San Francisco Marin Medicine, Volume 93, No. 2, March/April 2020

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

COVID CRISIS AND RESPONSE

Special Section: REPORTS FROM THE FIRST EVER CLINICAL CONFERENCE ON MEDICAL AID IN DYING Volume 93, Number 2 | MARCH/APRIL 2020

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IN THIS ISSUE

MARCH/APRIL Volume 93, Number 2

ADVOCACY AND EDUCATION FEATURE ARTICLES

MONTHLY COLUMNS

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2

Membership Matters

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President's Message: Self Care is Critical Brian Grady, MD

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Three Waves: Covid, Flu and Vaping Some Lessons and Implications John Maa, MD

COVID-19: Face Masks and Missed Opportunities Eric Denys, MD

10 Thank You San Francisco from an ICU Physician

Richard Wang, MD 11 Coronavirus: Bay Area Medical Practices Face Uncertain Future as Patients Disappear

Michael Cabanatuan 13

COVID-19: Flashbacks from the Early AIDS Era A Talk with HIV Pioneers Drs. Molly Cooke and Paul Volberding Steve Heilig, MPH

22 CMA Guidelines and Recommendations for

Reopening the Health Care System

California Medical Association

COMMUNITY NEWS 38 Kaiser News Maria Ansari, MD

38 Chinese Hospital News Sam Kao, MD

OF INTEREST

20 San Francisco Department of Public Health Advisory: Reporting Requirements for Coronavirus

San Francisco Department of Public Health

12 Taking Good Care- of Ourselves, Too

Jessie Mahoney, MD

26 Letter to a Dead Poet

Lonny Shavelson, MD

18 Climate Change, Public Health and "Green" Medicine

Mary L. Williams, MD

SPECIAL SECTION

28 A True First: Mainstreaming Medical Aid in Dying

Monique Schaulis, MD, MPH 30 Then and Now: Reflections on the Clinicians Conference of Medical Aid in Dying

Robert Liner, MD 31 Towards a Good Death

Charles Binkley, MD

32 A Delicate Topic and a Great Start

Laura Koehler, LCSW 32 Proud to be There

Steve Heilig, MPH

16 Q & A with AMA President Patrice Harris, MD

Shannon Firth 24 A Fond Farewell

Mary Lou Licwinko, JD, MHSA 25 Double Espresso

Jeff Newman, MD, MPH

31 The "Chilling Effects" of Public Charge: How Can We Fight Back?

Christina Schmidt and Leena Yin 34 2020 SFMMS Gala Highlights 44 Advertiser Index

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MARIN MEDICAL SOCIETY

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

MEMBERSHIP MATTERS Our sincere gratitude for all that you are doing to care for the community at this unprecedented time.

SFMMS is here for you - please don't hesitate to reach out.

Bookmark the SFMMS COVID-19 Resource Page For the latest news, policy updates, guidance and research related to COVID-19, visit the SFMMS’s COVID-19 Resource Page at www.sfmms.org/news-publications/covid-19.aspx. The page is updated regularly with local information, as well as from statewide and national resources. We recommend that you bookmark the page and visit often for the latest on the pandemic.

You’ll find a link to the California Medical Association’s COVID-19 web page and resources. Here are a few resources of note: • Financial Toolkit: Financial Assistance for Medical Practices During the COVID-19 Pandemic (https://bit.ly/3ccGCJP) – provides an overview of financial assistance available to medical practices during and after this difficult time, so physicians have the information they need to make the right decisions for their businesses and families.

• COVID-19 Frequently Asked Questions (www.cmadocs. org/covid-19/faq) – updated regularly • Confidential Physician Help Line (www.cmadocs.org/ confidential-line) - CMA offers a confidential phone line for physicians where they can call on their own behalf, or their family members or colleagues may call, to request help when facing problems of alcoholism, drug dependence or mental illness. This line is completely confidential and serves to ease any personal burdens that may be affecting a physician's well-being. The phone line is available to all physicians regardless of membership.

CMA Seeks Volunteers to Provide Remote Support to Health Care Workers Serving on the Front Lines of the COVID-19 Pandemic

The CMA Wellness Program is seeking volunteer physicians and nurses to serve as remote peer care coaches to assist physicians and other health care workers serving on the front lines of the COVID-19 pandemic. The new program, called Care 4 Caregivers, will offer virtual emotional and professional support to health care workers serving patients during the COVID-19 crisis.

Coaching services will be conducted remotely and are not considered practicing medicine, so a current license is not necessary. In particular, CMA is encouraging retired physicians (who may be at higher risk of COVID-19 exposure and thus, unable to work at a health care facility) to volunteer.

All interested physician volunteers should have: • Four hours of time available for online training • Access to computer audio and video and sufficient broadband (CMA will supply a Zoom account) • Passion for supporting fellow health care providers • Compassion, empathy and patience • Strong listening skills To volunteer for Care 4 Caregivers, please complete the application form available at https://cmawpca.org/.

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CMA Physician Services and Amwell Telehealth Solution Offerings In the midst of COVID-19, physicians and their practices need to be able to continue to see their patients under their current payer contracts and finding a solution that can be implemented quickly, easily, and securely is of utmost importance. CMA Physician Services, Inc. has partnered with Amwell, the nation’s leading telehealth platform, to provide all California physicians with access to a turnkey telehealth solution, enabling the delivery of virtual care to patients in response to the COVID-19 outbreak.

Aligned in mission, this partnership seeks to ensure that California physicians are able to practice in the modality of their choosing, armed with the best-in-class tools and technologies.

Read more at www.cmadocs.org/amwell.

Noridian Hosts Webinars for Physicians on Medicare Advance Payment Requests

The Centers for Medicare & Medicaid Services (CMS) expanded its accelerated and advance payment program for participating Medicare providers and suppliers to lessen the financial hardships of providers facing extraordinary challenges related to the COVID-19 pandemic. CMS said it provided $34 billion in advance payments in just the first week of the expansion.

Accelerated and advance Medicare payments provide emergency funding and address cash flow issues based on historical payments when there is disruption in claims submission and/ or claims processing. Noridian has also scheduled a number of webinars to assist providers with the process of submitting advance payment requests. Space is limited and registration is required, so sign up as soon as possible to reserve your spot at https://bit.ly/2RrcEKa.

Wellness Coaching Tips from SFMMS Physician Wellness Task Force Chair, Dr. Jessie Mahoney

As healthcare providers, we are facing unprecedented challenges. Wellness and self-care have never been more important than they are in this moment. Many physicians have been utilizing coaching tools as a way to support their mental and physical health during this unprecedented time. Dr. Mahoney shares some of her coaching tips. Read more at https://bit. ly/2UZyTZE.

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MARCH/APRIL 2020

YOUR COVID STORIES WANTED

Volume 93, Number 2

How has the pandemic impacted your practice, and your life?

The SFMMS journal will publish a section of members’ brief reports on your experiences with COVID-19 so far. How have you encountered it clinically?

Educationally? Financially? Emotionally? How has the virus and shutdown impacted your practice? Yourself? What do you think should have or still might be done? What are your thoughts going forward? Anything is fair game. Anything from a few words up to brief essays up to 400 words best, but don’t be limited. A submission judged as favorite by our editors will win a donation to a preferred relevant local charity. Deadline June 1.

To submit or for more information: Heilig@sfmms.org .

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

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MARIN MEDICAL SOCIETY

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PRESIDENT’S MESSAGE Brian Grady, MD

SELF-CARE IS CRITICAL "With great and sudden change, there is bound to be some reaction. Much of what we are feeling is akin to grief, and should be dealt with as such."

Dear Friends, I sincerely hope this finds you well, physically, emotionally, and spiritually.

When I started this year as your president, I thought that the biggest challenge of the year would be the transition to a new Executive Director. Then the world effectively said, “Hold my beer,” and along came COVID-19.

In a matter of days, our lives have changed completely. Uncertainty is the new normal: who will get sick, and how sick? How will I keep my practice open? What about my patients who need to be seen for routine and semi-urgent matters? What about my employees? When and how will we resume normal activities?

While we hope this sort of thing never happens, when it does, we muster the strength and courage to show up every day and do what we know to be best for our patients and for each other.

With great and sudden change, there is bound to be some reaction. Much of what we are feeling is akin to grief, and should be dealt with as such.

Self care is critical in this time. The simplest thing is to admit that this is difficult. Reaching out and connecting with others is critical. Try not to neglect rest, nutrition, hydration, and exercise. Find reasons for gratitude: Grateful people are happy, not the other way around.

The Bay Area has been very fortunate to have avoided the numbers of cases seen in New York, Detroit, Louisiana; we must continue to work hard to sustain that. We will return to “normal,” but when we do, it will be based on evidence and facts, and taking into account the value of all human life.

Remember, you are not alone.

Reach out.

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

IN THE TIME OF COVID-19 Although many experts in epidemiology and infectious diseases have long warned that serious pandemics were very likely coming, it is still somewhat surreal to actually be living and working amidst one. The last big one, HIV/AIDS, was (and to varying degrees in many places, still is) a tragedy that shortened many lives and required a massive response on many fronts. COVID-19’s biology has required an even broader one, and as with HIV, once again the Bay Area has been ahead of the curve, both figuratively and literally.

We are fortunate to have such undeniable expertise and aggressive leadership in our local and state public health leaders and elected officials. Our Mayor and Governor have appointed superb physicians and public health experts to leadership positions and then actually listen to and heed their advice, novel as that might appear in some other locales. Our early results are already evident. We will have more reports on those in future editions.

The SFMMS and CMA are working hard to help. CMA has done amazing work on all fronts of this pandemic, including to support medical practices impacted by the shutdown, and SFMMS supports that work on the local level, with efforts from education and policy advocacy to distributing PPE masks. We will continue. The picture evolves too rapidly and there is too much to be done to detail here, so here are the three COVID-specific sites we hope you are already finding useful: San Francisco Department of Public Health: https://www.sfcdcp.org/infectious-diseases-a-to-z/coronavirus-2019-novel-coronavirus/coronavirus-2019-information-forhealthcare-providers/ SFMMS: https://www.sfmms.org/news-publications/covid-19.aspx California Medical Association: https://www.cmadocs.org/covid-19

Finally, we very much hope you are all as well as can be in these trying times.

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– The Editors

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COVID Crisis and Response

THREE WAVES: COVID, FLU, AND VAPING Some Lessons and Implications

John Maa, MD The 1918 Spanish Flu pandemic claimed an estimated 6 5 0 , 0 0 0 A m e r i c a n l ive s , infecting almost 1/3rd of the world’s population and resulting in 50 million deaths worldwide. The pandemic occurred in three waves. The first wave in the US came in the Spring of 1918, among soldiers being prepared to deploy across the Atlantic for war. The second came in the Fall of 1918 as the nation celebrated the end of the World War I, and would ultimately claim the majority of lives. A third wave of illnesses occurred in the Winter and Spring of 1919, adding to the deadly toll. The experience provides valuable lessons to stem the coronavirus pandemic in 2020.

Three separate crises of severe acute respiratory illnesses over the last 10 months have strained the resources of the American emergency care delivery system, particularly impacting the fields of emergency medicine, critical care, pulmonary medicine and anesthesiology. Around June of 2019, hospitals across America noted a sharp rise in patient visits for major respiratory symptoms linked to the use of electronic cigarettes. The Centers for Disease Control reported that this outbreak of e-cigarette, or vaping product, use associated lung injury (EVALI) would result in 2,807 patients being hospitalized in all 50 US states, with 68 deaths. EVALI hospital admissions continued through the winter into the start of 2020, with many other vaping patients being evaluated without requiring hospital admission.

Overlapping with the EVALI crisis has been the annual influenza season in the United States, which runs from October through May. As of March 21, 2020, the CDC estimated that there have been at least 39 million US cases of the flu, leading to 400,000 hospitalizations, and 24,000 American deaths. A number of these deaths occur outside the hospital setting, and are captured by review of death certificates that list pneumonia or respiratory and circulatory causes of death, without formal testing for one of the 471 different influenza A or B viruses responsible for this year’s cases.

The third stress to the system has been the worldwide pandemic of COVID-19, which as of this writing totals 843,981cases in the US with 46,859 deaths. The first American case of COVID-19 was reported by the CDC on January 21, 2020 about a 6

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Seattle patient who had entered the US from Wuhan 6 days earlier. The first case of COVID-19 in Wuhan had been identified in a patient hospitalized December 16th, 2019, who began feeling ill December 10th.

The 2006 Institute of Medicine (IOM) report “Hospital Based Emergency Care – At the Breaking Point” detailed a national crisis in emergency care from hospital and emergency room overcrowding, and warned of inadequate capacity to handle a surge of patients. The three serial waves of EVALI, influenza and COVID-19 have depleted the supply of protective equipment, personnel and resources, and proven the IOM concerns about the American emergency care system to be true. In late February 2020, the CDC stopped tracking new EVALI cases, to better focus on the emerging COVID-19 pandemic.

The symptoms of fever, cough, and shortness of breath are shared among EVALI, influenza and COVID patients. Characteristic radiologic findings such as ground glass opacities are seen in all three conditions. There may also be a connection between the three successive waves of EVALI, influenza, and COVID. The number of influenza cases this season has been high, and it has recently been recognized that some early COVID cases were mistakenly attributed to influenza, as COVID testing was not yet available. Some later EVALI cases may have been incorrectly diagnosed as influenza cases.

Vaping and smoking likely adversely impact outcomes of COVID+ patients with pneumonia. Repeatedly inhaling from an electronic cigarette (possibly coated with viruses or bacteria) violates the principle of minimizing contact with one’s mouth and face to reduce the risk of contracting COVID-19. Sharing an e-cigarette with others only increases that risk further. Another concern raised is that the plume of vaping aerosol generated might result in virus particles that deposit on surfaces in the environment.

The HIV-1 virus that causes AIDS was identified in 1983.

Afterwards, scientists re-studied mysterious unexplained deaths from decades earlier, and recognized HIV-1 was present in preserved patient tissue samples dating as far back as 1959 in the Congo, and 1969 in the United States. The date of the earliest COVID death in America was moved weeks earlier to February WWW.SFMMS.ORG

2020 after reanalyzing tissue specimens of Santa Clara deaths originally attributed to influenza. The majority of cases from the EVALI outbreak were associated with vaping of marijuana/ THC contaminated with vitamin E acetate, which is thought to have caused the severe respiratory illnesses. But in nearly 15% of EVALI cases, a cause was never found, as the patients denied vaping THC. Perhaps some of the later mysterious EVALI cases from the winter of 2019 and early 2020 should now be re-analyzed, to determine if COVID may have played a role; bronchoscopy biopsies and lung specimens stored in pathology labs across America could be assessed to see if COVID RNA is present.

What this re-analysis might answer is whether the COVID virus began spreading in America even earlier than January of 2020, and whether we might now be in the second (or even third) wave of the COVID pandemic. If the first COVID wave arrived in the US in 2019 (either with EVALI or influenza), then the numbers of American COVID cases (and both survivors and deaths) are likely far larger. This might point to a best-case scenario where a significant number of Americans have now already recovered from COVID, and are likely protected from re-infec-

tion. Perhaps a silver lining for America is that we may be further along in the natural history of the viral timeline than anticipated.

COVID antibody tests are being undertaken to identify those Americans who have already been exposed to the virus, and are likely now immune. These individuals might be able to return to the workforce earlier, to help restart the American economy across all sectors of society. Given the adverse effect on respiratory health, the current COVID pandemic should serve as a message to both vapers and smokers to quit promptly, to improve both their own health and also reduce the stress upon the healthcare system from treating tobacco-related illnesses.

John Maa MD is an SFMMS Past-President and General Surgeon.

SMOKING: Quitting More Important than Ever “Bay Area turns to cannabis for calm” (April 10), which lists smoking and vaping among ways to consume cannabis, describes a potentially very unhealthy reaction to the stress from living amidst the COVID pandemic. This is a disease where healthy lungs are crucial, and smoking or vaping anything has been shown to be damaging to our lungs - and not only the users’ lungs, but those nearby due to secondhand smoke or vapors. This is not a “prohibitionist” message but a potentially lifesaving one. The imperative to quit smoking or vaping any substance is now more important than ever. Help for quitting these addictive behaviors is available - please seek it out, especially now.

Steve Heilig San Francisco Marin Medical Society (San Francisco Chronicle, April 13)

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COVID Crisis and Response

COVID-19: FACE MASKS AND MISSED OPPORTUNITIES Eric Denys, MD There is a Dutch expression that says the best helmsmen stand on shore, but what if these men see something from afar which the captain ignores? The Covid-19 pandemic is teaching us a lot of lessons we should not need if we had paid attention to the past.

The new coronavirus originated in Wuhan province in China in December last year. It became immediately apparent that it was a new and very infectious viral strain quickly spreading to South Korea and Taiwan. The genome was released to the world in January and China took immediate drastic action with total people isolation. Television pictures showed all Chinese people wearing face masks as they are accustomed to do for self protection and/or out of concern for others. Meanwhile, the rest of the world was watching. The World Health Organization issued statements declaring that the epidemic had not reached pandemic proportion, and the world kept waiting, hanging on the lips of the Director General as if waiting for marching orders. No country in the west wanted to be first in imposing restrictions.

Dr. Nancy Messonnier, director of the National Center for Immunization and Respiratory Diseases, was quoted as saying in a Jan. 30 briefing "The virus is not spreading in the general community." By mid-February Washington State had reported 21 of the 31 deaths then reported in the United States. On March 2, our Surgeon General stated masks do not prevent the general public from catching corona virus.

When I arrived in San Francisco on March 4 from an overseas trip in Australia wearing a mask, I was met with casual "business as usual" looks at the San Francisco airport. Slowly, way too slowly it turns out, the White House and its medical consultants

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began waking up to the reality. As more people died, including doctors and nurses, a shortage of personal protective equipment (PPE) became apparent. A little-known secret was that the lack of preparedness, which is now playing out, was well known to the government in great detail. The New York Times reported on a government draft document of October 2019 marked "Not to be disclosed" and codenamed "Crimson Contagion." Prior disasters such as 9/11, the H1N1 epidemic in 2009 and the Ebola scare in 2014 should have provided ample warning to prepare.

Meanwhile, as Covid19 casualties rose quickly, the federal administration scrambled to appease the public - until disaster stared them in the eye. Hospitals reported shortages and the White House kept wasting time talking about the need for a corona diagnostic test. Meanwhile, China was testing and South Korea had tested 100,000 patients by the end of January. A German company offered viral test kits, which were apparently rejected because they were not FDA approved.

Even in the face of death, officials were willing to incur further delay. Is this a sign of American exceptionalism, rejecting the notion that other people have knowledge and wisdom as well? People were asked to wash hands and avoid contact with sick people. Facial masks were indiscriminately argued against in a misguided message that they were only needed by hospital personnel and first responders. N95 masks for sure, but simple facial masks or protection? Sneezing had to be done into the elbow, please. Even as the quarantine was imposed, facial barriers were argued against again and again.

I asked in frustration why the focus was on coronavirus testing and statistics of the spreading pandemic and not on the

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tunate that even the medical profession has not been forceful enough in promoting the value of a facial barrier, until now just prior to publication of my report.

Since when is the concept of preventing a virus to escape from the mouth or nose by means of a barrier unnecessary and not to be recommended even in conjunction with social distancing? Do we still need a double blind study? What could be more efficient than to try to stop the spread at its origin. Is this not common sense?

Can we as physicians stand idle when a President first downplays the pandemic, and, in the midst of the quarantine, considers opening up the economy, because the cure is worse than the disease, when the President declares that he still will not use a mask although the NIH and CDC are finally advocating its use?

While our colleagues and nurses are fighting for patients lives and their own, we must stand together while keeping a social distance and all wear a facial barrier. It is common sense! most simple form of protection for all people at minimal cost: a facial barrier. I contacted our Governor, the White House Coordinator of the Corona Task Force, the Surgeon General, local health officials, Congress people and others. My local contacts replied but wished to adhere to the official science based party line. I contacted a large supermarket chain and was told the same, while adding that they did not want to sow panic. Meanwhile, the tellers were in close distance with a two way street of potential virus exchange. The focus on the shortage of N95 masks, while a priority, should not have interfered with a recommendation of simple facial barriers for the general public, be it a surgical mask, a scarf, bandana or a self made one.

Tests have never prevented an infection nor cured a disease.

They are necessary in the long run but the discussions have obscured the real issue of immediate prevention. Social separation became the order of the day, stay and work at home, close businesses and shops, paralyze the economy. Meanwhile, the White House Corona Task force was exempting itself from social distancing and on full display on the TV, huddled together with up to 8 people or more. What a pitiful example for the world to see. Listen to my words, do not look at my deeds!

Meanwhile in all of the Orient, people continued to wear facial masks while we were exceeding their number of deaths.

Their schools and factories are already reopening with all people still wearing facial masks and adhering to hand hygiene. If our people had been told that a facial barrier would not only offer some protection for self but prevent spreading the virus to others in case they were a carrier, I am convinced the American public would have risen to the occasion.

Dr. Fauci reiterated that only sick people or people who had been in contact with a sick person should wear a mask. It begs the question: When does an asymptomatic person feel sick and how does one know when he/she has been in contact with a sick person or carrier? Chinese physicians arriving in Italy to lend a helping hand were appalled when they saw people not wearing masks. As a physician, I was disturbed to hear that Dr. Fauci had mentioned that a lot was discussed behind closed doors but that he had to walk a fine line. What line? A political one? It is unforWWW.SFMMS.ORG

Eric Denys, MD, a retired neurologist, has been a former SFMMS board member and delegate, President of the San Francisco Neurological Society, Associate Clinical Professor Neurology at UCSF with over fifty publications, and received the UCSF Charlotte Baer Award for distinguished service and teaching and the Royer Award for Contributions to Neurology.

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COVID Crisis and Response

THANK YOU SAN FRANCISCO From An ICU Physician

Richard Wang, MD Dear San Francisco: In my seven years as a practicing physician, I have never taken care of more and sicker patients than I have now.

Caring for critically ill patients with COVID-19 is demanding and laborious. For many patients, even a ventilator does not provide enough support. Often, these patients can maintain adequate gas exchange only if they are positioned to lie on their fronts. Turning critically ill patients from their backs to their fronts is no simple endeavor. In addition to the tube in their throats that is connected to the ventilator, these patients often have catheters in their veins, arteries, noses and bladders — all attached to lifesaving monitors, pumps or drains. None of these must snag or tangle.

“Proning” a patient requires multiple nurses and respiratory therapists — each in layers of personal protective equipment — to act in a synchronized and coordinated fashion. Once on their belly, a patient needs careful positioning and repositioning to prevent the bed sores on their face and elsewhere.

A patient’s head is turned to one side. One arm is stretched up and one leg is slightly bent. A few hours later, the head is turned to the other side. The other arm is stretched and the other leg is bent. It is as if the patient is engaged in an hourslong, stop-motion forward crawl. For this reason, the roving team of nurses and respiratory therapists who position and reposition patient after patient have earned a special respect and moniker. They are our “COVID Swim Team.” Positioning patients on their fronts is one part of the manifold complexity of care for COVID patients in the intensive care unit.

At all hours of the day and night, the intensive care unit is a hive of activity. Everyone is in constant motion, deliberate and purposeful. It feels as if the entirety of the institution has a singular focus, and we are the tip of the spear. Everyone has stepped up their game: facilities and maintenance staff, supply chain managers, respiratory therapists, laboratory technicians, nurses, physicians, researchers and administrators.

The positive morale is tinged with darkness. There is sadness and grief for those patients who have died and for their families who could not be at their side. There is also the sobering realization that things could have turned out very differently.

Unlike in China, Italy and elsewhere, our intensive care units, while busy, are not overwhelmed and overrun. We can dedicate maximal efforts to each patient — even turning them onto their fronts when they need it, and then repositioning them, again and again and again and again, until their lungs heal.

Much is being written about how San Francisco has, so far, flattened the curve. Undoubtedly, there is an element of luck.

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have made a difference. But the most important person in this communal team effort? You. To all of San Francisco, I write this missive to express my deep and abiding gratitude.

Many of you are suffering the consequences of the massive economic downturn. Others of you continue to staff our essential businesses — grocery stores, gas stations, nursing homes — with bravery and calm and grace. Over our ubiquitous masks, everyone has had to learn how to smize (smile with our eyes). Everyone has had to endure the exquisite anxiety of not knowing exactly where we might find our next roll of toilet paper.

In your moments of frustration, sadness, anger and despair, I hope you remember this: From my view in the intensive care unit, your daily sacrifice has literally saved lives, especially among the elderly, the frail and the chronically ill. These saved lives are counted in the number of people who never come to the intensive care unit in the first place, because they were never infected, because the chain of transmission was broken by the humble, heroic acts of social distancing and sheltering in place, which all of us San Franciscans have committed to, as a community.

We will soon enter a new phase of the crisis. In some ways, what comes next may be even harder than what came before.

Life may stutter and syncopate. We may take two steps forward, only to take one step back. And yet — in this city that has played an outsize role in the public health history of the United States — I am confident that we will do the right thing.

As we did before, some decades ago during the darkest years of the AIDS epidemic, so have we pulled together today. We have found — as the slogan goes — our Strength in Numbers.

San Francisco, I could not be prouder to serve you and stand alongside you.

We will come out of this together, stronger than ever.

In solidarity.

Richard Wang is assistant professor of medicine at UCSF. He is an attending intensivist at UCSF Medical Center, San Francisco General Hospital and the San Francisco Veterans Affairs Medical Center. The views expressed above are his own and do not represent those of his affiliated institutions. This piece appeared in the San Francisco Chronicle on April 19, 2020.

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CORONAVIRUS:

Bay Area Medical Practices Face Uncertain Future as Patients Disappear

Photo: Nick Otto / Special to The Chronicle

Michael Cabanatuan, San Francisco Chronicle

Dr. Man-Kit Leung, an ear, nose, and throat doctor, in the empty waiting room of his office in San Francisco.

As the coronavirus crisis surges, many private medical practices in the Bay Area have seen a steep drop in patients and revenue that could force them to go out of business, leaving their workers — physicians, nurses, assistants and staffers — unemployed and patients in the lurch.

The term private practice may conjure images of the lone family doctor who runs his or her own office with a nurse and an assistant, but it covers everything from practices with a handful of physicians and staff to those with hundreds of doctors and staff members. They include specialists and surgeons as well as primary care doctors. The slowdown is also affecting dentists and optometrists and ophthalmologists.

“Anyone who isn’t in the hospital has pretty much shut down to all but emergency conditions,” said Andrew Tomlinson, a San Francisco ear, nose and throat doctor who serves as a delegate to the San Francisco Marin Medical Society. “Patients stand to be stranded,” he added.

While it may seem counterintuitive during a medical crisis, many people who work in private doctors’ offices, including physicians, are being furloughed as a result of declining business. Many patients are staying home and canceling routine or non-urgent medical appointments during the shelter in place — often at their doctor’s direction. Most elective surgeries have been canceled and many practices have stopped nonessential appointments, including checkups of patients with chronic conditions. Some offices have drastically reduced hours or even closed. This has led to the same financial challenges many small businesses are facing.

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“We’re like a restaurant that’s now only doing takeout,” said Brian Grady, a San Francisco urologist and medical society president. “We still have rent to pay, employees to pay, but fewer patients and less revenue.” He suggested that “a few dozen” of the society’s 2,000 members across two counties will likely close their doors. That number, of course, could be greater.

“It’s probably more than you would think,” said Dustin Corcoran, CEO for the California Medical Association. “It’s not just small practices. We are hearing of practices with as many as 250 doctors that are suffering as well. These are sophisticated operations.” In the East Bay, Joe Greaves, executive director of the Alameda-Contra Costa Medical Association, said that business in most outpatient practices “plummeted to about 30% of normal,” and several urgent care centers have either closed or consolidated. At Michael Schrader’s internal medicine practice in San Francisco, they’ve only seen about 10 patients, all in need of urgent treatment, in the past three weeks, he said.

Man-Kit Leung, an ear, nose and throat doctor in San Francisco’s Chinatown, said he worries that many practices will close, particularly in underserved communities. “That’s my fear,” he said.

His practice, San Francisco ENT Medical Group, should stay afloat, though it may require the use of Small Business Administration loans and some lines of credit, he said. The number of patients it’s seeing is about 10% of normal. “We’re furloughing staff, writing letters asking for rent relief, trying every way we can to avoid paying bills,” Leung said. “The physicians are forgoing salaries and pay while we’re trying to keep paying our staff.”

Closed medical practices could have immediate and longterm effects after the coronavirus crisis ebbs. After stay-athome orders are lifted, practices expect to be hit by what some are calling “a second surge” — a flood of patients who’ve deferred regular medical appointments or put off treatment for less-serious injuries. “Are all those practices going to be there when we need them when we get past the COVID surge?”

Corcoran asked.

Telemedicine — video appointments via smartphone or computer — could help practices keep serving patients during the crisis, doctors say. But many practices lack the equipment or the expertise, and telemedicine visits often pay less than office visits. Doctors’ groups are scrambling to help smaller practices to set up telemedicine, Greaves said, and Schrader said the number of practices that go under may depend on “whether we can adapt to a new model by using telemedicine if the pandemic lasts months.”

The Asian American Medical Group, a collection of 250 physicians in San Francisco and northern San Mateo County, was continued on page 12 MARCH/APRIL 2020

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COVID Crisis and Response continued from page 11 prepared for the shelter-in-place orders with an approved telemedicine app. The app and FaceTime have allowed the group to keep seeing patients, many of whom are older and many of whom have underlying conditions like diabetes or heart disease.

“That way we maintain our contact with the patient, have a faceto-face connection and can do a visual examination,” said Eric Leung, an ophthalmologist and the group’s chairman.

Physicians say they also need financial assistance, starting with breaks on rent and better reimbursements from Medicare,

Medi-Cal and health care plans. Stimulus legislation contained some aid to doctors, Corcoran said, and doctors are eligible for small business loans, but that might not be enough. “That bill is going to come due for us as a society,” he said. “We’re going to need our physicians, our clinicians, ready to go the minute that we’re able to get back to business. We don’t need physicians and nurses and other medical personnel worrying about their financial future when we’re sending them to the front lines of a health crisis.”

Michael Cabanatuan is a San Francisco Chronicle staff writer.

TAKING GOOD CARE –OF OURSELVES TOO Jessie Mahoney, MD

As healthcare providers, we are facing unprecedented challenges. Thank you to every one of you for your valuable contributions.

Wellness and self-care have never been more important than they are in this moment. We must care for patients to the best of our abilities but we must also care for ourselves. If you sacrifice your own physical and emotional health, who will be left to care for those in need?

Please put on your own PPE and metaphoric oxygen mask first. Sleep, eat healthy foods, breathe deeply in safe spaces, connect with colleagues, and do the internal work to actively work to manage your own stress, anxiety, and fear. Do it for you, do it for your colleagues, do it for your family, and do it for our patients.

Many physicians have been utilizing coaching tools as a way to support their mental and physical health during this unprecedented time. When there is so much happening that is out of our control, thought-work and coaching are a tool that can give you back some control and make a difference in your experience of situations like this. Choosing your thoughts is where your power and control lie. Choose and practice ones that serve you so that you can show up for this challenge as the best version of yourself. Do it for you, do it for your colleagues, do it for your families, and do it for our patients.

Some Coaching Tips to Try:

Notice, allow and accept the anxiety, fear, vulnerability and panic.

Of course, you feel this way. You are human. As physicians we often judge ourselves for having feelings such as these. Try instead to cultivate nonjudgemental awareness of your feelings.

Pause and be present with whatever feelings you have. When you resist them, they grow stronger. Consider bringing your anxiety, fear, and vulnerability along with you — ­ by your side but not in control.

Notice and focus on where you have abundance (as opposed to scarcity). You have an abundance of knowledge, training, caring compassionate and talented physician colleagues and medical teams, community family, love, compassion, and teamwork.

Notice and focus on what you can control. Your preparedness, your sleep, your voice. You also have full control of what is going 12

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on in your head. You can choose to make it more or less difficult by changing how you look at it.

Decide how you would like to feel about the current circumstance of being a physician in a pandemic. Many physicians want to feel calm, prepared, hopeful, deliberate, focused, purposeful, at peace, compassionate.

Below are some helpful thoughts/mantras gleaned through coaching your physician colleagues. Feel free to borrow any of them.

I am human.

I am not alone.

Every physician is feeling anxious.

I am doing what I can at this point in time.

I can do today today.

What is most important will get done.

I can be scared and anxious and still lead by example.

I have skills and knowledge to make a difference.

I have had years of training to prepare me for this.

I have done everything I can to prepare.

I am part of an amazing community of physicians working together.

Our physician voices have never been as powerful.

Physicians are coming together like never before.

Each of you can harness the power of helpful thoughts as a source of strength in the weeks ahead. Take some time to find the ones that are helpful and truly believable to you. And choose to think them often.

Honored to be among you. Available to support you.

May you all be well.

Jessie Mahoney is a Pediatrician, a Physician Coach, and a long-time Physician Wellness Leader. She served as a Chief of Physician Health Wellness at TPMG for many years, is the former Chair of the CMA Subcommittee on Physician Wellness, and she is the current Chair of the SFMMS Task Force on Physician Wellness.

She currently is serving her colleagues as a physician coach helping those who are successful on the surface yet struggling underneath. She can be reached at jessie@jessiemahoneymd.com.

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COVID-19: FLASHBACKS FROM THE EARLY AIDS ERA A Talk with HIV Pioneers Drs. Molly Cooke and Paul Volberding Interview by Steve Heilig, MPH Drs. Paul Volberding and Molly Cooke are renowned pioneers in the response to the AIDS epidemic. Both UCSF Professor of Medicine, their achievements, honors, titles and contributions are far too long to list here but "just a bit:" Molly Cooke, M.D. FACP, Professor of Medicine, is the inaugural Director of Education for Global Health Sciences across the five schools at UCSF (Medicine, Dentistry, Pharmacy, Nursing, and the Graduate Division.) She is a past-President of the American College of Physicians.

Paul Volberding, MD, Professor, Medicine, Epidemiology, and Biostatistics, has been Chief of the Medical Service at the San Francisco VA Medical Center, vice-Chair of the UCSF Department of Medicine, and Director of the UCSF AIDS Research Institute.

They are both members of the National Academy of Medicine (formerly the Institute of Medicine) of the National Academy of Sciences.

They are also married to each other. We are longtime neighbors and I was able to find them sheltering at home, although still busy. When I asked if the COVID pandemic was triggering any memories of early HIV, the response was "We get asked that a lot." So we decided to talk about it for publication, and here are excerpts from that wide-ranging chat, which took place in late March.

Molly Cooke, MD, FACP

Paul Volberding, MD

PV: But now with COVID we're seeing everybody at risk all over the world, from politicians like Boris Johnson or Prince Charles, and our own esteemed pulmonologist John Murray just died of it.

There's a big difference in virulence though.

MC: Right, with HIV we were seeing 100% mortality. But that doesn't mean COVID is not also very serious.

PV: Yes, I was just finishing my training and started on the faculty on July 1, 1981 when we saw the first KS patient.

PV: Right, the unpredictable mortality of this one is not reassuring. It began with the perception that only old people were dying, but clearly that is not true. So I don't know why anybody would be very relaxed about getting this virus.

The infectious agent wasn't yet identified. So there was a period where the routes of transmission weren't known. I still recall people worrying about aerosolized and mosquito transmission for some time.

PV: A good friend of ours, an HIV doc, got this from his son and they are both sick, with the son having minimal illness and the father much sicker. Nobody can assume they are immune.

You were both still training at San Francisco General Hospital when HIV was first spreading and showing up clinically.

MS: And I was a chief resident in 1980-81, and we saw patients who had HIV - in retrospect - in increasing numbers through my chief year.

PV: Right, but with COVID the identification of it was much quicker this time, like a matter of weeks. So much of the technology we had had been just developed, and now they can sequence things within a week or so.

MC: To just state the obvious, the huge difference is basically restricted versus unrestricted transmission. As even as anxious as we could get with HIV early on, we could kind of talk ourselves down - it turned out we weren't getting it via breathing on Muni, for example.

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But we have people saying we should go for herd immunity by exposing everybody.

I've lived my whole life on the California coast and about half a dozen times there have been tsunami warnings, where we wonder how big and when it might hit, with much anxiety. This waiting for the big surge to hit feels a bit like that to me. How about you?

PV: I don't get the sense of much of a true (San Francisco) crisis yet, and it might be magical thinking, but kind of the hope that I've got, which I think is common, is that as we were among the first to institute the shelter in place policies, maybe we blunted it.

But then the doubt comes in with this really transmissible virus... continued on page 14

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COVID Crisis and Response MC: The asymptomatic transmission makes it really troublesome, especially without much testing. So a lot of the things that UCSF and others are doing are probably going to prove to be only partially effective in the bigger picture. They've set up respiratory system centers as they don't want people with COVID fever showing up in my practice. What PPE is available will be prioritized to those places, but with asymptomatic transmission we're going to have infected patients getting through anyway.

PV: And we've just seen that patients got infected at Laguna Honda, and there and at the VA nursing home, with mostly older and immune-compromised patients, is a frightening scenario.

Back to early HIV days, testing, or lack thereof, was a big issue then too.

MC: There was a lag of about four years then before testing, with it looking like Hep B, which was not reassuring as that's a well-recognized risk for clinicians. We had needlesticks, but no test, so if they had an exposure that was potentially significant, there wasn't a damn thing you could do about it.

PV: Once we had a test for HIV, there was some serious epidemiology done, and we had an early vaccine trial, and the community helped organize random community testing, and that was where the real numbers started. With COVID the testing is of mainly asymptomatic people so we don't have any real idea of the denominator yet. We really need some good epidemiology, and don't get me started but the CDC has dropped the ball on this front.

They've been absent at a lot of federal briefings and such, but one factor is that they've been being gutted in recent years. The issue of effective therapy was a big one for HIV and is again now. What did it feel like for you in those years where there was no curative interventions for AIDS?

MC: One striking thing was how young how many of the patients were. With truly old patients it often feels less tragic, but these were many deaths of people in their thirties. And HIV then was so mutilative, with KS, abject dementia, blindness from CMV retinitis, and many things that were just horrible to see. I haven't seen really bad COVID yet, but dealing with ARVS is known medicine. So in some ways COVID is worse regarding transmission to anybody, but with AIDS we had a horrible constellation of conditions.

In both cases stigma was and is a big factor.

MC: Yes, it seems to be happening again, regarding race.

PV: Stigma was and unfortunately still is a big problem with HIV, and our President seems to be just making that worse with COVID. You both were training students a lot then, and now. How did or does a pandemic impact medical education?

PV: Molly was training more then, but I've heard her doing resident preceptorship and trying to teach patient care over the internet now, and that seems challenging.

MC: Yes. Looking back I don't recall any move to separate trainees from the HIV patients. There were those who were concerned about fear of the virus then, where we heard that some residency candidates didn't want to come here for training.

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But I never really saw any evidence of that. But things are quite different now. Overall I think it's a different era where the goal is to be more humane and kind to medical students. And we could find a way to get early participation, such as to train first-year students to do phone screening and so forth. You're not going to have them managing ventilators but we could make them feel they are part of the team from the start. I think it would be a mistake to forego that because of risk. So much of our experience with HIV was a profound forge for our professional values. But much of this now is the overall disruption where we are really not seeing patients in person; I just did two onsite provider shifts in the general medical practice where I didn't see a single actual patient in person. But that's likely to change in the coming weeks if the projections are accurate.

PV: At the VA we are now encouraged to see all our patients via video or phone. At UCSF video visits went from about 2% to 50% in a matter of days. But I don't think we really know how to best train people in this telemedicine environment yet.

MC: We absolutely don't. You just can't teach everything via didactics. The true clinical aspect is kind of important! It's definitely a work in progress. The questions include what technically can a student learn, what morally can they learn, and how much can they contribute - and what the risks might be to the student.

But really, one of the very first papers I ever wrote was stimulated by HIV, about how there have always been risks to being a clinician but when we have a lull, we forget about it. Think about all the physicians have gotten tuberculosis through the years, for one thing. That's part of what we do.

PV: And this is complicated by concerns about what should be or is not being done to minimize the risks as much as we can.

And thus the debacle about insufficient PPE, which is really upsetting a lot of people, and rightly so.

MC: Yes, and the current pandemic is certainly a reminder of occupational risks, and will drive a more rapid development of things like telemedicine, which people have been talking about for years.

PV: I should say that I had a telemedicine visit with my own doctor the other day, from his home office, and it was fine.

MC: And they remind us to be "professionally dressed from the waist up"!

This pandemic has spurred some ethical debates too.

The specter of insufficient ventilators has prompted development of triage or rationing policies, and our Sutter ethics program has just drafted a document on this for that system and CPMC.

PV: I just read of Northwestern in Chicago considering a policy where they would not resuscitate any COVID patient even if they or the family had wanted it, due to risk, which sounded appalling to me.

MC: At SFGH there was a lot of discussion about ICU access criteria for people with HIV. The argument was they had an underlying lethal condition, so what would the benefit be. But we never did limit it in that way.

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PV: There was a study from UCSF that showed the outcome of ICU care for HIV patients was poor, but not zero. 25% of those who required mechanical ventilation survived to discharge. But when I was in London at St. Mary's where they had lots of AIDS patients they used that data to justify not putting them into the ICU. So it's a matter of perception and judgment.

MC: What I've read from Northwestern and elsewhere is the proposal that if the predicted benefit of an intervention such as ventilation is 1%, don't do it. But what if it's 10%? And what if they have another organ system or two down, such as renal failure - that's very likely to be a bad outcome. These situations fall along a continuum, and so far there's not really enough data to predict things. And one proposal is to get more people to voluntarily decline ventilation, which some people likely would, especially if they were, say 95 years old.

PV: Well, I'd be pretty unhappy if I were facing this and somebody said up front "We're just not going to ventilate you due to your age."

Right. Truly informed consent and wider use of advance directives seems crucial. And most clinicians don't want to make those decisions, so this is why the draft policies tend to say a group other than the attending physician should be asked to do it. I'm on ethics committees and can see that scenario coming. Hopefully we won't have to.

MC: Yes. I remember being a resident when a paper came out titled something like "Foregoing interventions in burn patients when survival is unprecedented," where the proposal was that rather than doing all the things done to help severe burn patients, they could be told "We won't do that, but we can treat your pain with morphine while you say goodbye to your family" and such. And I recall just being blown away by the concept then.

What we still don't do much in this country now is say 'further treatment is futile and whether or not you and your family want it, we won't continue with that."

And developing effective treatment?

PV: That tends to take even more time. The idea that we can just take a drug like chloraquine off the shelf as a magical antiviral is not convincing. And Remdesivir is an IV drug for inpatients, and who knows if it might work for asymptomatic patients anyway.

So we're a long way from what works.

But there's been very positive action locally at a minimum.

UCSF has done amazing work, with 7,000 people on some of their virtual educational presentations. One thing we learned with HIV is that we need to appreciate and acknowledge that people are afraid. And tell people what we do know and what we don't, and that we'll tell them what we learn. So they can have a center of public health people that they can trust.

That brings up my last question, a "political" one I guess.

Back when HIV was new, President Reagan was infamous for inaction and not even mentioning AIDS for years. Any memories triggered there?

PV: Oh it's just torture to watch those presidential press conferences now. I know Tony Fauci very well and have worked with him for decades, and to see him have to stand there while Trump goes on about "I've got a good feeling about this" or "Let's open the beautiful packed churches by Easter Sunday" and so on, the level of ignorance and worse than that is‌."

MC: It IS ignorance, but it also seems malignant. And shameful.

When a reporter asked Trump what he would say to people who are afraid, he just said "I think you're a terrible person." That's the opposite of what one should say.

It seems a whole ethos of anti-expertise has taken over.

MC: Right. I hate to say it, but I'd take Reagan back in a heartbeat.

We did develop "nonbeneficial treatment" guidelines at the SFMMS many years back, and they have been adopted in some places and have been useful. Also regarding treatment and prevention, there is neither an effective antiviral nor a vaccine for COVID yet, and for HIV the former took 15 years to develop and the latter still doesn't exist.

Does this precedent concern you?

PV: Oh it's very scary. There's so much we don't know yet about this new virus. Will there be another wave in the Fall, as there was with flu in 1918? Will infection mean immunity, or not? And so on. There's so many uncertainties.

The time period being thrown around for a vaccine these days is 18 months, does that sound realistic to you?

PV: That's a very aggressive timeline. Beyond the biological lab work, you'd have to do a trial of first responders I guess, maybe nurses and docs. It takes a lot of time.

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COVID Crisis and Response

Q&A: PATRICE HARRIS, MD Shannon Firth, MedPage Today As you mentioned, increasing diversity in the workforce is a priority for you. In panel discussions, you've shared how medical school was initially a bit more challenging than you expected.

Harris: When you start at a medical school, it's very helpful when you have someone who can show you the ropes. But, as a first-year medical student, I didn't have anyone -- no relatives or even close friends -- who had been to medical school. And my classmates, they had relatives, cousins, friends, who had been to medical school recently.

In my first year, we had weekly quizzes, and I was not doing well on those quizzes and my reflexive response was "I must not be as smart as my classmates. I must not belong here."

But then, I don't remember how I found this out, there were old tests and old quizzes that were available and the other students had them. This wasn't breaking any rules, and it wasn't a secret.

I just didn't have the information.

At any rate, once I found out, I said, "Can I have copies of those?" and my colleagues said, "Absolutely." Once I had copies of the the test I started to do well. So I did belong.

As the first African-American woman to lead the American Medical Association (AMA), Patrice Harris, MD, is fiercely committed to promoting health equity and diversity in medicine. And as a child psychiatrist, Harris is also a strong advocate for addressing childhood trauma and integrating mental health into traditional healthcare.

What are your core priorities as AMA president?

Harris: Three things I want to highlight while I have this platform are: Number one, the importance of the integration of mental health into overall healthcare. Number two, increasing the diversity of the physician workforce in the service and in our goal for health equity. And number three, the importance of adverse childhood experiences (ACEs) and trauma.

AMA has a strong policy around ACE and trauma-informed care, but it's up to all of the stakeholders in the community, the school system, and pediatricians and others who see these young children, to deliver on them.

Once we screen, the physician community needs to make sure that the broader community has services available for the children.

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Is it true that your guidance counselor recommended you go to nursing school, even after you said you wanted to be a doctor?

Harris: I knew I wanted to be a physician since the eighth grade but didn't know how to get there.

I went to the advising center and said, "Hey, what should I major in if I want to be a physician?" and I was told, "Go to nursing school." And I did apply to nursing school and I got in, and I was sitting at orientation at the end of freshman year saying, "This is not my dream." So, I said, "Let me take a breath."

I knew I loved my Psychology 101 class. So, I said I'll just major in psychology and figure it all out.

Ultimately you chose a career in psychiatry, where you're exposed to all aspects of mental and behavioral health problems. As head of the AMA's Opioid Task Force, how do you balance the tensions between the pain community and the addiction community? Do you think the CDC's opioid guidelines exacerbated those tensions?

Harris: We were worried back then at the beginning that the CDC guidelines would be misinterpreted and misapplied and that legislators, regulators, and pharmacies would then use those guidelines to defend limits – pill count limits, and dosage limits. It gives us no pleasure to know that we were right.

From our standpoint there's been no push and pull. We want the balance. We were very supportive of the HHS Pain Task Force. When folks said, "Doctors, reduce the number of opioids," we said, "Absolutely." We want to be judicious about prescriptions. However, patients will have pain. As we said at WWW.SFMMS.ORG

the beginning, we need to make sure that alternatives to pain management such as physical therapy are equitable alternatives to pain and not just alternatives on paper.

What policies do you believe would increase access to opioid use disorder treatment? Does the AMA support getting rid of x-waivers for buprenorphine? Do you support safe injection facilities?

Harris: We are on record as recommending elimination of the need for the waiver. Currently, you can prescribe buprenorphine for other indications, but not for substance use disorder.

Regarding safe injection facilities, we encourage pilot sites and learning from those pilot sites.

What is the AMA doing to address gun violence?

Harris: Physicians see the immediate aftereffects of gun violence, from the trauma surgeons and the anesthesiologists. And people like me, as a psychiatrist, we see the long-term effects and the post-traumatic stress disorder. We don't get enough media coverage about that. We were in Orlando soon after the Pulse nightclub shooting in June 2016. So at that time, we reaffirmed that gun violence is a public health issue. People say, "That's jargon," but what that means is that we need research.

We need to look at primary prevention. As physicians, if I want to recommend something to my patients about gun safety, I want those recommendations to be based on the science. Where do we get the science? From the research.

We also support background checks and we support extreme risk protection orders.

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Congress is currently debating different versions of legislation aimed at stopping surprise medical bills. What is the AMA's position on how to resolve this problem?

Harris: From our perspective, our number one priority is to keep the patient out of the middle. Number two, we want to make sure that physicians have a level playing field as they negotiate with insurers, and that's why we believe that the arbitration and mediation piece is critical. We also don't believe that insurers should do the benchmarking. We think that that is not a level playing field. Finally, there are issues around network adequacy. In many ways, not in all cases, but often that's at the core of why these unanticipated bills come up in the first place.

Whether or not that's in the legislation, that has been a concern for us and we believe that should be a part of the conversation.

Harris has been on the AMA's Board of Trustees since 2011 and was inaugurated as president last June. She earned her bachelor's, master's, and medical degrees at West Virginia University, and she completed her residency and fellowships in child and adolescent psychiatry and forensic psychiatry at Emory University School of Medicine in Atlanta, where she is now based. Harris has held leadership positions at the American Psychiatric Association, Georgia's Psychiatric Physicians Association, and the Medical Association of Georgia's Council on Legislation. MedPage Today News Editor Joyce Frieden contributed to this article.

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COVID Crisis and Response

CLIMATE CHANGE, PUBLIC HEALTH, AND “GREEN” MEDICINE Mary L. Williams, MD Climate change, global warmi n g , a n d g re e n h o u s e g a s emissions do not threaten only our way of life on this planet.

They also have very specific and negative consequences in the area of public health. Here we will outline some of those consequences—with an emphasis on its effects on our skin—and then address ways in which physicians can raise awareness and also reduce the considerable environmental footprint of the medical industry itself. Our skin has developed an admirable array of defenses over time through the process of evolution.

But none of those defenses are perfect. We will look briefly at how climate change is challenging skin’s defenses against infectious diseases, skin cancers and heat stress.

Insects and Infectious Diseases

Evidence abounds that our warming climate is changing the landscape of infectious diseases, which are growing at an alarming rate due in part to expanding habitats for disease-carrying vectors, including fleas, mosquitos, sand flies, and ticks.

Insect populations are both expanding and exploding, as are cases of Lyme disease and West Nile Virus. The lone star tick is also expanding its range: no longer confined to the Southeast, it now is found in large numbers as far north as Maine and as far west as Texas and Oklahoma. Although it does not carry Lyme disease, it can cause a rash resembling erythema chronicum migrans, can be a vector for Erhlichosis, and, uncommonly, can induce a severe form of allergy to mammalian meats. According to the Centers for Disease Control (CDC) these vectors of disease have increased in distribution, range, and abundance over the last 20 to 30 years, largely due to warming temperatures.

The Aedes genus of mosquitos, formerly found exclusively in the tropics, is now endemic in the Southeastern United States and migrating northward to New England. Cases of dengue fever —one of the severe viral illnesses carried by this genus — have been acquired in Hawaii, Texas, Florida, and beyond. Other viruses of concern that it transmits are Zika, Chickungunya, and Yellow Fever. Where the mosquito resides, the 18

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viruses it hosts can be expected to follow. Our warming climate is similarly leading to a resurgence of sand flies in Southern California and Texas, migrating up from Mexico. These sand flies can carry the mucocutaneous form of Leishmaniasis that produces disfiguring ulcerations, and for which highly effective and nontoxic treatments are lacking. In Texas, presently, endemic cases of Leishmaniasis are more common than those acquired outside the US.

Warming Oceans and Flooding

O u r wa r m i n g c l i m a t e is leading to rising tides and increased hurricane activity. The resultant flooding brings with it Vibrio vulnificus, a naturally occurring and extremely virulent bacterium of the warm, brackish water in coastal areas, estuaries, and flood zones. V vulnificus can lead to gastroenteritis, blistering dermatitis, and can be lifethreatening to those with compromised immune systems. Our warming oceans are also leading to an increasing presence of jellyfish and their associated stings, called envenomations. One type of jellyfish found in the waters off of Australia has venom that can cause neuromuscular and respiratory paralysis. There are approximately 150 million jellyfish stings annually, and while most are not fatal, they are typically very painful.

Sun Exposure, Skin Cancers, and Pollution

The current skin cancer epidemic has been largely caused by changes in human behavior leading to greater exposure of the skin to ultraviolet light. As the world’s climate warms, it is anticipated that time spent out of doors, exposing skin to sunlight, will increase, particularly among children. This alone is likely to augment the skin cancer epidemic of the future. But in addition, in decades past, flouro-hydrocarbon pollution generated “holes” in the stratospheric ozone layer that have permitted the increased penetration of harmful ultraviolet B (UVB) radiation into the atmosphere, further fueling this epidemic. And, according to experts, these holes in the ozone won’t close for at least three decades, thus continuing to augment the toxicity of sunlight.

This stratospheric ozone is the “good” ozone. But the other WWW.SFMMS.ORG

one, the “bad” or tropospheric (or ground level) ozone may also contribute to the skin cancer epidemic. Better known as smog, this form of ozone is generated through the action of heat and sunlight on pollutants generated from the combustion of fossil fuel. Increased ozone pollution is a direct consequence of a warmer climate. This is of concern, because ozone is particularly noxious to skin and lungs, due to its potent pro-oxidant activity. In addition to its known contributions to asthma flares, there are theoretical reasons to anticipate carcinogenic effects on skin. Indeed increased air pollution, in general, can be considered a “fellow traveler” of climate change, since both are produced by the burning of carbon fuels. This is not news to residents of Sonoma County, who are now all too aware of the association between climate change and air pollution, as our seasonal wildfires consume forests and homes and poison the air. Indeed, we are just now learning how skin is vulnerable to a variety of pollutants, yielding more cases of eczema, acne flares, and other disorders.

Heat-Related Morbidity and Mortality

Another direct effect of our warming climate is increased numbers of heat-related illnesses and deaths. Indeed, heatrelated mortality is the most common cause of death during extreme weather events in the U.S. Even with a shift in mean temperature of only a few degrees, the number of extremely warm days increases disproportionately. It behooves all physicians to understand not only the signs and symptoms of heat stress, but also to understand the physiology of heat dissipation. Humans evolved a unique adaptation to manage excess body heat: the widespread distribution of eccrine sweat glands, the glands that produce a watery, salty sweat across the skin’s surface. Confined to palms and soles in our ancestors, these glands in humans densely populate the entire skin surface. Evaporation of their secretions pulls heat from our bodies, protecting our “sensitive” brains from overheating. But not everybody sweats equally. The elderly and the very young have higher internal temperature set points before sweating is initiated. Indeed, in children, this does not mature until after their teens. Hence, student athletes are at particular risk for heat-related illnesses during heat waves.

Chronic medical conditions, liked diabetes and renal failure, can also affect eccrine function. Moreover, many medications, particularly those with anti-cholinergic effects, can impair the sweat response.

“Green” Medicine

It is important for our medical community to recognize we have both an appropriate role and a powerful voice in increasing public awareness of the myriad health threats posed by climate change. But in addition, we who populate the House of Medicine must “clean our own house.” Medical care in the U.S. itself generates ~ 10 percent of the carbon released into our atmosphere annually. If our medical industry were a country, it would be the 13th most polluting nation in the world! These concerns can and must be addressed in order for us to speak in an authoritative, unified voice.

How to effect change in our own backyard by making the practice of medicine more “green”? Several excellent resources exist, including Health Care Without Harm (noharm.org) WWW.SFMMS.ORG

whose mission is “to transform healthcare worldwide so that it reduces its environmental footprint, becomes a community anchor for sustainability and a leader in the global movement for environmental health and justice.” Another excellent group, My Green Doctor (mygreendoctor.org), is “a free practice management tool used in 52 countries and 34 U.S. states by hundreds of medical offices, clinics, and outpatient centers. …to provide everything your practice needs to become environmentally sustainable.”

There is also the Medical Society Consortium on Climate and Health (medsocietiesforclimatehealth.org), which “brings together associations representing approximately 500,000 clinical practitioners to carry three simple messages: climate change is harming Americans today; the way to slow or stop these harms is to decrease the use of fossil fuels; and these changes in energy choices will improve the quality of our air and water and bring immediate health benefits.” Many of the medical societies we belong to are member societies of the consortium.

As physicians, our role in this crisis is to get involved -- now.

One can work with the Medical Consortium, as mentioned above, or work within our own medical societies to address these issues.

Attend the one of the many conferences on climate change and green medicine held regularly at UCSF. Look up and join forces with the Physicians for Social Responsibility (psr.org), which has chapters nationwide, and locally in both San Francisco and Sacramento. One of PSR’s areas of focus is to provide a strong medical voice for climate solutions, targeting specifically clean, renewable energy; fighting the practice of “fracking,” a technique employed to force the extraction of oil and natural gas; and providing health leadership on climate issues.

While it is true that physicians are today busier than ever, experiencing a high rate of burnout due to the demands of the EMR and a variety of other concerns, nothing is more important to our patients’ health, and to the health of the planet as a whole, than combatting the effects of man-made climate change. I would suggest that our community will find much greater satisfaction on the job by making climate health a top priority, because everything else we do is ultimately subordinate to that objective.

Physicians have always led the way, and protecting and preserving our planet for generations to come is the central issue of our time. Let us take all necessary steps to achieve that end, beginning with the healthcare industry itself.

Dr. Williams is a retired UCSF pediatric dermatologist who remains affiliated with the university. For more information, please see “Adapting to the Effects of Climate Change in the Practice of Dermatology,” co-authored

by Dr. Williams: https://jamanetwork.com/ journals/jamadermatology/issue/155/4.

Please also visit Dr. Williams’ website at: https://eliasandwilliams.com/.

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COVID Crisis and Response

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COVID Crisis and Response

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Read the full guidelines at cmadocs.org

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EXECUTIVE MEMO

Mary Lou Licwinko, JD, MHSA

Executive Director/CEO 1998-2020

A FOND FAREWELL After 21 years as the Executive Director and CEO of both the San Francisco Medical Society (SFMS) and the San Francisco Marin Medical Society (SFMMS), I am retiring. While it was not the retirement I had expected, including a retirement party cancelled because of COVID-19, I welcome the beginning of the next phase of my life while wearing a mask and sheltering in place.

In 1998, I was practicing health care law at a firm in San Francisco and feeling like the law firm was not the place for me when I came upon an announcement for a new Executive Director of the San Francisco Medical Society. The qualifications seemed to match my own, so I applied. My first interview was via a telephone call from Dr. Rob Margolin and the late Dr. Bob Lull. They were friendly and thorough, and I was immediately impressed. Dr. Margolin would later tell me that initially he and Dr. Lull took one look at my resume, saw I was a lawyer and threw it in the trash. A little later they reconsidered and took another look. I was a trash can away from ever having this position.

Over the years, Medical Society has experienced successes and failures. The 2002 dot-com crash was the first of several financial ups and downs. At that time, the SFMS owned a 16,000 square foot Victorian mansion on Sutter Street. The costs associated with this venerable building were paid for by offering rentals and catering services, events such as weddings and bar mitzvahs and renting out office space to not-for-profit organizations. The plan worked well for several years until the crash that seriously reduced the sources of income to support the building. When it became clear that the SFMS could not afford to keep the building, I took the unpopular step of presenting the financial analysis that led to the sale of the building in 2006. This turned out to be fortuitous given the financial crisis of the last part of the decade. In 2008 the real estate and stock market crashed, but SFMS had the financial reserves to weather the storm and subsequently has grown and prospered.

In 2017, SFMS merged with the Marin Medical Society (MMS) to form the SFMMS. Thanks to Dr. Peter Bretan, current CMA President and then MMS President, Dr. Dick Podolin, then SFMS President, Dr. Michael Kwok, Dr. John Maa and Dr. Man-Kit Leung, the merger was completed quickly and painlessly. In December 2016, I contacted Dr. Bretan, who within 24 hours arranged a meeting between the leadership of both organizations and within a week we were off and running.

We made the transition in 2017 and received our new Charter from the California Medical Association (CMA) in October of that year. The merger of the two organizations has proved beneficial to physicians of both counties.

Membership has grown and is at an all-time high. Over the years we expanded our ranks to include the physicians from the San Francisco Department of Public Health and Marin Health and Human Services. We are shortly looking forward to welcoming a large contingent of physicians from UCSF. This year, we have almost doubled the number of SFMMS delegates to the CMA House of Delegates and have added a second CMA Trustee seat. Last year, we worked to elect Dr. Bretan to the Presidency of the CMA. We were also proud that SFMMS CMA Trustee, Dr. Shannon Udovic-Constant, was elected Vice Chair of the CMA Board of Trustees.

SFMMS has become a vocal and powerful advocate for physicians and in the public health arena. We have tackled a myriad of issues over the last 21 years, often leading the way on unpopular issues like physician assisted dying. We early on championed smoking bans, e-cigarette legislation, and tackled sugar and immigration as public health issues. We have repeatedly represented physicians on scope of practice and reimbursement issues and have fought at least three times during my tenure to preserve the cap on MICRA. We are currently assisting the entire physician community, members and non-members, during the COVID-19 pandemic.

As this will be my last Executive Memo, I want to take this opportunities to thank all the SFMS and SFMMS Presidents, particularly 1998 SFMS President Dr. Bill Goodson, who worked so closely with me during my first year; all the Officers, Board and Committee members with whom I have had the honor to work; my hard working and clever staff and all the physicians I have served over the years. It has been an excellent journey. Be well and thanks for everything you do.

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DOUBLE ESPRESSO I’m the nurse on your hospital team. Want to find out more about you. Do you have any questions?

Yes. Could I have a cup of real coffee? Drinking that decaf is like putting a quarter in the pay phone and not getting a dial tone.

I’ll ask your doctor. What made you come here?

To die.

Please elaborate.

I know this lung cancer is getting bad. The pain is worse and can’t eat much. Then I got fever and chills, and came to the ER Have you been taking any medicine for the cancer?

I tried some, but they made me feel worse.

Do you still see the oncologist?

What for?

Do you have family or friends?

Sure, I have lots of friends, at the bar. But now drinking makes me sick.

Are you better here at the hospital?

Sure, now I can breathe, and the pain isn’t bad.

What’s your plan after discharge?

Don’t have a plan. A good cup of coffee would help me think better.

I’ll ask the doctor.

Hope you like this. When was your last coffee?

Just before I came here. It woke me up, and I knew the end was near.

Tell me about your life.

Was a merchant seaman for 40 years. Hard to be stuck on land, living in a fleabag hotel.

What about your family?

My mom and dad died years ago. Heard my brother is also gone.

Were you married?

Yes, but it didn’t last long. My wife and daughter are still angry with me.

Anyone else?

Only my granddaughter, Rosie. When she was a little girl, I took her to the zoo.

How old is Rosie now?

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Jeff Newman, MD, MPH She must be around your age.

Do you ever think about seeing her?

If I thought she’d be nice to me, like you, I might.

Do you know how to get in touch with her?

Hell no!

Maybe I can find her online.

Here’s the information for Rosie. Would you like me to contact her.

Sure. Ask her to bring a double espresso.

Rosie was sorry to hear you’re in hospital, and wants to visit tomorrow afternoon.

Sure, that’s something to live for.

So how did it go?

Rosie’s an angel like you. Brought that double espresso, and we talked for hours What does she do now?

She works in a shop to save up for art school. Already invited to exhibit her work!

Her boyfriend is talking about marriage. Told her I want to meet him - if I ever get out of here.

Thought you just wanted to die.

Now I’d like to hold off for a while.

The doctor will prescribe the rest of the antibiotic and more pain medicine, with an appointment to her clinic in a couple of weeks. We suggest you move from the hotel into a hospice.

Can I leave tomorrow? Want to go to the bank and transfer money to Rosie. Hope to live long enough for the opening of her show. Will ask her to invite you also.

Jeff Newman MD MPH is Adjunct Professor at the UCSF Institute for Health & Aging, and CoLead of the SF Palliative Care Work Group. He likes to write stories consistent with the William Osler adage: It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.

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Special Section: The First Clinicians' Conference on Medical Aid-in-Dying

LETTER TO A DEAD POET Lonny Shavelson, MD On a warm Valentine’s Day at UC Berkeley, some 300 frontline clinicians joined together in an expansive Spanish Colonial conference center for the first National Clinicians Conference on Medical Aid in Dying—to explore evidence-based knowledge about what until then had been considered more a political than a clinical issue. But 22% of the U.S. population now has legal access to aid in dying, making it a significant option for terminal patients—who are increasingly considering this with their bedside clinicians.

Doctors, nurses, social workers, chaplains, clinical ethicists, pharmacists, hospices and more have been providing and managing this care without formal training or knowledge of rapidly evolving best practices. The highly energized crowd in the soldout auditorium was a sign of their craving for knowledge about everything from prognosis to pharmacology, the role of hospices to evaluations of decision-making capacity, and what “self-administration” means in the real world.

But strangely, as the Board Chair and one of the lead organizers, I wanted to reign in the enthusiasm—or at least put it into perspective. From an on-stage podium facing 300 of my colleagues, here’s what I said to initiate the two days of clinical presentations.

I’m the founder of Bay Area End of Life Options, focusing on patients who are (and pay attention to this next word)considering aid in dying. And this may seem strange, given this conference—but I do not advocate for medical aid in dying. I do advocate for the best of end-of-life care for patients who are considering it.

Whether they complete aid in dying or not, these patients have unique desires and needs. And that, not just medical aid in dying, is the focus of this conference.

Let me tell you about a poet, Chana Bloch, now deceased.

Chana was terminally ill when I met her, at her poetry reading called “Dying for Dummies.” A cancer was eating up the muscles in

Chana’s leg, and she insisted she knew exactly how she would die— from a lethal medication, by medical aid in dying.

It didn’t happen that way. And a year after Chana died, I was asked to speak at a film about “Dying for Dummies.” Puzzled about what to say, I needed Chana’s help. So I wrote to her, a Letter to a Dead Poet, and read it to the audience. Here today in Berkeley, I’ll read that same letter, to explain the focus of this conference, which is about so much more than medical aid in dying.

Dear Chana, We talked, a lot, about your plans to take a poison potion—aid in dying—when your time came.

Do you remember telling me, “I'm very aware of trying to create a good death. For me, and for my husband and sons—to show them a good death is possible.”

Chana, think of that—responsibility. Your “good death” became another requirement. I’d heard that a lot from my patients. This good-death obligation is a side effect of the new right to choose how and when you will die.

We talked more, you and I, about how you get only one chance to die. No rehearsals, no editing, no rewrites. And we talked about how a predictable death, under your complete control—is not possible. No legislatively-permitted End of Life Option Act has made death—not a death. And no End of Life Option Act would stop your will, Chana, to live.

You said, “Once my cancer was declared incurable, treatments became my way to buy time. Having more time is always good.

Isn't it?”

And so I found you, months later, in a bed in the hospital, severely ill. You told me you were there to slow the cancer, to gain back weight and strength—to walk again. And then, maybe weeks later, you’d go home. You were so filled with hope, for more time, for less death.

We had the “how-you-die” conversation—a talk about how your specific death might come about. In detail. You had asked for that conversation, but then repeatedly delayed, as one treatment after the other bought you, with some expense, time.

Now, in the hospital, I explained that the treatments were highly unlikely to make you walk again; they were likely to end in the hospital, not at home. You might think, I said, about just going home, facing the now inevitable in your own bed. You said you’d think about it, talk with your husband and sons. And I left you there, still smiling, still hopeful, tethered to wires and IVs. You had bragged that your oncologist is also a jazz singer. Jazz is a hopeful sort of music, an improvisation that relies on faith. So is oncology.

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And you had joined your oncologist in an improvisation of hope.

But now you chose to go home, to improvise the ending. You didn’t want a single false note to this, your last poem. And as you cherished every moment, thoughts of that poison potion evaporated.

In spite of years of thoughtful planning for aid in dying, you played the final notes as they came to you. You found death, peacefully, no poisons involved.

And in that, Chana, you did teach your children, and all of us— that dying, as you said, is a lesson. That dying well is dying with attention to the moment.

Dying is not a prearranged event.

Do you fear, Chana, that you copped out? That after talking so much about the aid in dying you would choose—in the end, you didn’t do it? Do you think that somehow you got this wrong? That instead of taking a four-ounce cocktail of death, you tried for every last ounce of life—until, well, you simply died.

But wasn’t that really the goal? To have a good death? Death— is not a political statement, a statement of policy preferences.

Death comes in so many ways—and you don’t know which route yours will take, until it happens.

Does this sound like I am not in favor of the so-called “right to die,” or “death with dignity,” or the more accurately described “medical aid in dying?” Of course not. I do it all the time. I offer patients the four-ounce potion when they decide they have reached the end, not an ounce of good life left. But the supporters of death with dignity at times get—confused. They think there’s some monopoly process for a dignified death. But thinking that is, well, undignified. There are so many ways to die with dignity—and you, Chana, found yours.

I read this Letter to a Dead Poet to open this conference because I want to remind myself today–that we are not here to advocate for medical aid in dying. Rather, to accept the many routes terminally ill patients have to their deaths. Medical aid in dying is now certainly one of them, and I think it’s really important. But we who practice aid in dying have no monopoly on a good death; no corner on death with dignity. What we do have, and what I hope we’ll be demonstrating in these two days—is the desire to listen to the songs our patients are singing, and to follow their lead. That will, at times, mean providing medications to help them die. Or, not. There are many doors to death, and we’ll be focusing at this conference on just one.

But I hope we’ll have no illusion of an answer. We are only responding to patients’ independent decisions and desires. And those change as death approaches, even with the best of plans.

Our job, I think, is to dance while our patients lead, until their song has ended.

What we’re attempting today and tomorrow, is to understand a new and crucial part of end-of-life care. It is essential. But I hope we’ll maintain this larger perspective. The point is—we are providing care as people die, not just medications.

Thank you.

So let’s dispel a myth about aid in dying: That it is the best way to die; the most dignified way to die; the way you show yourself and your children that you still have—control. That you will die on your terms, not death’s.

How silly.

The lesson of your death, Chana, and there is one, is that the path to death is not, by any means, certain. Because in death, like in jazz, no one knows the final notes until they are, final.

So I would like my patients to learn from your lesson: To think about death, to talk about death, to face death head on. And, to make plans. Talk with your doctors and nurses; talk with hospices; listen carefully and make your decisions with care. But in the final moment—listen to the song your death is singing, and improvise the ending. Because you won’t know what that ending will be, for you, until that last note is played.

With love, and gratitude

Dr. Lonny Shavelson heads Bay Area End of Life Options, a Berkeley medical practice that offers advice and services to patients seeking aid in dying under the state law enacted in 2016.

Lonny

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Special Section: The First Clinicians' Conference on Medical Aid-in-Dying

A TRUE FIRST: MAINSTREAMING MEDICAL AID IN DYING Monique Schaulis, MD, MPH SFMMS co-sponsored the first National Clinicians Conference on Medical Aid in Dying. The conference was held in Berkeley on February 14 and 15, 2020. The SFMMS's Steve Heilig and Monique Schaulis attended and were on the organizing board of the event. The conference covered a broad range of topics related to end of life care and aid in dying, drawing upon the experience with the California End of Life Options Act passed in 2016.

The goal of the conference was not to promote aid in dying, but to promote excellent care at the end of life. The conference brought together a diverse group of providers from all over the US as well as Canada and covered a range of topics related to Medical Aid in Dying. It also served to foster the connections between MAID practitioners in the Bay Area.

The incentive for the National Clinicians Conference on Medical Aid in Dying originated from the pressing need for clinical discussions, explorations and evidence-based knowledge about medical aid in dying. In the past three years, Oregon, Montana, Vermont and Washington were joined by California, Colorado, Hawaii and, most recently, New Jersey and Maine, as states with legal access to medical aid in dying. Some 22% of the U.S. population now has access to medical aid in dying, so it has become a significant part of terminal patients’ end-oflife options. Patient requests to consider medical aid in dying as one option at the end of life have driven clinicians’ need to respond with support and knowledge.

The current mandatory waiting period ranges from 0 days in Oregon (when patient is unlikely to survive the usual 15 day waiting period) to a mandatory 20 day waiting period in Hawaii. The current waiting period in California is 15 days.

Many patients die of their diseases during this waiting period and thus it is important for systems to streamline access to the program for patients that desire it.

Hospice plays an important role for many patients that choose aid in dying as they are often the most involved with day to day care at the end of life. Hospice enrollment is not mandatory for patients that request aid in dying. Hospice policies vary with regard to discussing aid in dying and around being present with patients when they ingest. Hospice physicians sometimes are attending or consulting physicians for 28

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patients who choose aid in dying but practices vary.

Hospice by the Bay presented their bereavement experience for families who have chosen aid in dying and recommended separate aid in dying bereavement care as issues families face can be different than “natural death.” Specifically, though aid in dying families experienced less “unfinished business” than typical hospice deaths, there was a sense that some family members felt they could not openly grieve for fear of judgement.

In every state, patients must have the capacity to understand the choice to take aid in dying medication and must be able to physically take the lethal medication (though there are some subtle differences in the wording.) A psychiatrist and panel of bioethicists presented ethically and socially complex cases for discussion. The panel explored the benefits and burdens of mental health evaluation (mandatory at UCSF but not at other local institutions) as well as the prevalence of mental health issues like depression in patients with advanced illness along with its impact on decisions to request MAID. A robust conversation about the importance of the presence of a trained person when a patient ingests the end of life medication was a theme throughout the day. A volunteer from End of Life Washington shared his experience with walking patients and families through the process. Time from ingestion to death can vary from minutes to many hours and some family members found that extremely stressful. However, Dan Diaz, husband of Brittany Maynard, commented that when Brittany took her lethal medication it was a very private moment for their family and they would not have desired medical personnel, instead wishing to “de-medicalize” the dying process.

The discussion continues around best practices regarding staff presence during aid in dying deaths.

Dr. Lonny Shavelson and Dr. Carol Parrot presented current data on various aid in dying regimens and shared their current pharmacologic recommendations. Using data, they also have been able to identify patients at higher risk for prolonged death—patients with absorption problems (often due to GI malignancies,) previously athletic patients, patients with high BMI, and patients habituated to high dose opioids—and have come up with strategies to mitigate this. These physicians WWW.SFMMS.ORG

also discussed the importance of informed consent and good communication around the aid in dying process.

Tracey Bush, Regional Practice Leader, End of Life Option Act Program at Kaiser Permanente, Southern California led a session on factors contributing to inequity in healthcare and care received at end of life. She discussed how historical events like the Tuskegee experiment and Hurricane Katrina affect the perception of palliative care and aid in dying for African Americans. Ms Bush and Terri Laws, PhD, Assistant Professor of African American Studies at University of Michigan, Dearborn also addressed social determinants of health and spiritual beliefs and practices.

Finally, The American Clinicians Academy on Medical Aid in Dying is being created to promote quality of care for the aid in dying population. Dr. Stefanie Green, President, Cana-

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dian Association of Medical Aid in Dying Assessors and Providers (CAMAP) spoke about the Canadian experience. This new academy will serve to implement educational opportunities that will promote quality of care for the aid-in-dying population using data about inquiry, utilization and practice of aid in dying.

Monique Schaulis, MD, MPH is a palliative care and emergency physician at Kaiser San Francisco and President-Elect of the SFMMS.

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Special Section: The First Clinicians' Conference on Medical Aid-in-Dying

THEN AND NOW: REFLECTIONS ON THE CLINICIANS CONFERENCE ON MEDICAL AID IN DYING Robert Liner, MD Truth be told, I was close to tears at least once or twice during the two days of the first national clinicians conference on medical aid in dying (MAID).

No shame in that. After all, being with over three hundred clinicians, all paying close attention to medical information that was illegal to impart less than five years ago was a kind of benediction; many of us had worked for years in the hope of seeing this palliative care option become more widely available.

Forty years ago, a 25 yr-old woman with terminal ovarian cancer schooled me on the desperate need for a change in California law. Back then, caring for this proud, self-possessed patient at the bedside was isolating, frustrating, even anxiety producing.

She knew she was dying… had come to terms with the fact of her impending death, but not with the means. She wanted to exit while she was still recognizable to herself and to her family and didn’t want to linger in a coma; sedation to unconsciousness wasn’t her vision of how to do her final scene. But options then were limited. Given the existing statutes, there was also a paucity of evidence-based science about how best to assist the death of a patient with complex medical problems: ascites, partial bowel obstruction, and opioid tolerance from weeks of pain palliation, to mention only three.

Now, things could be different: providing her with a key to the exit would be legal.

As we learned, a highly efficient and humane combination of drugs can avoid the problem of opioid dependence. Premedication can prevent side effects.

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As conference director Dr. Lonny Shavelson has empirically proven, the problem of bowel obstruction can be finessed by rectal administration of the lethal drugs.

This conference inaugurated something new under the sun: The American Clinicians Academy For Medical Aid In Dying. Going forward, the art and science of this field of medicine will continue to advance. It’s already come a long way and is something for which we can be proud and grateful. It was historic and poetically fitting that the last comment from an attendee at the conference was voiced by Dr. Peter Reagan who on March 28, 1998, in Oregon, was the first U.S. physician to legally prescribe for MAID. Now ten states have decriminalized the practice and, as Dr. Reagan said, we no longer need to be anonymous. No doubt he found the presenters and fellow attendees at the conference welcome company.

Robert Liner MD is a retired Ob/Gyn and former SFMMS delegate to the CMA, where he was a proponent of legalizing Medical Aid in Dying.

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TOWARDS A GOOD DEATH Charles Binkley, MD From the beginning of time humanity has asked the difficult question, “How can I have a good death?” How each of us defines a good death is a rich narrative. We will likely each die in a different way, and for those of us who find that our emotional, spiritual, relational selves have already failed and we are anchored to this world only biologically, medical aid in dying may provide a potential avenue to enjoy a good death.

A few weeks ago I had the opportunity to participate in the National Clinicians Conference on Medical Aid in Dying. This was the first conference of its kind; an historic event. Throughout my life, as is true of you my colleagues, I have dedicated myself to keeping my patients from dying. As a pancreas surgeon treating one of the most fatal cancers, I offered a surgery that provided the only potential chance of survival, and even with the best surgery, neoadjuvant and adjuvant therapy, most of my patients would die within a few years.

A few things at the conference struck me deeply. First, no one was suggesting that medical aid in dying is the right choice for every patient, but for those who do choose to avail themselves of it, we must ensure that it is implemented thoughtfully, compassionately, and lovingly. As well, because this is a relatively new option for the terminally ill, we are still figuring out how to do it well and to apply it justly. This is but one of the many tools that we as physicians possess. We must be guided by wise Hippocrates: “Do good and avoid harm.”

I sat down for lunch and introduced myself to the man sitting next to me. “Hi, I’m Charles Binkley.” I said. The man next to me replied “Hello, I’m Dan Diaz – Brittany Maynard’s husband.”

Besides the California Medical Association's decision to maintain neutrality on the issue, Brittany Maynard is perhaps the most consequential factor behind the legalization of medical aid in dying in California. Diagnosed with a malignant brain tumor, Brittany was not able to end her life by stopping treat-

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ment. Instead, she faced months of suffering that would erode everything that she valued in life. Because medical aid in dying was not an option for her in California at the time, she and her family moved to Oregon where it was legal.

Living in the startup world here in the Bay Area, we hear terms like “disruptive” “bootstrapping” and even “Ramen profitable” wherein the tech influencers live off instant noodles, sacrificing for their cause.

During the course of this historic conference, I was struck by the same passion, but here the profit is measured in the amount human suffering avoided. These women and men are truly disrupting our traditional views of a good death. They are figuring out, as they go along, how to help patients – sharing information, creating a community, adopting best practices. And they are truly sacrificing to alleviate the suffering of their patients.

This is not an indictment of the quality of end of life care, but a recognition that for some patients their spiritual and emotional self is going to cease before their physical self does. They are exhausted by all the treatments that we have to offer, besides a good death. And to this end, the conference made great strides in addressing.

Charles Binkley, MD, FACS, is a liver and pancreas surgeon, bioethicist, and founder of ProNobis Health (Pronobishealth.org) which promotes patient core values in healthcare decisions and supports providers, organizations, and industry in responding to moral dilemmas in medicine.

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Special Section: The First Clinicians' Conference on Medical Aid-in-Dying

A DELICATE TOPIC & A GREAT START Laura Koehler, LCSW As a social worker one who has been in the hospice world for three decades, I have attended many end-of-life conferences. This conference was unique and highly successful because of the panel format, which required all participants to hear all of the same information – no breakout sessions – no sequestering by discipline. As Dr. Shavelson said, "Since this is the first time a clinical conference on MAID is taking place, we should all start with the same information." The panel format allowed many voices to be heard and many experiences to be described.

I attended the conference with 16 coworkers and we universally found the conference interesting, stimulating, and very rich.

It also validated the great work we have accomplished at Hospice by the Bay to create a robust, sensitive, and comprehensive aidin-dying program.

However, some thoughts for future consideration…

I wish there had been more speakers/sessions on the psycho/ spiritual aspects of MAID. There were no chaplains represented on the panels, an absence that was noted by my colleagues. Also of concern at times was the over-arching "pro-A-I-D" flavor.

Though I personally and professionally support the law, I still have great respect for my many peers who struggle with MAID as

an option for the terminally ill. I believe no one should feel judged for not fully embracing MAID. For an employee of an agency that maintains a thoughtfully developed neutral stance about MAID, it was not helpful to have this approach doubted or questioned, which happened on a few occasions.

MAID is a delicate topic...this is new...and people have strong feelings about it. These feelings should be respected and supported so that more clinicians can feel increasingly comfortable with this new end-of-life intervention.

In spite of this, the dominant feeling I was left with was great appreciation and respect for Dr. Lonny Shavelson, Dr. Lael Duncan, and Thalia DeWolf, RN, for their hard work that resulted in a meaningful, well-thought out, and stimulating experience for all who attended.

Can't wait for the next one. This was a fabulous beginning!

Laura Koehler, LCSW is Clinical Director & SF Site Manager at Hospice by the Bay. She has worked for the organization – the first hospice on the west coast- for over 28 years assuming many different roles. She developed and oversees HBTB’s program on EOLOA.

PROUD TO BE THERE The big MAID conference maid me proud. Not because I had that much to do with planning the actual event, but because it happened at all. Just a few years back it could have been deemed an illegal gathering. Instead it was a sold-out (over 300 attendees), enthusiastically-received gathering of clinicians from far and wide all with the goal of learning and sharing very detailed best practices on medical aid in dying (MAID).

Thus it was a first-of-its-kind, landmark event. I sat through the two days with a feeling of amazement and yes, vindication.

Most of the people there I did not know, but there were quite a few I did, some for decades. Conference organizer and chair Dr. Lonny Shavelson was one of the latter; I met him many years back when he wrote a book about people needing, seeking and sometimes finding assisted dying, which I reviewed for the San Francisco Chronicle. Soon after that we were among co-authors of clinical guidelines for the practice published in a medical journal and eliciting New York Times front-page coverage titled "Guidelines for the Unthinkable."

But in fact many, both patients and clinicians, had been forced to think about it. In the late 1980s, spurred by experience in the early HIV epidemic where infection was lethal and untreatable, I conducted the first survey of American physicians on the topic, with a strong majority favoring a legal option (spurring more

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Steve Heilig, MPH

shocked front-page news). The San Francisco Medical Society, being a democratic membership organization, thus became the first medical association to stop opposing legalization. And thus we began a crusade to change the prohibitive policy of the California Medical Association, which had successfully blocked any effort to legalize MAID, via legislation or ballot initiative. We argued, with evidence, that physician opinion favored choice in dying, that other states had legalized it without the feared negative impacts, and that in fact end-of-life care in general could be improved. But still it took many years and many efforts until we finally prevailed in 2016, the CMA went "neutral," and the legislation finally made it to the Governor, who signed it with a moving personal statement.

So this conference, an actual mainstreaming of education in MAID with CME and everything, seemed a sort of culmination, and even validation. "Why are you smiling so much?" more than one person asked me there. I just thought of the hundreds of patients who had already benefitted, and the thousands more to come, and just thought, once in awhile, persistence really does pay off. And yes, I felt proud.

Steve Heilig is on the staff of the SFMMS and co-editor of the Cambridge Quarterly of Healthcare Ethics.

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THE “CHILLING EFFECTS” OF PUBLIC CHARGE: HOW CAN WE FIGHT BACK? Christina Schmidt and Leena Yin I printed out a picture of apple cider vinegar and instructed my patient to show it to the grocery store clerk. He was uninsured, and the prescription ear drops that I would have given him for his infection were too expensive at $40 a bottle. When I asked if he wanted to sign up for MediCal, he politely declined: he immigrated to California a few years ago and didn’t want to jeopardize his chances of applying for a green card.

It has been less than two months since the Trump administration’s “public charge” policy took effect. This policy, which is informally known as the immigration “wealth test,” ties eligibility for documentation status to utilization of social services.

People like my patient, who apply for green cards or seek visas to enter the United States, can have their applications denied for trying to take care of themselves or their loved ones. Public charge has generated fear amongst immigrant communities since it was proposed in 2018, and clinics across the country - in addition to the nonpartisan Urban Institute - have reported that families are going without food, housing, and health care.1 Much of the fear surrounding public charge is secondary to confusion about who the policy actually affects. For example, for mixed-status families, the administration has clarified that the use of public programs by a family member will not count against those applying for a green card/visa; this means that officials cannot count a child’s use of any public programs against an immigrant parent. Despite this, the child uninsured rate increased in 2018 for the first time in a decade2 - showing that the Trump administration is effectively weaponizing fear to deter families from accessing much-needed resources.

It is therefore crucial to understand what programs will and will not affect someone’s green card application. The initial draft created by the Department of Homeland Security in 2018 targeted families who use a wide range of public programs, including the Earned Income Tax Credit (EITC) and Women, Infants, and Children (WIC) nutrition assistance. However, due to immense pushback that generated more than 250,000 public comments, the final regulation only covers Medicaid, “SNAP” nutrition assistance, cash assistance, and “Section 8” housing assistance.3 Make no mistake: even scaled back, the regulation unjustly targets immigrants based on their wealth and abilities.

Seniors,4 people with disabilities,5 and people with incomes below $60,0006 or credit scores below an arbitrary limit7 will have a more difficult time gaining entry into the United States.

When combined with the stipulations surrounding the use of public programs, the policy effectively blocks those who are not wealthy from immigrating to the United States – especially women8 and people of color.9 As physicians, employers, and community members, we can mitigate the harm of public charge by encouraging families to do WWW.SFMMS.ORG

three things: First, understand how public charge applies to you.

Immigrant rights and human services experts in California have put together with information that is accurate and accessible. 10 Second, seek out legal advice. Informed Immigrant has a searchable database of immigrant legal services across the country.11 Finally, make the best choice for your family. It is important to weigh legal concerns against the necessity of obtaining food, shelter and healthcare for your family. While the implementation of public charge was a setback for our country, we must join together to protect the families in our communities and fight for a more just future.

Christina Schmidt and Leena Yin are third-year medical students at the University of California, San Francisco, and cofounders of Medicine for Migration.

References 1. Bernstein, H., Gonzalez, D., Karpman, M. & Zuckerman, S. One in Seven Adults in Immigrant Families Reported Avoiding Public Benefit Programs in 2018. (2018).

2. United States Census Bureau. Income, Poverty and Health Insurance Coverage in the U.S.: 2018. The United States Census Bureau https://www.census.gov/ newsroom/press-releases/2019/income-poverty.html.

3. U.S. Citizenship and Immigration Services. Inadmissibility on Public Charge Grounds. Regulations.gov https://www.regulations.gov/document?D=US CIS-2010-0012-0001.

4. Cohens, K. Justice in Aging Files Amicus Brief Arguing that the Department of Homeland Security’s Final Public Charge Rule Illegally Targets Older Adults and Their Families. Justice in Aging (2019).

5. State of Washington et al. vs. United States Department of Homeland Security et al.

6. Fremstad, S. Trump’s ‘Public Charge’ Rule Would Radically Change Legal Immigration. (2018).

7. National Consumer Law Center. Statement Regarding Credit Report/Score Requirement in DHS Public Charge Regulation. (2019).

8. National Women’s Law Center. NWLC Deplores Final Department of Homeland Security’s ‘Public Charge’ Rule as Assault on Women, Families, and Communities of Color. National Women’s Law Center https://nwlc.org/press-releases/ nwlc-deplores-final-department-of-homeland-securitys-public-charge-rule as-assault-on-women-families-and-communities-of-color/.

9. Center on Budget and Policy Priorities. Trump Administration’s Overbroad Public Charge Definition Could Deny Those Without Substantial Means a Chance to Come to or Stay in the U.S. Center on Budget and Policy Priorities https://www.cbpp.org/research/poverty-and-inequality/trump-administra tions-overbroad-public-charge-definition-could-deny (2019).

10. Keep Your Benefits California. https://www.keepyourbenefitsca.org/.

11. Informed Immigrant. Informed Immigrant https://www.informedimmi grant.com/.

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Alex Barrett-Shorter from Assemblymember David Chiu’s staff presented proclamations to Immediate Past President, Kimberly Newell Green, MD and SFMMS Executive Director/CEO Mary Lou Licwinko on behalf of the California Legislature.

CELEBRATING 152 YEARS OF PHYSICIAN LEADERSHIP, ADVOCACY AND CAMARADERIE Nearly 150 physicians, community leaders, and their guests joined SFMMS for the 2020 Annual Gala on January 31, 2020 at The Green Room at the San Francisco War Memorial & Performing Arts Center. Attendees were able to network with colleagues, meet SFMMS and community leaders, and take in stunning views of the Civic Center decked out in colors for the Super Bowl-bound San Francisco 49ers.

Guests were treated to a reception with live jazz music performed by students from the San Francisco Conservatory of Music. The festivities continued with dinner and a formal program that celebrated SFMMS’s history, its members, and their contributions to the local medical community.

Long-time SFMMS Executive Director/CEO Mary Lou Licwinko was honored for her 21 years of service to the medical society. Mary Lou announced that she will retire once a successor has been selected. Immediate Past President Dr. Kimberly Newell Green was acknowledged for her contributions to the medical society, and 2020 SFMMS President Dr. Brian Grady received the President’s Gavel from Dr. Newell Green and delivered his inspirational remarks and vision for SFMMS. Special tributes were made to Dr. Filmore Rodich for attaining 50-year membership status in the medical society, and to Dr. William Breall and Dr. Arthur Lyons for reaching 60-year membership status. Dr. John Maa was honored as an outgoing member of the SFMMS Board. The evening’s program concluded with readings by the authors of the two winning entries from the SFMMS physician-in-training writing contest, medical student Christina Schmidt and resident Dr. Jeffrey Russ.

SFMMS would like to thank our members, sponsors, and special guests including San Francisco Board of Supervisors Rafael Mandelman, Marin Board of Supervisors President Katie Rice, Alex Barrett-Shorter of Assemblymember David Chiu’s staff and Shalini Rana from Mayor London Breed’s staff for their support of the event and of SFMMS. Special thanks go to our event sponsors, including Presenting Sponsor, MIEC, and Platinum Sponsors, Cooperative of American Physicians and Kaiser Permanente San Francisco.

We hope to see you at the next SFMMS Annual Gala!

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Shalini Rana, Health Policy Advisor for San Franciso Mayor London Breed presented commendations to Mary Lou and Dr. Newell Green.

San Francisco Supervisor Rafael Mandelman stopped by to deliver a commendation to SFMMS President Dr. Grady.

Marin County Board of Supervisors President Katie Rice presented proclamations to Dr. Newell Green and Mary Lou.

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The 2020 SFMMS Gala was attended by 12 Past Presidents.

2020 SFMMS Officers from left: Gordon Fung, MD-Editor, San Francisco Marin Medicine; Michael Schrader, MD-Treasurer; Heyman Oo, MD-Secretary; Brian Grady, MD-President; Kimberly Newell Green, MD- Immediate Past President; and Monique Schaulis, MD-President-Elect.

Dr. Newell Green presented incoming SFMMS President Brian Grady, MD with the President’s Gavel. Dr. Grady presented Dr. Newell Green with a certificate of appreciation for her service as SFMMS President.

From left: Managing Editor of San Francisco Marin Medicine Steve Heilig; writing contest winners Christina Schmidt and Jeffery Russ, MD; and Editor of San Francisco Marin Medicine Gordon Fung, MD.

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2020 SFMMS President Dr. Brian Grady delivers his President’s remarks.

50-Year Member, Filmore Rodich, MD was honored at the gala by Anne Cummings, MD.

SFMMS President Brian Grady, MD presents a certificate of appreciation to outgoing SFMMS Board member, John Maa, MD.

60-Year Member, William Breall, MD was honored at the gala by Richard Podolin, MD.

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COMMUNITY MEDICAL NEWS Kaiser Permanente

Chinese Hospital

Maria Ansari, MD

Sam Kao, MD

Physicians are trained as healers and relish that role. Increasingly, however, physicians are acting as advocates to make the public and elected officials aware of issues that impact the health of our communities.

When e-cigarette maker JUUL Labs placed a measure on the November 2019 ballot in San Francisco to repeal the ban on flavored tobacco products and devices that have not been approved by the Food and Drug Administration, our physicians joined the fight to oppose the measure. We helped educate voters by explaining how e-cigarettes hook young people who are unaware that the nicotine-laden devises can lead to a lifetime of addiction.

Recently Kaiser Permanente took a strong stand to protect the health and safety of California’s youth by becoming the first major health care provider to support California Senate Bill 793 to ban the sale of all flavored tobacco products in the state.

Kaiser Permanente’s vision for total health also includes promoting environmental stewardship. Our medical center’s “Green Team,” is comprised of physicians and staff who work on the local level to accomplish KP’s company-wide green goals which include becoming carbon neutral by 2025.

There’s no doubt that meat consumption contributes to the planet’s greenhouse gas emissions. In 2017 we introduced Thrive Kitchen, a monthly class taught by a physician that offers participants hands-on experience preparing plant-based recipes.

Another major concern of our time is homelessness and housing insecurity. Kaiser Permanente is committed to addressing this issue because we believe that safe, stable housing is critical to good health. Last month, we were the first private contributor to Governor Gavin Newsom’s newly announced fund to combat homelessness in the state, committing $25 million to the effort. The pledge supports Kaiser Permanente’s efforts statewide and builds on a $200 million investment that we announced in 2018 to support affordable housing.

Beyond our clinical practice, physicians must speak up on issues that impact the well-being of our communities.

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Change has come. An entire new order has descended ever so swiftly upon our Bay Area medical community since our last column. Covid-19 has come to dominate our daily existence, and by the time this is published, we will be well into our surge.

Chinese Hospital is as grateful as all Bay Area hospitals at the extra time gained by our collective commitment to social isolation.The ‘flattening of the curve’ afforded us time to plan for the surge; and thankfully kept the peak of illnesses within striking range of our overall capacity for critical care.

There is so much credit to go around, for the peerless leadership by members of our Medical Staff and the relentless efforts of the Hospital Staff, with countless meetings and brainstorming, running through a myriad of scenarios, creatively solving for anticipated problems, some highlighted by the experience of harder hit communities elsewhere. We particularly need to recognize Dr. Eric S. Kenley, Chief of Emergency Services, Dr. Cynthia Lin, Chief of Medicine and Head of the Hospitalist program, Dr.Fred Hom, Head of Critical Care, Nia Lendaris, Chief Nursing Operations Officer, Gina Yam, Director of Operations, and our CEO Jian Zhang. We also need to highlight the contributions of Dr. Maisie Chan, Medical Director of Performance Improvement, David Jordan, Laboratory Services Manager, Rich Boyer, Chief Engineer, Patricia Chung, Director of Quality & Medical Staff/Compliance Officer, and Kim Tran, Safety Officer. We sincerely hope that all the hard work pays off.

We also want to give credit to our community physicians who have been taking on the outpatient portion of managing this pandemic, screening the less ill and helping their patients recover in place whenever possible. This has allowed our Hospital staff to focus on the most ill patients. These community physicians are well represented by the Asian American Medical Group (AAMG) and the Jade Medical Group, both of whom have also had members volunteer to staff any overflow should this surge outstrip our normal inhouse capacity. It is a particular credit to AAMG as they continue to await a finalized contract with the Hospital, that they are ready to pitch in and support the entire community despite any lingering disputes.

These are the times that remind us all of the importance of our collective efforts, large and small. We wish all of you good health, and offer deepest condolences for those lost to this terrible contagion.

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THANK YOU TO OUR NEW MEMBERS REGULAR ACTIVE MEMBERS Michelle Dawn Adams, MD | Obstetrics and Gynecology Julia Elizabeth Adler, MD | Psychiatry Stacy Hinako Akazawa, MD | Family Medicine Cheryl A Albuquerque, MD | Maternal and Fetal Medicine Diana Mirella Antoniucci, MD | Endocrinology, Diabetes and Metabolism Audrey May Mariko Arai, MD | Family Medicine Gurpreet Kaur Aujla, MD | Psychiatry Amy Louise Baca, MD | Internal Medicine Benjamin Bailey Barreras, MD | Psychiatry Isa Barth-Rogers, MD Robert James Bartz, MD | Family Medicine Kanchi K Batra, MD | Hospitalist Rachael Haas Beckert, MD | Pediatrics Joshua James Benham, MD | Obstetrics and Gynecology Steven Lawrence Blumlein, MD | Cardiovascular Disease Julie Mara Bokser, MD | Pediatrics Bruce Norman Brent, MD | Cardiovascular Disease Jeannie Anita Brewer, MD | Internal Medicine William I Bry, MD | General Surgery Anna M Buchsbaum, MD | Obstetrics and Gynecology Izumi Nomura Cabrera, MD | Obstetrics and Gynecology Cristina Marie Glorioso Casas, MD | Pediatrics Alexander Alfonso Chang, MD | Internal Medicine Charlene Chen, MD | Neurology Yvonne Cheng, MD | Maternal and Fetal Medicine Jose Adolfo Chibras-Sainz, MD | Internal Medicine Hideki Paul Chin, MD | Psychiatry Kenneth Marcus Chin, DO | Psychiatry Catherine Marie Chin-Garcia, MD | Internal Medicine Jessica Shin Choe, MD | Neurology Angelo Asa Clemenzi-Allen, MD Douglas Evan Cohen, MD | Hospitalist Stewart Lyndon Cooper, MD | Hepatology Louis Joseph Cubba, MD | Internal Medicine Aparna A Dandekar, DO | Family Medicine Rachel Lynn Darche, MD | Obstetrics and Gynecology Timothy James Davern, II, MD | Hepatology Charles Uy Delatore, MD | Internal Medicine Alissa Anne Detz, MD | Internal Medicine Jennifer Ha Do, MD | Pediatrics Jeffrey A Draisin, MD | Family Medicine Karin Maria Dydell, MD | Internal Medicine Karen Elizabeth Earle, MD | Endocrinology, Diabetes and Metabolism 40

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Robert J Eldabaje, MD | Internal Medicine Stacy Fang, MD | Obstetrics and Gynecology Cynthia Anne Farner, MD | Gynecology Richard Todd Frederick, MD | Hepatology Billy Shu Gao, MD | Neurology Sweta Laxmikant Ghodasara, MD | Internal Medicine Melissa M Goebel, MD | Internal Medicine Inessa Gofman, MD | Pediatrics Eric David Gordon, MD | Family Medicine Susannah Graves, MD | Internal Medicine Pam Kaur Grewall, MD | Internal Medicine Nima Ann Grissom, MD | General Surgery Jennifer Ellen Guy, MD | Hepatology Alexandra Lee Haessler, MD | Gynecology Anne Han, MD | Dermatology Joyce Elaine Hansen, MD | Internal Medicine Susana Ines Smith Harbutt, MD | Endocrinology, Diabetes and Metabolism Assad Abidon Hassoun, MD | General Surgery Lorena Frances Hillman, MD | Family Medicine Garrett Masato Hisatake, MD | General Surgery Chanda Kendra Ho, MD | Hepatology Edward W Holt, MD | Hepatology Cynthia Ann Hom, MD | Internal Medicine Richard Hikaru Hongo, MD | Clinical Cardiac Electrophysiology Jennifer Hsu, MD | Pediatrics Shilpa Harish Jain, MD | Endocrinology, Diabetes and Metabolism Juliet Alexa Liberty Jenkins, MD | NeuroMuscular Medicine Stephanie Jo Jeske, MD | Hematology Oncology Judy Jing Jia, MD | Neurology Judith Draisin Jones, MD | Family Medicine Babak Kanani, MD | Internal Medicine Mohammed Kashani-Sabet, MD | Dermatology Jonathan Scott Katz, MD | NeuroMuscular Medicine Michael Katz, MD | Maternal and Fetal Medicine Steven Katznelson, MD | Nephrology Michael Chinwen Ke, MD | Neurology Gauri Dilip Kelekar, MD | Hematology Oncology Lena Heesun Kim, MD | Obstetrics and Gynecology Kjersti M Kirkeby, MD | Endocrinology, Diabetes and Metabolism Sharon Kathleen Knight, MD | Urology Thomas Clarke Kravis, MD | Occupational Medicine Melissa Atmadja Kwon, MD | Internal Medicine Kha Nguyenduy Lai, MD | Internal Medicine WWW.SFMMS.ORG

Kenneth David Laxer, MD | Neurology Bonnie Joy Leboff, MD | Pediatrics Eugene Earl Lee, MD | Internal Medicine Jonathan Hongsupp Lee, MD | Family Medicine Susan Jen Lee Char, MD | General Surgery Stanley Pui-Lock Leong, MD | General Surgery Kira Liana Levy, MD Erin Ilana Lewis, MD | Obstetrics and Gynecology Mimi Shaw Mong Lin, MD | Gastroenterology Zuolu Liu, MD | Neurology Peter Charles Albert Lovett, MD | Internal Medicine Guy H Lubliner, MD | Internal Medicine Matthew Grady Macdougall, MD | Neurological Surgery Harish D Mahanty, MD | Surgical Oncology Tanya Majumder, MD Devan Mohan Marar, MD | Cardiovascular Disease Erin Irene Martin, MD | Internal Medicine Silvia Aki Mccandlish, MD | Internal Medicine Gwyneth Mary Mccawley, MD | Neurology Raphael Brendan Merriman, MD | Hepatology Robert Gordon Miller, MD | Neurology Dzovag Minassian, MD | Internal Medicine Armen Jirair Moughamian, MD | Neurology Gene A Nakajima, MD | Psychiatry Robert Elias Napoles, MD | Internal Medicine Alan William Newman, MD | Psychiatry Claude Bernard Nguyen, MD | Neurology Akilesh Palanisamy, MD | Family Medicine Jeremy Agu Parker, MD | Psychiatry Brian Michael Parrett, MD | Plastic Surgery Nisha Patel, MD | Internal Medicine Parul S Patel, MD | Nephrology Shilpen Ajit Patel, MD | Radiation Oncology Veena Patel, DO | Internal Medicine David R Pating, MD | Psychiatry Venkat Ram Peddi, MD | Nephrology Nelli Boykoff Perkins, MD | Neurology Kate Estelle Pettit, MD | Maternal and Fetal Medicine Lara Noelle Pickle, DO | Family Medicine Julie Ann Romero, MD | Maternal and Fetal Medicine Benjamin G Romick, MD | Cardiovascular Disease Monica Ann Rosenthal, MD | Emergency Medicine Arshia Sadreddin, MD | Neurology Teresa Rene Worstell Safer, MD | Obstetrics and Gynecology Robert David Saken, MD | Pediatrics Amarpreet Singh Sandhu, DO | Nephrology WWW.SFMMS.ORG

Ingeborg Sabine Schafhalter-Zoppoth, MD | Internal Medicine Kelley Michele Scott, MD | Internal Medicine Melinda Mara Scully, MD | Obstetrics and Gynecology Catherine Anne Seeley, MD | Internal Medicine Shilpa Madhavan Shah, MD | Internal Medicine Lawrence Gleason Shore, MD | Family Medicine Adam Simons, MD | Internal Medicine Mark Irwin Singer, MD | Head and Neck Surgery Neeru Kaur Singh, MD | Family Medicine Vandana Singh, MD | Internal Medicine Trudy Katrina Singzon, MD | Family Medicine Allanceson Jay Smith, MD Ilanit Spokoyny, MD | Neurology Sara L Swenson, MD | Internal Medicine Teresa Tang, MD | Internal Medicine Kathryn Elyse Taylor, MD Yakira Heather Teitel, MD David Manuel Tejeda, MD | Pediatrics David Chia-Hann Tong, MD | Neurology Robert C Vazquez, MD | Family Medicine Mariel Marques Velez, MD | Neurology Adil Salih Wakil, MD | Gastroenterology Danielle Marder Walker, MD | Internal Medicine Mustafa Wardak, MD | Internal Medicine Peter Broun Weber, MD | Neurological Surgery Melissa E Weinberg, MD | Endocrinology, Diabetes and Metabolism Stephanie Denise Wilson, MD | Psychiatry Susan Bassett Wilson, MD | Gynecology Nicole Yvette Winbush, MD | Family Medicine Christine Shaun-Yue Wong, MD | Neurology Kristin Fung Mei Wong, MD Alice Woo, MD | Plastic Surgery Stephan Paul Wyss, MD | Psychiatry Rupsa Ray Yee, MD | Internal Medicine Kidist Kidane Yimam, MD | Hepatology Anthony York Yul Yin, MD, FACE | Endocrinology, Diabetes and Metabolism Dongmei Yue, MD | Psychiatry Shamiq Zackria, MD | Internal Medicine Janos Zahajszky, MD | Psychiatry Ming Kun Zhou, MD | Maternal and Fetal Medicine

HOUSE OFFICERS Leanne Duhaney, MD, MPH | Pediatrics MARCH/APRIL 2020

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

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

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

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