. And, it takes no federal monies to carry out its mission, but relies solely on donations and volunteer providers for its utter existence. It’s called Clinic by the Bay (ClinicbytheBay.org) and it is flourishing!

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ENT’s, orthopedists, health coaches and mental health specialists, we have now found a new home in San Francisco: the old Alemany Emergency Hospital. This newly renovated historic space not only gives us the ability to meet the growing need for affordable healthcare, but it also allows us to provide free dental care and pharmacy services to our patients—brand new services for Clinic by the Bay.

Historic Care Funded by a 1928 public bond measure and built in 1933, the Alemany Hospital is an historic medical space in San Francisco.

It was designed almost 100 years ago to extend the City’s emergency hospital system to cover the Excelsior District. In fact, the Alemany Hospital site was the final piece of a model citywide emergency hospital system, one that was nationally known and respected. Indeed, as it stands today, the building is a remnant of a noble and controversial effort to provide free and efficient emergency health care to underserved areas of San Francisco.

Clinic by the Bay is currently restoring this historic structure, frescoes and all, and returning it to its original use as a site for free health care for our community. We are very excited to move into this historical building and revitalize a longstanding history of volunteer-powered, high-quality healthcare. Our plans include opening San Francisco’s first free dental clinic and first free pharmacy, and to expand our mental health, health coaching, and specialty care services.

Amidst this growth, expansion and historic goodness, what we at Clinic by the Bay value most and greatly need are volunteer care providers. Retired or not, you are essential to our continued success as a model of urban medical care for the underserved.

Is this a call to action, you ask? Why yes, it is! Recall the words of Winston Churchill: “We make a living by what we get, but we make a life by what we give.”

Dr Turek graduated from Yale College with summa cum laude honors and attended Stanford University School of Medicine, also graduating with honors. He then trained in urology at the nation's first hospital: The Hospital of the University of Pennsylvania. He received fellowship training in Male Reproductive Medicine at Baylor College of Medicine in Houston TX, and then joined the faculty at the University of California San Francisco. After retiring as an Endowed Chair in Urology, he started The Turek Clinic in San Francisco and Beverly Hills.

CMA files declaration in district court in support of masks in schools CMA recently submitted a declaration with the U.S. District Court for the Central District of California, in support of the Los Angeles Unified School District (LAUSD) and the Los Angeles Board of Education, which are currently being sued by a group of parents seeking to overturn the district’s mask requirements. CMA recommends and advocates for universal masks (subject to limited exemptions) and face coverings for the reopening and returning to schools during the COVID-19 pandemic.

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COMMUNITY MEDICAL NEWS Kaiser Permanente

Chinese Hospital

Maria Ansari, MD

Sam Kao, MD

Kaiser Permanente is acutely aware that the pandemic created an unequal burden on communities of color. Latinx, Black, and Native Americans are contracting and dying from COVID-19 at significantly higher rates than white Americans, while lower-income, Latinx, and Black households face some of the lowest vaccination rates.

To help address these issues we have joined forces with community and government partners to address critical needs and assist the populations that have been hardest hit by the pandemic. We created Vaccine Equity Grants for a group of community-based organizations (CBOs) to support activities that increase COVID-19 vaccination rates among their constituents.

Working with the San Francisco Department of Public Health (SFDPH) and CBOs, Kaiser Permanente has provided more than $400,000 in Vaccine Equity Grant funding to local nonprofit partners. The nonprofits that were funded predominantly serve persons residing in high-need geographic areas, populations with high COVID-19 infection and/or mortality rates, and communities with low vaccination rates or demonstrable barriers preventing access to vaccinations.

In addition to providing financial support in the form of grants, physicians from the San Francisco Medical Center are providing a variety of services to communities that are disproportionally affected by the virus.

Our physicians have been educating community members through virtual, bilingual vaccine confidence presentations.

These sessions aim to be sensitive and attuned to the concerns of diverse audiences, are free to the public, and provide participants the opportunity to learn about the vaccines’ safety and effectiveness in an engaging and open environment.

Kaiser Permanente has also joined the San Francisco COVID Command Center and the SF DPH’s “Ask the Doc” initiative which deploys physician volunteers to have an in-person physician presence at community vaccine sites. There the doctors can answer questions about vaccine safety/efficacy or help administer the vaccine.

We are committed to continuing these efforts to support an equitable pandemic response in our communities as we face the challenges of this public health crisis.

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Along with the entire Bay Area community, the waning of the Covid epidemic has brought welcome relief to Chinese Hospital. Now we are all in the midst of picking up the pieces after the storm, trying to get back to our pre-pandemic routines and workflows.

On the other hand, some things never change, such as Joint Commision hospital site visits! We had the opportunity to host a pair of surveyors via remote access in March, and managed to survive without too much trouble. It was the usual, mostly good, but always room for improvement. Kudos to the entire Hospital leadership team and Compliance team, and our Medical staff stars: Performance Improvement Chair Dr. Justin Quock, Credentialing Chief Dr. Clifford Chew, and Critical Care and Vice Chief of Staff Dr. Fred Hom. On another note, we have taken up the hosting duties of the next Federation of Chinese American and Chinese Canadian Medical Societies (FCMS) Scientific Meeting in October of 2022. The FCMS actually originated from our Medical Staff in 1981 with the vision of a Conference concentrating on the health issues related to the care of the Chinese in North America, the first Conference occuring the following year. With member societies representing physicians from New York City, Los Angeles, and Toronto, this is a bi-annual scientific meeting continues to focus on the medical needs of our unique cultural communities. The 2020 Meeting hosted by the NYC delegation focused on the cutting edge information on Covid, as well as the unique mental health needs of our communities.

This next meeting will no doubt have further summary presentations regarding our Covid experiences. Just as importantly, we hope to highlight some of the Tech related trends in healthcare that have or will impact our healthcare communities. Dr. Gordon Fung has graciously stepped forward to helm the planning committee. We hope that we will be able to pull off some form of a hybrid meeting, utilizing some of the remote technology we’ve all perfected during the pandemic, while offering some semblance of an in person experience. Stay tuned as we roll up our sleeves and get to work!

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CLASSIFIED ADS GYN office sharing in Carmel. Ready to slow down and spend more time with patients? We have room for another physician. Contact: Stephanie Taylor MD, 831-622-1995, drtaylor@womanswellspring.com. https://womanswellspring.com.

Medical Office space available at 2100 Webster Street, San Francisco. Pacific Professional Building http://webster.com 415-923-3915. Contact: v.vidaurri@2100webster.com

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