San Francisco Marin Medicine, Vol. 93, No. 3, May/June/July

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

Volume 93, Number 3 | MAY/JUNE/JULY 2020

IN THIS ISSUE

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FEATURE ARTICLES

MONTHLY COLUMNS

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Membership Matters

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President's Message: We Must Speak Up Brian Grady, MD

The Path Towards a U.S. Surgeon General Report on Firearm Injuries John Maa, MD and Peter Masiakos, MD

10 SFMMS Interview: George Rutherford, MD on COVID-19 Transmission, Prevention, Masks, Vaccines, Schools, Sports and More

Steve Heilig, MPH 13 The Moral Pandemic of COVID-19

Charles E. Binkley, MD, FACS 18 Safe Practices in the COVID Era:

Re-opening Our Offices

Michael Schrader, MD, PhD

19 Physician Wellness: Put on Your Own Oxygen

Mask First

Jessica Mahoney, MD

20 Pandemic Playbook Diaries: Emergency Physicians Confront COVID-19

Scott J. Campbell, MD, MPH and Hallam Gugelmann, MD, MPH 22 Novel Concepts to Preserve Traditional Private Practice

Joseph Woo, MD and Man-Kit Leung, MD 24 The Community Readiness Collaborative: A Targeted COVID-19 Mitigation Program for Residential Care Facilities for the Elderly in Marin County

David Miller, MD, MPH 26 Rational Rationing: Developing Guidelines for Tough Ethical Choices in the COVID Era

William Andereck, MD

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Executive Memo: A Time for Renewed Engagement Conrad Amenta Protecting Physician Practices During COVID-19

COMMUNITY NEWS 32 Kaiser News Maria Ansari, MD

32 Chinese Hospital News Sam Kao, MD

OF INTEREST

30 Dr. Richard Pan Introduces SB 483 to Protect Health Officers from Personal Threats and Attacks 36 CMA COVID-19 Telehealth Toolkit for Physician Practices Available 36 Thank You to Our New Members 36 Advertiser Index

28 Environmental Pollutants and Inadequate Policies

Veena Singla, PhD and Patricia D. Koman, MPP, MPH

SAN FRANCISCO

MARIN MEDICAL SOCIETY

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

MEMBERSHIP MATTERS SFMMS Speaks Out in Support of Public Health Officials The San Francisco Marin Medical Society (SFMMS), representing approximately 3,000 physicians across medical specialties and practice types in San Francisco and Marin Counties, strongly condemns recent attacks on local health officers who provide evidence-based leadership and guidance to protect their communities from the spread of COVID-19. As a result of these attacks, a number of public health officers in California have left or have expressed their intention to leave their positions.

Attacks on and harassment of public health officials must stop. The health officers of San Francisco and Marin Counties are undertaking crucial work to protect the public’s health during an unprecedented medical emergency, and their actions have led directly to lives saved. Physicians in San Francisco and Marin Counties rely on local health officials and partner with them to keep their communities safe. Public health officials develop key guidance for physicians and their patients. Their expertise and leadership is vital. We urge elected officials at every level of government to take steps to ensure that health officers feel safe and are empowered to continue their critically important work.

PPE Masks Available at No Charge from SFMMS

If you wish to receive a package of KN95 masks to be picked up at a central San Francisco location, email Steve Heilig at heilig@sfmms.org, stating practice location, specialty, number of physicians, and email and phone number. These masks were purchased via the generous offer of the California Healthcare Foundation and its CEO, SFMMS member Sandra Hernandez, MD. Thousands have already been supplied to many local physicians.

SFMMS Speaks Out on Institutionalized Racism

San Francisco Marin Medical Society (SFMMS) President Brian Grady, M.D., released the following statement in response to the death of George Floyd, institutionalized racism in America, and the protests of recent days: “Like so many Americans, the physician communities of San Francisco and Marin counties reacted to the murder of George Floyd in Minnesota with sadness and horror. We are reminded that institutionalized racism is a social determinant of health and that underrepresented communities face the stark reality of state-sanctioned violence. As physicians embedded in our communities and dedicated to protecting the most vulnerable among us, we believe that there is no room in America for hatred and discrimination and that so long as it persists, it affects the health and well-being of all Americans. As physician leaders, we have a responsibility to stand with our patient communities against institutionalized racism.

Dr. Peter Bretan, President of the California Medical Association and a member of SFMMS, wrote yesterday that "We respect and commend the professional ideals of those serving in law enforcement. We also acknowledge the sacrifices of those committed to protecting and serving our communities with honor.

But we cannot ignore the systemic problems embedded within 2

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our justice system that endanger the lives of Black and Brown communities. We cannot tolerate any culture that cultivates the infliction of racial violence and the mistreatment of its people.

This means we must also examine the systems and practices of our own medical profession.”

Bay Area Medical Societies Write to Governor Concerning Outbreak at San Quentin

Five Bay Area Medical Societies, representing over 10,000 physician members, submitted a joint letter to Governor Newsom drawing attention to the alarming COVID-19 outbreak at San Quentin state prison. The number of infected, which has passed 1,000, has implications for the incarcerated population and the staff at San Quentin, and for the capacity of the local hospitals to which many of these patients have been transferred. You can view the joint letter on the blog page at sfmms.org.

SFMMS Protests Donald Trump’s Racist Remarks

At his rally in Tulsa, Oklahoma, President Trump referred to the novel coronavirus, COVID-19, as the “Kung Flu.” This is not the first time he has done so. At a press conference last month, President Trump was asked by reporters about the backlash against Asian Americans because of he and his administration’s insistence upon referring to COVID19 as the “Chinese virus.”

It’s unconscionable that anyone, let alone the President of the United States, would stoke animosity toward a segment of our own. There have been so many awful things said by this man and his administration. This President has disparaged women, African Americans, Latinx, LGBTQ, Muslims, and Asians. He has failed to condemn white supremacists, neoNazis, and supporters of the Confederacy in times of crisis.

We are now confronted with a global pandemic. What we need is cooperation, coordination, and unification in a common cause. What we need is leadership. As doctors, and as human beings, we abhor these and all racial attacks and will not tolerate it.

SFMMS Membership Hits Milestone, Passing 3,000 Members

The San Francisco Marin Medical Society (SFMMS) has hit a milestone, signing up its 3,000th member - the most in its 152-year history. SFMMS’ growing membership represents physicians of all specialties in every practice setting. Our history of progressive policy and successful advocacy in matters of public health is made possible because of the diversity, experience, and passion of our members. SFMMS remains dedicated to convening and connecting the physicians of San Francisco and Marin Counties to discuss issues of vital importance, to solve pressing problems, and ultimately to nourish and sustain physician practices.

All these updates and more are at the SFMMS blog at www.sfmms.org

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First COVID-19 Virtual Grand Rounds webinar

Volume 93, Number 3 Editor Gordon L. Fung, MD, PhD, FACC, FACP Managing Editor Steve Heilig, MPH Production Maureen Erwin

State of COVID-19 with California Public Health Leaders JULY 14, 2020 | 12 PM - 1:30 PM COVID-19 is likely to be part of the clinical landscape for the foreseeable future, so the California Health and Human Services Agency (CHHS) and the California Medical Association (CMA), in partnership with the California Academy of PAs (CAPA) and Osteopathic Physicians & Surgeons of California (OPSC), are hosting a monthly and virtual grand rounds series on the evolution and management of COVID-19 patients. State health leaders will discuss past and current state efforts to prepare for COVID-19 surges and data collection methods for surveillance and planning, as well as related impacts to California communities.

Presenters: Mark Ghaly, M.D., CHHS Secretary Alice Chen, M.D., Chief Medical Officer and Deputy Director for the San Francisco Health Network and UCSF Professor of Medicine Sonia Angell, M.D., MPH, State Public Health Officer and California Department of Public Health Director

Diversifying Revenue Through Value-Based Care, a Physician's Experience JULY 28, 2020 | 12:15PM - 1:15PM

CMA Physician Services has partnered with Aledade to help independent primary care physicians and health centers successfully pursue value-based care. Aledade does this by working with practices and centers to build and lead accountable care organizations (ACOs), allowing them to remain independent and thrive financially while keeping their patients healthy. By way of example, in the 2019 Medicare Shared Savings performance year, physician practices that partnered with Aledade are projected to receive an average of $380,237 in shared savings bonuses, in addition to seeing a 20%+ increase in their Medicare fee-for-service revenue. And since its founding, Aledade has reduced health care costs by over $350 million. In this interactive webinar, CMA Physician Services and Aledade will give an overview of value-based care and Aledade's partner services. Participants will also hear from a physician who has partnered with Aledade and transitioned into value-based care.

Presenters: Sarah Summer, CEO of CMA Physician Services Michael Lubin, Vice President of Growth, Aledade

Fundamentals of ACE Screening and Response in Adult Medicine JULY 29, 2020 | 12 PM - 1 PM

Panelists will discuss the components of screening adult patients for Adverse Childhood Experiences (ACEs) and toxic stress and developing comprehensive treatment plans. With distinct clinical viewpoints and a case-based format, this webinar will cover: • The value of screening adults for ACEs and toxic stress and responding with evidence-based interventions and trauma-informed care.

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 Conrad Amenta Associate Executive Director, Public Health and Education Steve Heilig, MPH Director of Operations and Governance 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

• An overview of the ACEs Aware online training for providers, ACE Screening Clinical Workflow, and the ACEs and Toxic Stress Risk Assessment Algorithm.

• On-the-ground examples of how adult medicine providers are screening for and responding to ACEs and toxic stress.

Register today.

https://www.cmadocs.org/event-info/sessionaltcd/CME20_0714_GRCOVID/t/ grand-rounds-change-this-to-the-title Have questions? Contact covidrounds@cmadocs.org for more information.

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Cover art: Cynthia Fletcher, "Masked" 16 x 20 oil painting CynthiaFletcherArt.com

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PRESIDENT’S MESSAGE Brian Grady, MD

WE MUST SPEAK UP At his rally in Tulsa, President Trump referred to the coronavirus as the “Kung Flu.” This is not the first time he has done so.

At a press conference last month, he was confronted by reporters about the backlash against Asian Americans because of he and his administration's insistence upon referring to COVID-19 as the “Chinese virus.”

Prior to this he sparred with CBS’s Weijia Jiang. She questioned him on his claim that the US was doing far better than any other country, and why he viewed it as a global competition. He stated, “They’re losing their lives everywhere in the world, and maybe that’s a question you should ask China. Don’t ask me, ask China that question, okay?”

Even today, Peter Navarro, the White House economic advisor, referred to the coronavirus as the “Wuhan Chinese virus.” He was trying to make the point that the President was speaking “tongue-in-cheek” when he said he asked to slow testing so as to keep numbers down.

It’s unconscionable that anyone, let alone the President of the United States, would stoke animosity toward a segment of our own population.

It’s inconceivable that this same “leader” would try to slow testing and endanger the lives of Americans in order to

make his numbers look better. And even if he were jesting (he wasn’t), is 120,000+ people dead of this virus a subject for joking?

In addition, the administration is now mounting another assault on the Affordable Care Act through the court system.

Stripping care from millions of Americans, especially the most vulnerable part of the population, in the midst of a pandemic, is not simply irresponsible, but cruel.

There have been so many incredible things said by this man and his administration. It goes all the way back to his candidacy when he was recorded on tape describing how he treats women. We have become inured to despicable behavior.

But people of conscience have to speak up. We have to say “enough.” We must go on record and say that this will not be tolerated.

As doctors, and as human beings, we abhor these and all racial attacks and will not tolerate it.

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

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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EXECUTIVE MEMO Conrad Amenta, SFMMS Executive Director

A TIME FOR RENEWED ENGAGEMENT Our members face unique and urgent challenges.

We're here for you.

It’s been a pleasure and privilege to advocate on behalf of physicians and their patients for most of my career, first with the Canadian Medical Association, then the California Academy of Family Physicians. I’m grateful for this opportunity to build lasting relationships with the incredible physician communities of San Francisco and Marin as the San Francisco Marin Medical Society’s new Executive Director.

What attracted me to the opportunity was the organization’s history of bold, progressive policy. I was inspired when SFMMS physicians took a leading role in establishing the city’s ban on the sale of flavored tobacco products, a win that will protect thousands of children and underrepresented patients. The organization was an early and vocal opponent of the inhumane practice of family separation at the border. SFMMS’ leadership on issues related to HIV and AIDS in the 1980s is still talked about and admired in policy circles. As the oldest county medical society in the state, our history of public health leadership is central to our identity, and it’s an honor to help carry that tradition forward.

Our members face unique and urgent challenges. A recent study found that 44 percent of physicians reported feeling burned out, and that “a major cause of this crisis is an unbalanced clinical role that separates physicians from most organizational innovation and strategy, as well as the colleagues, staff, and the communities they serve.” (“Rethinking Physician Roles in Community Health Centers and Beyond,” 2020.)

I believe that the distinct value of a county medical society is to convene and reconnect members to innovation and strategy, colleagues, staff, and their communities, to help them to build authentic relationships with each other, to solve difficult problems, and to build consensus around progressive ideas. In these early days, I will be piloting several initiatives to provide you, the SFMMS member, frequent, compelling opportunities to engage with your society and your community.

The times we are living in are unprecedented. The COVID-19 pandemic and the recent protests against systemic racism and injustice highlight the urgent need for the Society and its physician leaders to organize and to lead. I will prioritize the hiring of additional staff who are mission-driven and utterly dedicated to serving our physician members as we face these challenges together.

Finally, I’d like to extend a warm welcome to new SFMMS members. Several hundred new physicians from the University of California San Francisco and Sutter Health have recently joined. I so look forward to getting to know you, your values, your needs, and your priorities.

Gratefully,

Conrad Amenta

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THE PATH TOWARDS A US SURGEON GENERAL REPORT ON FIREARM INJURIES

John Maa, MD and Peter Masiakos, MD

The landmark 1964 US Surgeon General report “Smoking and Health” has been central to the concept of smoking cessation and tobacco control1.

Since it was published 56 years ago, Dr. Luther Terry’s report and the 40 subsequent reports that it inspired served to educate our citizens and inform our policy makers about the dangers of tobacco use and has helped decrease smoking prevalence from 42% to under 14%. Collectively, this compendium of information further characterized the health hazards associated with cigarette smoking and the impact that secondhand smoke had on children and non-smokers. Firearm violence claims nearly 40,000 American lives each year by suicide or homicide, and like cigarette smoking directly and indirectly affects countless more. For this reason, gun violence has been declared a public health crisis by the American Medical Association2. Despite this declaration, guidance on the next steps to mitigate this problem has not been addressed by any US Surgeon General. We feel that the time has come for Congress to commission a first US Surgeon General report on firearm injuries, to help our citizens, healthcare providers and public health researchers better understand what we can all do to reduce the deaths and injuries that result from gun violence.

The first US Surgeon General report Smoking and Health in 1964 was preceded by a letter sent from the American Heart Association, American Cancer Society, American Public Health Association and the National Tuberculosis Association to President John F. Kennedy on June 1, 1961. The letter urged the formation of a Presidential Committee to study the “widespread implications of the tobacco problem.” The response by the White House was to establish the Surgeon General’s Advisory Committee on Smoking and Health that began in mid-1961. On January 4th, 1962, representatives from these four organizations met with Surgeon General Luther Terry, who then proposed to the Secretary of Health, Education and Welfare to form an advisory committee comprised of experts to assess the existing evidence and make public health recommendations. This resulted in recurring meetings that led to the January 11, 1964 SG report, which included over 7,000 medical references. The report was careful to refer to chronic smoking and nicotine use as habituation, and not addiction.

Dr. Terry’s report provided the first public evidence for the health hazards of smoking which until that time had not been fully understood. But getting to this point was not an easy task. In June 1956, the US Public Health Service engaged in the issue of smoking and health when a scientific Study Group was established by the National Cancer Institute, the National WWW.SFMMS.ORG

Heart Institute, the American Cancer Society, and the American Heart Association. Upon reviewing 16 independent studies from 5 counties over a period of 8 years, the group concluded that there was a causal relationship between excess smoking and lung cancer. In 1957, US Surgeon General Leroy Burney published an article in the Journal of the American Medical Association, stating that there was a causal relationship between smoking and lung cancer. This was followed by the Royal College of Physicians in 1962, clearly stating that smoking was the cause of lung cancer and bronchitis, and probably heart disease. This was part of the impetus for the medical community’s plea to President Kennedy.

The Parkland 2018 Valentine’s Day mass shooting was the inspiration for a 2018 NEJM paper calling for a US Surgeon General’s report on firearm injuries3. A related bill HR 11144 by Congresswoman Robin Kelly on Capitol Hill, calling for an annual Surgeon General report on gun violence, was first introduced by her on Capitol Hill in June 2013, and offered in every Congress since then. HR 1114 currently has 58 Congressional co-sponsors.

The primary goal of a SG report on gun violence would be to gather data and evidence to guide a bipartisan, national discussion about gun violence prevention in the same way that the 40 SG reports did for smoking.

Additional steps could include a call to action from all previous US Surgeons General for this report to be commissioned.

State and national medical societies could join the AMA in calling upon the President to act. We have recently seen the power of united physician action, when an AMA resolution on vaping resulted in a key White House summit in November 2019, and federal action to curtail vaping in December.

A recent series of perspectives written by nurses, surgeons, public health officials, gun violence researchers, educators, gun violence prevention advocates and law enforcement officials, on gun violence appeared as a Topical Collection on Gun Violence in Current Trauma Reports5. These twelve chapters covered a broad range of topics and was summarized by Dr. Richard Carmona, the 17th Surgeon General of the United States. This compendium could act as a template for a comprehensive SG report on gun violence which will 1) raise awareness (which had promoted steep decline in smoking rates), 2) promote safety and protect all Americans, including firearm owners, by enhancing the safe storage of weapons among other strategies, and 3) serve as the foundation to identify unanswered research questions to focus future research, and perhaps lead to the creation of a new continued on page 12 MAY/JUNE/JULY 2020

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Responses to COVID

PROTECTING PHYSICIAN PRACTICES DURING COVID-19 The California Medical Association (CMA) is closely monitoring the impact COVID-19 is having on physician practices across the state. CMA has been advocating on many fronts for appropriate relief and regulatory flexibility so the physicians of California can provide quality care to patients during and after the COVID-19 pandemic.

CMA has also developed a wide array of resources to help physicians during the public health emergency.

These resources are available FREE to physicians, regardless of their membership status.

REOPENING HEALTH CARE RESOURCES

TOOLKITS FOR MEDICAL PRACTICES

PPE RELIEF: The State of California made millions of pieces of medical-grade personal protective equipment (PPE) – including N95 masks, surgical masks, shields, gowns and gloves – available FREE to physician practices. The California Office of Emergency Services is partnered with CMA and its local medical societies to distribute this equipment to qualifying small and medium sized medical practices.

CMA understands that things are changing rapidly – sometimes daily – during the COVID-19 pandemic. Our team of experts is distilling the information into easy-to-read toolkits that are updated regularly to keep you informed.

REOPENING GUIDELINES: CMA convened a taskforce of practicing physicians from different parts of the state, different sized practices, and various specialties to develop guidelines and recommendations for reopening the health care system.

CMA’s guidelines are heavily referenced by the Newsom Administration and the California Department of Public Health in their own guidelines for resuming deferred and preventive health care.

BEST PRACTICES FOR REOPENING: CMA’s reopening taskforce also developed actionable best practices for physicians to consider as they reopen their medical practices for office visits. The document includes steps to take prior to reopening, financial and staffing considerations, and universal safety precautions.

REOPENING WEBINARS: CMA hosts a series of FREE webinars on topics related to reopening medical practices during the public health emergency. These webinars are also available for on-demand viewing for physicians who were unable to participate in the live events.

TELEHEALTH TOOLKIT: CMA’s telehealth toolkit includes payor guidance for billing and coding telehealth services, as well as privacy and security concerns and flexibilities, and key considerations for physician practices.

FINANCIAL TOOLKIT: Physician practices are confronting operational and business challenges as they continue to deliver high quality care to their patients during the COVID-19 pandemic. This toolkit provides an overview of financial assistance available to medical practices so physicians have the information they need to make the right decisions for their businesses.

EMPLOYER TOOLKIT: New laws have been quickly enacted that have expanded unemployment benefits, sick leave provisions and family medical leave laws to help both employers and employees affected by this public health crisis. CMA’s toolkit for physician employers addresses these rapidly evolving personnel and other employment-related issues.

Learn more about CMA’s reopening resources at cmadocs.org/covid-19.

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EDUCATION

PHYSICIAN ADVOCACY

COVID-19 NEWS UPDATES: CMA has increased the frequency of its member communications during this time, to ensure that physicians have the most up-to-date information. CMA’s COVID-19 Resource Center at cmadocs.org/covid-19 is also updated in real time as new information becomes available.

Through aggressive political and regulatory advocacy, CMA has positioned itself as one of the most influential stakeholders in the development and implementation of health policy. CMA’s physician advocates remain engaged on all fronts to ensure that the interests of physicians and their patients are considered as local, state and federal governments are responding to the rapidly evolving public health emergency.

VIRTUAL GRAND ROUNDS: CMA is partnering with the California Health and Human Services Agency and academic medical centers across the state to host California COVID-19 Clinical Updates, a regular series of virtual grand rounds for the state’s clinicians on the evolving understanding and management of COVID-19 patients.

COVID-19 WEBINAR SERIES: Since the beginning of the public health emergency, CMA has been hosting free COVID-19 webinars to keep the physicians of California informed on critical topics. These webinars are free for all physicians regardless of their membership status. If you are unable to attend a live event, they are also available to play back at your convenience in CMA’s on-demand webinar library.

FREQUENTLY ASKED QUESTIONS: CMA is maintaining a searchable frequently asked questions database to answer the most common questions received from physicians during the COVID-19 outbreak. You can also subscribe to be notified whenever a new answer is published.

Learn more about CMA’s educational resources at cmadocs.org/covid-19.

CAREGIVER WELLNESS The emotional stress of responding to patients during the COVID-19 pandemic puts front line health care workers at exceptional risk of emotional burnout. In response, CMA Wellness launched the Care 4 Caregivers Now program, which focuses on the mental and emotional well-being of caregivers while they fight COVID-19. Care 4 Caregivers Now connects physicians, physician assistants, nurses, nurse practitioners and respiratory therapists serving on the front lines of the pandemic with a trained peer coach who will provide remote and confidential coaching sessions at no cost.

PHYSICIAN FINANCIAL HEALTH: The COVID-19 pandemic has created an unprecedented threat to the viability of physician practices. The fallout from this crisis threatens to fundamentally alter California’s health care delivery system not just during the COVID-19 outbreak, but for years to come. CMA continues to strongly advocate on behalf of physicians, making sure that government agencies understand the immediate and ongoing need for financial assistance for physician practices.

BUDGET ADVOCACY: Due in large part to CMA advocacy, the 2020-2021 state budget preserves essential health care safety net programs at a time when the Medi-Cal caseload is expected to grow by more than 2 million cases in the coming year. The budget also protects investments in California’s health care workforce, which will help ensure all Californians, regardless of economic status, will have access to care when they need it.

REGULATORY FLEXIBILITIES: CMA is working to ensure that government agencies understand the regulatory flexibilities necessary so that physicians can continue serving patients during the COVID-19 pandemic. From telehealth flexibility and payment parity, to waivers on privacy and security requirements to expedite the incorporation of telehealth into practice workflows, CMA has been at the table making sure policymakers understand the needs of physicians and their patients.

Learn more about CMA’s COVID-19 advocacy at cmadocs.org/covid-19.

Learn more at cmadocs.org/care4caregivers.

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Responses to COVID

SFMMS INTERVIEW: George Rutherford, MD on COVID-19 Transmission, Prevention, Masks, Vaccines, Schools, Sports, and More Steve Heilig, MPH

George Rutherford, MD, began his career in the 1980s in one pandemic and is now in the middle of confronting one again. A widely-renowned expert in infectious disease issues, he is the Salvatore Pablo Lucia Professor of Epidemiology, Preventive Medicine, Pediatrics and History; Head of the Division of Infectious Disease and Global Epidemiology in the Department of Epidemiology and Biostatistics in School of Medicine at the University of California, San Francisco and Professor of Epidemiology and Health Administration in the School of Public Health at the University of California, Berkeley.

He graduated from Stanford and the Duke University School of Medicine, and is board certified in pediatrics, general preventive medicine, and public health. He has a long list of publications and ongoing research contributions and first became widely known as an HIV epidemiologist, and more recently has been a star leadoff speaker on the widely-watched weekly UCSF Covid Grand Rounds, covering epidemiology and other issues.

Do you recall when you first heard of this new virus?

In late December. I actually put a bet down with someone in my office that it would be a coronavirus.

Did you have an inkling of what was coming at that point?

I actually thought it might be a SARS replay, with most of it being primarily nosocomially transmitted.

Did it surprise you in any way that it is of zoonotic origin?

Not in the least. That's what we'd expect from experience.

And at this point in early June, how do the trends look to you?

They are not going in the right direction, that's for sure. Worldwide there are 7.4 million cases and 418,000 deaths. Overall there are 56 million deaths per year from all causes and about 2.5 million of those in the United States, so we're now pushing up against those numbers. It's not as dramatic as in the 1918 flu, partly as we have much better ICU and other care, but it's dramatic and problematic. The numbers in the United States are going up, with initial peaks in New York, New Jersey and Connecticut, with secondary peaks in Detroit, Chicago, and New Orleans, maybe in Southern Florida, to be replaced by other outbreaks in other parts of the country like the Southeast, Southern California, and the upper Midwest, particularly tied to meatpacking plants. In Southern California it's particularly in Los Angeles, with a bunch 10

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of nursing home outbreaks, and disproportionately in Latinx populations. In Northern California this is fairly true too, in the Mission, the Canal district of San Rafael, down in Gilroy, San Jose, and Santa Clara.

How about the high proportion in older people in institutional settings like care homes?

That's a very, very problematic issue. This is a very frail population, and it can go through them very rapidly. The other interesting problem is that a number of people who work in nursing homes work in more than one site, which opens up even more potential for spread via healthcare workers.

Regarding transmission, the R0 estimates have been all over the place, starting very high in China. How is that going?

I would guess at the start it was as high as maybe 3.8 or 3.9 in Wuhan, but came down pretty quickly after that. But the last numbers I've seen for San Francisco is .98, which is good. We'd like a little more cushion, but it's good, and it's dependent on what's getting reported, which is dependent on who is getting tested.

And dependent on the interventions, mostly behavioral, correct?

Yes, compliance with the predominant ones of staying at home if you're sick, wearing a mask if you go out, and doing social distancing too. I think that all gets us on the good side of 1.0. With contact tracing, isolation and quarantine and intense case investigation are all important in helping us getting a handle on transmission, when it's relatively lower. If you're having a zillion cases a day there's not enough contact tracing and such in the world to do those, but with the kind of numbers we have here now, say 25-ish a day, we have the capacity for that.

You're estimated overall prevalence in the Bay Area of about 1-2%, which is something of a success story, right?

Absolutely, especially compared to other places.

How about the controversial case study of Sweden, which has taken a more "relaxed" approach and not shut much down, hoping for herd immunity?

The prevalence in Stockholm is about 7.3%, so they've hardly got herd immunity. Plus it's hardly clear what antibody positivity means for immunity.

So you don't think that hoping for herd immunity is a realistic strategy.

No, it's not a realistic strategy, as it comes at a tremendous cost of mortality. About 25% of those hospitalized for this disease who recover from illness have no measurable antibodies, with only a handful, like less than 5%, having high titers of neutralizing antibodies. What we know from the alphacoronaviWWW.SFMMS.ORG

ruses, the ones that cause the common cold, is that immunity is transient and lasts for about 4 months or something like that.

So the whole picture of immunity here is still not clear. We do know that for immunization we have to raise antibodies in the binding domain of the viral spiked protein.

Asymptomatic transmission, or maybe lack thereof, is a hot controversy as we talk, with confusing messaging from the WHO. Yeah. I don't know how that got out from WHO, and what exactly they were talking about. They said, without documentation, that they couldn't find many cases of spread in asymptomatic infected people. But we do know there are lots of people with no symptoms who do transmit. What's being conflated is whether they remain asymptomatic or are actually pre-symptomatic and will develop symptoms.

Isn't it true that viral load seems to be increasing steadily until somebody does become symptomatic, and that this would likely mean higher transmission then?

Yes, it's not yet clear, but it's likely that you have the highest viral load right around the time of the first day of symptoms.

That's important.

You trained in pediatrics. Transmission and symptoms in children has been a confusing picture too.

Children under ten have fewer receptors than teenagers, who have less than adults. So the observation that only 2% of total cases are in children and adolescents, at least in the US, leads people to think that children are less likely to get infected and to transmit, which I think is true, but it's not zero. So there are 75,000 or so cases under 17 years, a disproportionately small percentage, but it does occur. Children tend to get it from older people in the family and are not commonly the first person in the family to get it. So taking it out to schools, it might be that this is different from influenza A, where schoolchildren are huge transmitters and amplifiers of infection. This is based on narrow evidence and I'm worried we don't yet have the big studies to clarify it.

What should schools be doing at this point?

We also haven't seen big spread in schools, but that's likely at least partly as most schools here have not been in session.

But some are coming back into session and it's important to follow that. There have been high school outbreaks in France and Israel, and it's likely older kids will be much more like adults than younger children in terms of transmission. So I think we can imagine how to get schools open, and I think we can bring elementary kids back by minimizing mixing with separate lunchtimes and recesses, morning versus afternoon sessions, so that you have a smaller cohort of kids mixing together, kind of like having those watertight compartments in a ship to keep spills to one place. High school will be much more difficult, with less mixing, everybody having to wear masks, and so forth.

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Regarding vaccines, how optimistic are you?

I'm optimistic. I think that based on what Tony Fauci and Francis Collins, head of NIH, have said, we have to be optimistic.

We have vaccines in trials or going into trials, so we should have a couple vaccine candidates by the end of the year. The questions there are about choosing which antigen we're going to go with, or both, and we have the manufacturing capability to do it pretty quickly. Then the question is who gets it first - do we prioritize health care workers, longterm care facility residents, and so forth? And then we would think about more vulnerable people, geographical areas with ongoing high transmission, and so forth. Remember when we had the new swine flu vaccine in 2009 there was a big press to get it into healthcare workers and pregnant women, and we'll see this kind of staged approach to who gets it first.

You are starting up some research into healthcare worker risk.

Healthcare workers are at risk, but there are not a lot of cases in the Bay Area so far, to be frank. It's not that kind of overwhelming caseload we saw in Italy and New York, for example.

Stanford screened all its workers and found about 0.3% infection. We may not see enough incidence to give us a lot of answers regarding real risk here.

Masks are a hot topic, with evidence and recommendations that this is a big factor in reducing transmission.

Absolutely. This is what is going to save us. Too many of us seem incapable of maintaining social distancing, and of not entering risky situations. So masks are a huge deal. These are simple masks, and we're not asking people to wear N95s. Because of asymptomatic transmission people are spreading the virus without knowing it.

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Responses to COVID Finally, if you were appointed Covid "czar' - after the next election - what are your main first orders?

Hmm. Don't do or say stupid things? I think we have to temporize until a vaccine is here, meaning wearing masks, keeping social distance, figuring out how to safely do larger events, and lean on the federal government pushing the research agenda, chasing therapeutics and vaccines, get everybody on the same page so we don't have a patchwork of interventions around the country. That's a big problem.

Regarding "reopening," we are seeing states that started this early having new surges in cases. California is being more cautious. What might we see?

I don't see that these states will go backwards, but we want to see them slow down, push masks, social distancing, and avoid the kind of "meat market" gatherings we saw over Memorial Day weekend.

Do you see the "Spanish Flu" of 100 years ago, with a big 'second wave' of infection and mortality in the Fall, is the cautionary case study here?

You would think so, right? But that doesn't seem to have sunk in very widely.

How about big events like sporting events - would you feel that these should continue to be shut down for the time being?

Well, I think there are some ways around it, depending on the sport and such. I have pictures of the Pacific Coast baseball league from 1918 where the batter, umpire and catcher all have masks on. So you can do it. Some will depend on which sport.

It will also really come down to frequent screening and essentially quarantining. I could see that happening. But it will still be something of a mess.

What about the "politics' of all this - what do you think of our governmental response so far? Way back in early HIV days we had Reagan not even mentioning AIDS, and now we have a guy many of us wish might not talk about Covid…

(Laughing, ruefully) Exactly. Our federal response here has not been impressive. Tony Fauci is totally impressive, but CDC has not been particularly impressive, at least in leadership - the next tier down has been very smart and capable and impressive. It's tough.

One argument now is that the economic shutdown could have more negative health impacts than the virus would have.

That's pure conjecture, with no evidence.

How about resuming travel at this point?

It depends on where you're going and what you're doing when you get there. I had a daughter just here from Virginia who just went back, and I didn't say don't do it. Planes may be safer than a lot of other things we do.

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This all entails a big increase in public health resources, but historically that's been shortchanged, as when prevention succeeds, nothing happens, so people don't value it.

Uh-huh. How much should we spend on public health? Six percent of our budget, as an ounce of prevention is indeed worth a pound of cure. At a minimum.

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agency to reduce firearm injuries in America. Furthermore, the report would enable effective legislation, guide research, dispel myths, and educate the public, and serve as a credible resource for best evidence regarding the determinants of gun violence.

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

Peter T. Masiakos, MS, MD, FACS, FAAP is a Pediatric Surgeon and the Director of Pediatric Trauma Service at Massachusetts General Hospital (MGH) and the Co-Director of the MGH Center for Gun Violence Prevention. He is an Associate Professor of Surgery at Harvard Medical School and an Associate Visiting Surgeon at MGH, and has a clinical interest in pediatric trauma care and injury prevention advocacy.

References 1. Historical Surgeon General’s Reports | Smoking & Tobacco Use | CDC [Internet]. 2019. Available from: https://www.cdc.gov/ tobacco/data_statistics/sgr/historical-reports/index.htm 2 AMA press release June 14, 2016 “AMA Calls Gun Violence a Public Health Crisis.” Available at US News and World Report, June 14, 2016 https://www.usnews.com/news/articles/2016-06-14/ ama-calls-gun-violence-a-public-health-crisis 3 Maa J, Darzi A. Firearm Injuries and Violence Prevention- the Potential Power of a Surgeon General's Report. N Engl J Med. 2018 Aug 2;379(5):408-410.

4 Congress.gov – HR 1114 introduced in the 116th Congress – “to require the Surgeon General of the Public Health Service to submit to Congress an annual report on the effects of gun violence on public health.” https://www.congress.gov/bill/116th-congress/ house-bill/1114 5 Masiakos P Editor. Current Trauma Reports Topical Collection on Firearm Injuries. https://link.springer.com/journal/40719/5/4

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THE MORAL PANDEMIC OF COVID-19 Charles E. Binkley, MD, FACS COVID-19 has presented a seemingly endless litany of moral crises. Soul wrenching decisions such as how to allocate a single ventilator between two equally deserving patients, or how to keep clinicians safe despite inadequate personal protective equipment (PPE) will certainly leave lasting moral residue. A lack of transparency and the propagation of misinformation, at times seemingly unchecked by medical authorities or institutions dedicated to public health, have eroded trust. Concerns about inadequate PPE, pleas for accurate information, and attempts to assure the common good of humanity have often received an overwhelmingly authoritarian response. These leaders have stripped away the veneer of transparency, democracy, and our “speak up” culture, risking a greater and more enduring moral harm than the virus itself.

The earliest and most profound example is that of the Chinese government in attempting to silence Dr. Li Wenliang when he warned colleagues about a cluster of patients with SARS (severe acute respiratory syndrome) like symptoms. Detained by the government, Dr. Li was threatened with punishment if he continued to speak out about the patients he had observed in Wuhan. Dr. Li died from COVID-19 and is now hailed as a martyr for transparency and justice. In Hungary, Turkmenistan, and the Philippines, government leaders have used the pandemic to seize greater control, limit free speech, and silence their critics. In the United Kingdom, police have used authoritarian tactics to enforce social distancing policies, leading one former supreme court justice to be concerned that such precedent would risk setting Britain up as a “police state.”

Multiple reports have emerged of physicians, nurses, and other health care workers being threatened, suspended, and terminated after speaking out about the lack of adequate safety measures to protect staff and patients. This led a group with medical, legal, and advocacy backgrounds to start Beacon, an organization that assists health care workers who have been silenced, terminated, or disciplined after speaking up about unsafe workplace conditions.

Another pattern that has emerged is calling into question the emotional stability of whistleblowers and those who raise legitimate concerns, thereby discrediting the source and discounting their claims. U.S. Navy Captain Brett Crozier, commander of the aircraft carrier Theodore Roosevelt, was dismissed by former acting Secretary of the Navy Thomas Modly after Crozier alerted Navy officials about a COVID-19 outbreak aboard his ship. In dismissing Crozier, Modly implied that Crozier had become emotionally “overwhelm[ed].” Similarly, when a whistleblower raised concerns about the inadequacy of training and PPE given to a team from the CDC sent to help process Americans evacuated from China and other areas with high rates of COVID-19 infection, the whistleblower’s “mental health and emotional stability” was questioned.

In contrast to these latent authoritarian tendencies which COVID-19 has unmasked are instances of effective and decisive leadership. San Francisco Mayor London Breed is one example. As Russell Berman put it in the April 12, 2020, issue of The Atlantic, “Mayor London Breed’s early and aggressive moves to contain the outbreak have made San Francisco a national model.”

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How does one determine whether an act is immoral and authoritarian or virtuous and decisive? Some may argue that the outcome determines how history will judge such acts, however the ethical crux seems to reside in the principles on which, and the process whereby these decisions are made.

Veracity, or truth telling, is one of the foundations of public trust.

Suppressing truthful voices when they attempt to speak up about unsafe conditions or inadequate protections erodes trust. Similarly, governmental suppression of data, promotion of misleading information, and discrediting whistleblowers is detrimental to the common good. The lasting effect of these shows of authority is to deter others in the future from expressing potentially life-saving concerns. In contrast, virtuous leadership is honest and seeks to reveal the truth, even when it may be painful and unflattering. Such truth can lead to change, such as that which we are seeing all across the country as individuals, businesses, and governments finally embrace the truth about racism and police brutality.

The harm principle is used to justify the restriction of individual freedoms when such restriction results in a greater benefit to society. It is the ethical justification for quarantine and “shelter in place” orders. However, in order to be justified, such restrictions must be proportionate, meaning that they are the least restrictive and of the shortest duration to meet the stated goal. Whereas authoritarian systems have capitalized on the pandemic to limit freedom for their own gain, moral leadership has based restrictions on scientific data with identified benchmarks for the incremental easing of limitations.

Procedural justice requires that the process whereby decisions are made be collaborative and transparent, that the decisions be enacted equitably, and that there be a system for accountability.

This is perhaps the most important element in determining whether the action of a leader is ethical, particularly when the decision involves the potential harm of another person. Sometimes leaders are forced to choose between two bad options, and they must pick the one that is less bad. Sometimes there are competing interests, such as loyalty to a brand and loyalty to colleagues. Sometimes implicit and systemic biases unjustly affect decisions. Despite these confounding factors, an ethical process for decision making will welcome criticism, be just in its application, and subject itself to accountability.

Finally, one should be wary of a leader who is absolutely sure of their justification for a difficult and value-laden decision, who is stubbornly convinced of their moral grounds. Decisions that affect others, particularly if there is a chance for harm, must be approached humbly, no matter who is making the decision.

A truthful leader who is proportionate, just, and humble will be judged favorably by history, regardless of the outcome of their action.

Charles E. Binkley, MD is a surgeon and Director of Bioethics at the Markkula Center for Applied Ethics at Santa Clara University.

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SAFE PRACTICES IN THE COVID ERA: RE-OPENING OUR OFFICES Michael Schrader, MD, PhD As physicians our duty is to do our utmost to protect patients, staff, and ourselves from Covid19. Many of our patients belong to the most vulnerable groups and the nature of our profession is to evaluate the ill.

The stealthy pattern of Covid-19 transmission and its novelty make barriers to transmission harder as do confusing and impractical recommendations. For example, maintaining six feet of distance among staff when hallways are four feet wide. Seemingly healthy people may be infectious.

We have tried to consider practical measures to reopening a medical practice. The most important intervention is to educate ourselves, our staff, and our patients.

It starts with wearing masks and not coming to work if ill or exposed to a case.

Observing social distancing to the extent possible is also an impor-

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tant aim. Promoting physical distancing, temporal distancing, barriers, and disinfection are the best means we have to prevent infection. The adoption of telemedicine has greatly expanded the potential for distancing and decreasing flow through the office.

We have a small office with between four and eight doctors and staff on any given day. During the initial part of the shelter order we tried working from home. The main difficulties we faced were transferring a multi-line phone system to staff cell phones and the onerous HIPAA restrictions on electronic communications.

We have limited the occupancy of the waiting room. We have sealed the waiting room window.

We have constructed a barrier between the exam rooms and the rest of the office. These measures may not be transferable to other office layouts.

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PHYSICIAN WELLNESS

Put on Your Own Oxygen Mask First Jessica Mahoney, MD The necessity of putting on our own and compassion for yourself and others.

A Moment In Time oxygen mask first has never been more Use mindfulness as a form of preventive A moment in time. clear than now, during COVID. care or PPE for your emotional health.

Even this moment is just that - a moment.

Bringing wellness into the mainstream Intentionally choosing your thoughts Yet we make each moment so much more. culture of medicine and empowering and is a form of directed mindfulness. Not letWithout intention or consciousness, we give moments an adjective. The adjective determines healing healers so they can heal others has ting our minds go unmanaged and causing the story. Our control, our experience, our been the focus of my leadership work my unnecessary struggle is powerful self-care. feelings, our joy, our contentment, our overwhelm and our exhaustion come from entire career in medicine.

Medicine and life itself are already chalthe adjective we choose.

It took a pandemic to bring national lenging enough without adding in uninThis COVID moment could be: widespread focus to this issue. The cultural tentional thoughts that make it harder. You A defining moment. shift is finally beginning. For the sustaincan learn to notice and be aware of your An overwhelming moment. naturally occurring thoughts. As physiability of the practice of medicine and for A chaotic moment.

A tragic moment. the health of all of us, it is time. We must cians we are trained to spot problems and Or it could be: continue to keep the spotlight on the imporplan for the worst. Negativity bias causes A pivotal moment. us to feel more anxiety, fear, and scarcity. tance of optimally caring for our healers An opportune moment.

Allow compassion for your highly-trained even after this pandemic has passed.

An inspiring moment. brain. Opting out of self-judgement is part If doctors are not well, they cannot heal It could be: of self-care. others to the best of their abilities. They A loving moment.

Once you notice and accept the cornumust care for themselves so they can best A moment of awe. care for others. The culture of self-sacrifice copia of negative thoughts in your head, A healing moment. in medicine is outdated. Professional athyou can intentionally shift your focus to A growing moment. more helpful yet equally true thoughts. letes optimize their own health and wellness A life-changing moment.

This is not to minimize the challenges, so they can perform optimally. Physicians A mindful moment. stresses, or tragedy at hand. It is to allow are asked to perform at an equally high, if A moment of pause. you to change your experience of it. When not higher level, for longer careers. Human A moment of presence. you focus your mind on more positive lives are at stake.

The moment you shifted course. thoughts you struggle less, and experi We must start to create a culture within medicine where physician self-care is nurtured and valued. Selfence less stress, emotional exhaustion, and vicarious trauma. care is not selfish. It is needed and important. Through modeling Choosing thoughts that highlight what is abundant rather than self-care and allowing and encouraging others to do the same, scarce and what is in your control rather than happening “to we will save the most lives and the practice of medicine as a you” is like turning on the oxygen flowing through your mask. sustainable career.

Self care is a gift for ourselves and for those to whom we I hope you will all start by starting. Make a commitment to provide care. With our physician oxygen masks on, medicine prioritize your sleep, to eat healthy food, to get some exercise will be a more healing and healthy space for all. and fresh air, and to make time for connections with others as Dr. Jessie Mahoney is a Pediatrician, a Phywell as for recovery. If it seems hard, it is likely because judgsician Coach, long-time Physician Wellness mental thoughts about scarcity, time, and value are getting in Leader, and yoga and mindfulness instructhe way. tor. She served as a Chief of Physician Health Breathing is another a simple and accessible tool for selfWellness at TPMG for many years. She is the care. Many physicians hold their breath throughout the day. former Chair of the CMA Subcommittee on Physician Wellness, and the current Chair of Your breath is always available. Deep breaths are healing and the SFMMS Task Force on Physician Wellness. change the reactivity of your nervous system. Paying attention She speaks on physician wellness, burnout, to the breath and using it to nourish yourself and create space coaching and mindfulness frequently and she is a founding leader can make a huge difference. of the Mindful Healthcare Collective. She currently coaches indi Mindfulness is also an evidence-based self-care tool that vidual physicians who are struggling or who want to find more impacts health and performance that can easily fit into the life of calm, contentment and meaning in their personal and professional a physician. You can do it anywhere anytime. Just pause and be lives through Pause and Presence Coaching. She also provides present. Notice and allow. Don’t make it complicated. It is a pracgroup coaching for fellows at Stanford. She can be reached at tice and is not about perfection. Use mindfulness to create space jessie@jessiemahoneymd.com.

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PANDEMIC PLAYBOOK DIARIES:

EMERGENCY PHYSICIANS CONFRONT COVID-19 Scott J. Campbell, MD, MPH and Hallam Gugelmann, MD, MPH The San Francisco Emergency Physicians Association (SFEPA) was established in 1987, and now serves as a centralized hub of communication and action for the city’s emergency departments.

As practicing clinicians and the organization’s presidents, we have had the privilege of watching the evolving SARS-CoV-2 pandemic from two perspectives: entrenched in our own emergency rooms, and with the input and insights from frontline physicians in each of the city’s frontline emergency rooms. In hindsight, our journey began back in September of 2019, although at that time we had no idea of what was in store for the city and our world.

We have compiled our perspective in a timeline below, and then present the concerns for ongoing evolution of the pandemic as we see them.

A TIMELINE 9/18/2019: The Chinese government sends 20 physicians to San Francisco from Szechuan, China to study disaster preparedness.

For nine hours, a group of ten San Francisco emergency physicians presented the city’s approach and philosophy, with the help of a Mandarin interpreter, in a conference room at Kaiser San Francisco. Also present was the state’s assistant director of public health, Dr. Charity Dean.

1/20/2020: Washington state identifies and confirms what was, at that time, believed to be the first US case of COVID-19: a man returning to the US from Wuhan, China is hospitalized.

1/21/2020: SFEPA holds its end of year dinner in San Francisco’s Marina. Dr. John Brown, a long-standing SFEPA member and Medical Director of the San Francisco Emergency Medical Services Agency since 1996, is unable to attend due to citywide Superbowl planning and talk of a novel viral threat.

1/23/2020: Wuhan, China is placed under lockdown.

2/7/2020: Dr. Li Wenliang, Chinese physician and COVID-19 whistleblower, dies of the disease.

2/15/2020: The San Francisco Marin Medical Society publishes an article with four lessons learned from the September 2019 Chinese delegates visit, including the critical role of horizontal communications across medical specialties; the need to predict and plan for extreme disaster scenarios; generate mechanisms to facilitate “reverse triage” for mass disaster planning; and the need to brush up on those rusty skills sitting just outside our respective comfort zones. In a personal communication to the SFEPA, physician delegates from China email requesting contact information for US manufacturers of ventilators and personal protective equipment (PPE).

2/17/2020: In retrospect, the US has its second COVID-19 death: a Santa Clara man dies, and a delayed autopsy in 4/2020 identifies the cause. The SFEPA tests its emergency department back line system, which allows for direct communication between physicians on the ground in all of the city’s emergency departments in the event of an emergency.

2/19/2020: Fit testing for N95, donning and doffing of PPE, and instruction on the use of powered air-purifying respirators (PAPRs) for KSF ED physicians.

2/23/2020: Italy is now the country with the 3rd highest number of cases, with the beginnings of exponential case growth.

2/29/2020: The United States reports its first death from COVID-19.

3/2/2020: The SFEPA sends out its “National COVID-19 Readiness Survey” to every emergency physician we know. A total of 250 individuals from around the nation responded to a simple set of 20 questions on emergency preparedness. Over the next three days, alarming responses from frontline emergency physicians signal a crippling overcrowding of the emergency system, combined with a lack of equipment, medications, ventilators, and an overall lack of preparedness for what was now being called a pandemic. An SFEPA member is placed in quarantine after exposure to a patient with COVID-19 from a cruise ship; public health investigations are ongoing. (Go here to see our survey results: https://bit.ly/3e0Eczf) 3/5/2020: The Grand Princess cruise ship is quarantined off the SF coast.

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3/8/2020: Two physician colleagues of Scott’s are diagnosed with COVID-19 after he travels with them for a ski trip to Vail, Colorado, where hundreds of Italian and South American spring breakers had been the week before.

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3/14/2020: While on shift, faced with a homeless patient whose symptoms are concerning for COVID-19 but don’t meet criteria for admission, Hallam is told by an infectious disease specialist from the CDC that “there’s just no way we could’ve anticipated these issues with the homeless.” The patient is admitted for the 3 days required for a PCR test to be performed; he refuses to stay in his room and wanders the corridors without a mask on.

3/16/2020: San Francisco issues its “shelter in place” order. The SFEPA distributes its second National COVID-19 readiness survey.

3/17/2020: In a 30 minute call with the US Department of Homeland Security, Scott and Hallam explain the results of our survey, and the alarming sense of inadequacy of preparedness around PPE, ventilators, and other equipment and processes. The reaction and response from the DHS contains two overarching themes: “Thank you for your service,” and “Don’t worry, ASPR (Assistant Secretary for Preparedness and Response) has this covered.” On this day, the US confirmed more than 1,600 cases, to a total of more than 6,000 cases in the country.

3/23/2020: Scott begins building a real-time COVID patient digital tracker with help from an analytics team at Kaiser SF, tracking every potential case seen in the Kaiser SF emergency room since 3/1/2020 and their medical journey from there.

3/24/2020: SFEPA initiates a city-wide COVID-19 update phone meeting, a weekly “check-in” on all SF emergency departments.

Topics include availability of PPE, emergency preparedness, problems encountered, and a perplexingly low emergency department census across the city. SFEPA member Dr. Lily Muldoon begins coordinating manufacture of face shields and intubation boxes using otherwise shuttered Bay Area plastics processing facilities, coordinating supply and demand through #GetUsPPE.

3/27/2020: Exactly 10 days after reassurances from ASPR, the US now leads the world and confirmed cases with more than 100,000 cases, and more than 1,500 deaths, per Johns Hopkins University figures.

3/31/2020: Citywide reports at the SFEPA’s weekly meeting bring home the crippling effect of the US’s failed testing efforts: SARSCoV-2 PCR test turnaround times average 4-6 days for discharged patients, and emergency room physicians are scrambling to identify appropriate contact tracing support.

4/6/2020: Day 21 of shelter in place in SF. The daily growth rate of cases in the city is now 2%. As we watch the curve flatten we can’t help but worry about the inevitable need for herd immunity to protect the population; conversations with colleagues ensue about how to triple the beds in an intensive care unit.

4/7/2020: The SFEPA’s weekly call discusses a disturbing trend of COVID-19 cases from the underserved and impoverished southern end of San Francisco. Although technology for PCR testing has improved, availability progresses in fits and starts.

Johns Hopkins reports that more than 74,000 people have died worldwide; New York State’s death toll approaches 5,500.

4/14/2020: SFEPA weekly call: topics of note include impending PPE shortages, staff anxiety, mental health service needs for providers, homeless and skilled nursing placement issues, testing sensitivity and specificity, and the ongoing conundrum of preWWW.SFMMS.ORG

paring for a surge while facing a historically low volume of emergency patients across the grid.

4/30/3030: As part of deliberations on additional alternate care sites for an eventual surge, Scott tours the old CPMC Pacific campus with Dr Tom Peitz. Brainstorming: “Are we really going to need this place?”

5/1/2020: Scott is contacted by a family member: their 10 year old son has positive IgM antibodies to SARS-CoV-2. He is now faced with the arduous task of describing medical uncertainty, and is left wondering why the test was ordered.

6/2/2020: Final weekly Covid-19 SFEPA call.

6/4/2020: San Francisco records 2,698 COVID 19 positive cases, with 43 deaths; the city’s case fatality rate is 1.6%, and its day over day growth rate is 1%.

6/5/2020: On shift in the emergency room, Hallam is increasingly facing patients presenting with delayed diagnoses: ignored mild heart attacks now in fulminant heart failure; metastatic liver cancer with months of weight loss; gangrenous lacerations that went without medical attention. Each time, the story is the same: The patient knew something was wrong, knew they should go to the hospital, but didn’t want to get the coronavirus.

As the SFEPA’s leadership contemplates the concerns and fears of the past six months, we can’t help but feel even more apprehensive about the next phase of this pandemic. Through a timely shelter in place order and an extremely dedicated cadre of essential workers—and with a great economic toll—the Bay Area has flattened its curve… for now. But the tireless dedication that all of us have shown to self-isolation and quarantine may have delayed an inevitable surge. Without a vaccine, effective treatments, or at least a cohesive nationwide strategy involving social distancing, rigorous universal testing, and contact tracing, the Bay Area will face an unprecedented influx of critically ill COVID-19 patients. The SFEPA has seen the area’s emergency departments muster their resources to face this onslaught, but our stalemate is tenuous at best. As the area’s economy gradually begins emerging from its forced hibernation, as protestors rightly take to the street to protest a system plagued by inequity, the SFEPA remains alert, but with a plea: wear a mask and wash your hands.

Scott J. Campbell, MD, MPH is in Kaiser San Francisco's Department of Emergency Medicine, Emergency Medicine Services Liaison to the City of San Francisco and Co-President, San Francisco Emergency Physicians Association.

Hallam Gugelmann, MD, MPH is Attending Physician, CPMC Mission Bernal Hospital Emergency Department. Medical Director, Safety Science, Genentech South San Francisco.

Medical Toxicology Attending, University of California at San Francisco Assistant Medical Director, California Poison Control System, San Francisco Division and Co-President, San Francisco Emergency Physicians Association.

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Responses to COVID

NOVEL CONCEPTS TO PRESERVE TRADITIONAL PRIVATE PRACTICE: How a Medical Group is Saving Independent PhysicianOwned Offices in the time of COVID Joseph Woo, MD and Man-Kit Leung, MD Traditional private practice was already reeling. In fact, according to recent AMA Benchmark Surveys, 2016 was the first year in which less than half of physicians (47.1 percent) had an ownership stake in their practices, and 2018 marked the first year in which there were more physician employees (47.4 percent) than physician owners (45.9 percent). Faced with increasing overhead costs and decreasing reimbursement, the future of private practice was already unstable.

Then COVID-19 struck. With shelter-in-place (SIP) orders forcing cancellations of routine appointments and elective procedures, independent private practices are now facing drastic reductions in patient volume and devastating financial losses. SFMMS sat down with Dr. L. Eric Leung, Chairperson of the Asian American Medical Group (AAMG) and private practice ophthalmologist, who shared how one local medical group is trying to save independent private practice.

Eric, why has traditional private practice been in decline?

Many people believe that the private practice doctor is an endangered species. Recruiting young doctors is challenging.

Physician reimbursements have been worsening. We have high overhead that doesn’t scale. For years, these are some of the complaints that the physicians of the San Francisco Chinese Community would voice at their yearly retreat. The situation is actually much more ominous when you consider these same doctors safeguard the health of the underserved Chinatown Community.

How has the COVID-19 pandemic exacerbated the difficulties of private practice?

Not only are our physicians now risking their lives to care for their patients, but the private practice physician had the additional stresses of Shelter In Place. Elective procedures were prohibited, outpatient visits trickled, and consultations were almost non-existent. Several representative specialists report only 10% of normal volume. How can this doctor pay his employees or his rent even as he forgoes his own needs? The situation may force many physicians out of practice and unable to care for the community they love.

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How is AAMG trying to save the independent physicianowned practice?

AAMG is a physician-owned organization that is responsive to doctors, run by practicing doctors, and based on a philosophy of putting our community first. We already knew that our physicians were committed and providing great care, but no other group was aligning accountability, effort, reward, and displaying information to the doctors in a transparent manner.

Way before COVID, we noticed that most of the young physicians who were coming to the community were the children of existing physicians. We asked ourselves, how do you set up a system that mimics a parent bringing you into practice?

To this end, we set up a centralized billing service, provided a free doctor focused EMR/practice management system, and sent out techs to give MIPS assistance. We also committed to subsidize SFMMS and CMA membership as we value the contributions of organized medicine.

We then made a drastic change to remuneration issues for primary care E&M coding. After all, that is not the way Medicare compensates a health plan or medical group. Why not reimburse the doctor the same way that Medicare pays the medical group? Take what the insurer pays the medical group, subtract the costs of care, and the remainder goes to the physicians. It’s that simple. Now the doctors are motivated to take care of multiple health conditions and preventative services because value based care rewards for these metrics. For the past three and a half years, AAMG has been paying adult PCPs on this model and continues to have the most generous capitation rate in the Bay Area; 3-4 times more than its closest competitor. Thus in the time of COVID, cash flow is preserved to their practices allowing the PCPs to adapt to telehealth and other strategies to care for their patients.

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In this model, aren’t PCPs incentivized to decrease specialist referrals to decrease cost of care?

Absolutely not! We do not view specialists as cost centers, but rather as critical components of our care team. For that reason they are rewarded for both quality and for clinical integration, resulting in a very competitive rate. We then developed a ‘shared savings’ program to give specialists a large portion of the funds from improving the efficiency of care. However, the nature of specialist practice has them remain on a fee for service model.

So in the midst of this crisis, they are the most vulnerable to the sequelae of shelter in place.

How is AAMG helping practices facing acutely reduced cash flow?

The medical group itself is in a secure financial situation. As a risk bearing organization, it receives uninterrupted funds from its health plans to provide professional services to its network.

Thus, it is actually in a position to profit handsomely from a steep decline in utilization. Morally, we can’t do that. After all, the group had no hand in eliminating waste, increasing efficiency, or developing some ingenious business strategy. Further, just in terms of strategy, we feel the group is more competitive by preserving its robust specialty network.

Since the announcement of SIP, we quickly mobilized any funds that could be immediately payable to its doctors (withholds, clinical integration incentives). Then, AAMG’s leadership decided it would put itself at some financial risk. First, AAMG elected to project its Specialist Shared Savings for the year and distribute it early and quickly. But more importantly, it developed its COVID Specialty Pillar Program (SPP).

The idea is to form as a financial bridge to get our committed specialists through this pandemic period. Using 2019 as a benchmark, the program calculates the average monthly claims for a given specialist and simply pays that sum to him/her. It’s a monthly capitation of sorts based on last year’s claims. This is money that would have been artificial profit to the group. As each month passes, the payment will decrease by the specialist’s claims until such time that claims exceed SPP payments.

This move commits more than $3million towards the viability of our Specialist practices, a vast sum for a small medical group.

In the end, this is the right thing to do. Medical Groups and Health Plans who end up profiting from the misfortunes of doctors during this COVID pandemic period (and we know there will be many) do not hold themselves to the same vision and standards as AAMG. We have no desire, and perhaps more significantly, have no need to profit off the backs of physicians during this unprecedented time. Moreover, our actions compliment the April CMA sustainability proposal to the California Legislature.

This request asks that Insurers “issue one-time grant payments to In-Network Providers based on previous year’s average billings” to protect provider networks.

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Is AAMG open to non-Asian physicians or patients?

Good concepts transcend ethnicity. Historically, we started with predominantly Asian physicians and patients, however, we’ve now had success beyond that in other parts of the City.

We will continue to grow among those physicians and patients who believe in our mission regardless of race, demographics, or geography.

How do you envision the future of private practice after the pandemic?

Of course, telemedicine is here to stay. Our physicians are commenting that it is a very efficient way to provide care. The challenge remains to access those patients without computers or smartphones and to teach those with less IT experience.

Also, we’ve learned that our patients still love having their own independent doctor who knows them well and cares for them as individuals. Cost effective, individualized care has never gone out of style.

From the doctor’s perspective, private practice continues to appeal to many young physicians who have an independent, entrepreneurial spirit. Clearly, we are in competition with employed physician organizations. We’ve adapted by implementing a ‘hybrid model’ which integrates most of the benefits of private practice yet centralizes and assumes many of the headaches. In this way we are trying to get the best of both worlds.

Most importantly, we believe that our culture based on rewarding effort, the alignment of group and physician motivation, and transparency will continue to be successful. The future is bright for physician centric/run groups.

Joseph Woo is an Emergency Physician and is on the Boards of both AAMG and SFMMS.

Man-Kit Leung is an Otolaryngologist, Past President of SFMMS, and on the Board of AAMG.

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Responses to COVID

THE COMMUNITY READINESS COLLABORATIVE: A Targeted COVID-19 Mitigation Program for Residential Care Facilities for the Elderly in Marin County David Miller, MD, MPH The COVID-19 pandemic has resulted in an outsized number of fatalities among residents of long-term care facilities, yet there is little published evidence on how best to protect these facilities and their inhabitants. Since late March 2020, the Community Readiness Collaborative, consisting of San Rafael Kaiser Permanente, MarinHealth, and Marin Health and Human Services has pursued a shared vision focused on supporting the long-term care facilities in order to protect the health and Photo by Lisa Beth Anderson safety of their residents and staff.

The Residential Care Facilities for the Elderly (RCFEs) are non-medical facilities providing housing for residents 60 years and older, and include Board and Care, Assisted Living, Memory Care, and Independent Living. Some are backed by corporate entities, while others are small independently-operated businesses. RCFEs house a large volume of vulnerable residents, with an estimated 1,744 residents in Marin county alone.

SARS CoV-2 may enter these congregate settings via residents, visitors, and staff. The essential workers that comprise the RCFE workforce have experienced disproportionate rates of infection during “shelter in place” and frequently work at multiple facilities, thus providing avenues for viral cross pollination.

The COVID-19 pandemic presents extraordinary challenges for RCFE administrators; they have had to implement new infection prevention measures, monitor residents and staff for symptoms of illness, and develop outbreak containment strategies.

Moreover, they have had to operationalize these strategies using non-medically trained staff, in a setting of supply chain shortage, and with typically little access to clinical guidance or training.

Complicating matters, staff anxiety and exodus from these workplaces frequently threatens to destabilize facilities, leaving their resources even more stressed.

In March 2020, it became clear that this vulnerable population needed attention both from a human rights standpoint as well as from a practical standpoint to avoid a major hospital surge of elderly COVID patients. While the impetus and design for this targeted community focus started at Kaiser Permanente, it quickly became clear that no siloed hospital, physician 24

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group, or County Department of Health was scaled to meet the community challenges presented by pandemic without partnering together. Kaiser Permanente’s comprehensive and integrated system provided flexibility that was key to repurposing staff with skillsets that would become useful for our community efforts.

My concern, as an Infectious Diseases specialist, was that these facilities were not only at risk, but could become an incubator for the entire community. After one RCFE administrator kindly toured me through his painstaking preparedness efforts and challenges, I had a better understanding of how we might design a support team. Within a week we organized a small team of nurses to respond to calls from RCFEs to provide testing of patients with potential symptoms (PUI) on-site and ensure proper PPE implementation while awaiting test results.

From there, our structure and operations organically adapted to meet the needs of the RCFE community.

Kaiser Permanente members comprise an estimated 40% of the RCFE resident population, with variable penetrance per RFCE, so we extended an offer to partner with other community hospitals including MarinHealth which was also eager to address the pandemic needs of the congregate settings. Upon outbreak detection, we joined forces with Marin Health and Human Services (Marin HHS, the county department of public health) for outbreak management. Our agencies met in the field to crosstrain, share resources, and workshop our methods together.

The result of this work is what we call the Community Readiness Collaborative (CORE Collaborative), an innovative parallel team approach utilizing a Mobile Assessment and Triage Team (MATT), and an Education-based Capacity Building Team (ECBT), supported by a Life Care Planning program (LCP).

Together with Marin HHS and MarinHealth we partner with RCFEs to help build their capacity and draw them closer into the healthcare network in order to best protect and care for their residents during the pandemic.

MATT is a clinical fieldwork team largely staffed by physician assistants (PA), and nurse practitioners (NP) who provide WWW.SFMMS.ORG

onsite clinical assessments, COVID-19 testing, POLST reconciliation, and basic facility assessments for COVID-19 preparedness.

MATT operations are led by a team of internists and geriatricians with supportive expertise from an infectious disease specialist.

MATT responds to field calls in order to assess symptomatic residents who would otherwise need hospital transfer for testing.

During these visits, we ensure sufficient PPE is on-hand and that proper practices are in place for resident isolation. The CORE Collaborative leverages our full networks of hospital, clinic, and Department of Public Health data and contact tracing to provide early outbreak identification and management. We participate every morning in a multi-agency call to collate our data, strategize our approach, and coordinate our efforts.

RCFE operations can also benefit from medical community support to meet the pandemic challenges. The RCFE staff workers vary in levels of training, and the facilities differ in resources and access to external support. Residents often have intensive supportive needs and/or behaviors (such as wandering) that make implementation of infection control practices challenging. To help build capacity in this complex environment, the ECBT is deployed to provide education appropriate for the varying levels of skill, training, learning, and language needs. The ECBT is comprised of Health Educators working closely with Marin HHS counterparts. These Health Educators are well versed in adult learning and the intricacies of navigating behavior change. Focusing on implementation of “best practices” and de-escalation of staff anxiety, the ECBT uses outreach to visit facilities and prepare their staff for possible COVID-19 spread, and can provide stabilizing consultation to the RCFE staff during an outbreak.

Many residents in RCFEs prefer to be supported “at home,” and not to be transferred to the hospital for COVID-19 testing or care. Although a pandemic outbreak setting can make honoring and respecting these wishes difficult, it is essential that medical providers strive to do so. For this reason, the CORE Collaborative is supported by an integrated RCFE Life Care Planning Program as well as close partnerships with hospice agencies that enables rapid implementation of hospice when desired. The LCP team updates, reconciles, and provides facilities “best practices” for making POLST forms readily accessible should EMS be called.

Goals of care discussions tailored to the COVID-19 era are supported by a physician super-trainer, who specializes in the art of these complex discussions. For Kaiser Permanente members living in a facility in active outbreak, the LCP accelerates their processes in order to ensure that our most at-risk members, or their DPOAs, have an opportunity to clarify their wishes.

The CORE Collaborative operates in a dynamic environment with the support of Marin’s innovative County Public Health Department. Public health orders addressing this pandemic include employer disclosure of COVID-19 positive status, daily updated line list requirements for facilities, and palliative care automatic referrals for residents of congregate settings, and other measures. In parallel, Marin HHS has focused on ensuring testing for essential workers, including the employees (or those that live with the employees) of congregate care facilities, thus providing contact tracing leads to facilities exposed to SARS-CoV2.

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Over the last two months we have detected and managed COVID-19 outbreaks at 12 RCFEs. Because many of our outbreak detection and management methods also apply in the skilled nursing facilities (SNFs), we have been able to assist in responding to three SNF outbreaks. While in the first several weeks, the team was responding to more advanced outbreaks, we are now detecting pre-outbreaks (or “facility exposures”) captured through our contact tracing measures. This experience has allowed us to refine our outbreak management strategies specific to setting (i.e. Memory Care Center, Assisted Living, Independent living, etc) at a variety of outbreak stages. Our education teams have reached all RCFEs in the county to improve preparedness and have provided critical guidance to RCFE staff workers enduring intense stress during an outbreak.

Many of our COVID+ patients have elected hospice care, all of whom were able to receive this care “at home” in accordance to their wishes. Many others with symptoms potentially consistent with COVID-19 have tested negative and have been taken off isolation. We noted a sharp decline in RCFE hospital admissions during this time.

By investing in a comprehensive yet targeted community effort, ranging from medical assessment and triage to education and capacity building to high quality life care planning, the CORE Collaborative has saved lives and honored the wishes of our vulnerable patients living in congregate settings during this pandemic. We feel our work can serve as a model for addressing RCFE COVID-19 mitigation and as an alternative or adjunct intervention distinct from the resource intensive mass routine surveillance strategy currently gaining momentum in California.

This model promises to be especially pertinent in the time of lower community prevalence. We hope other counties can benefit from our experiences and adapt the lessons learned from our Marin Community Readiness Collaborative. SARS CoV-2 viral replication respects no institutional boundaries. We will fare much better with collaboration in this time of crisis.

Dr. David Miller is an infectious diseases specialist at Kaiser Permanente in San Rafael, California. The views expressed above are his own do not represent organizational statements from Kaiser Permanente.

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Responses to COVID

RATIONAL RATIONING: DEVELOPING GUIDELINES FOR TOUGH ETHICAL CHOICES IN THE COVID ERA William Andereck, MD Like most of you, I still sit in modified lockdown months into the Covid 19 pandemic.

At this point, it looks like San Francisco has been spared the infection rate and death counts experienced in other parts of the world. But in early March, we could see the virus coming and within a week the potential scarcity of our protective equipment and ICU resources, particularly ventilators, seemed like a looming reality.

The Ethic Of The Epidemic

First, it is important to recognize the psychological context of the times. Like 9/11, we had fallen through a rabbit hole into Alice’s strange new world. Fear changes your perspective in lots of ways, especially on what is important. Priorities and values shift in ways that are sometimes not so subtle. My colleague of many years, Professor Albert Jonsen, described it as the “ethic of an epidemic.” Letting a salvageable patient die is contrary to our acceptable moral standards. What is the ethical framework that would allow this to happen?

We had to recognize the traditional ethical principles of Medicine: avoiding harm, promoting benefit, respecting the individual rights and dignity of the patient, and respecting our responsibilities to promoting a just health care system (although this latter principle has always been a bit vague in the mind of those of us in the trenches). What became immediately apparent was that those responsibilities to “steward resources” took on an increasingly prominent role while an individual’s rights to receive a particular resource diminished proportionately.

Still, it remains that a "Duty to Care," incorporating principles of beneficence, nonmaleficence, and respect for persons is fundamental to medical care and cannot be abandoned by doctors and nurses at the bedside. The moral distress of being burdened with rationing decisions was considered too great to inflict on the direct providers.

We also recognized an organizational “Duty to Plan” as part of the principle to promote a just health care system. Insomuch as practitioners have a responsibility to steward resources at the micro level, health care organizations have a duty to develop 26

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a response plan and provide the appropriate resources to accomplish this goal. This duty is intertwined with a provider’s duty to care. How can a doctor fulfill their duty if they are not supplied with appropriate personal protective equipment?

An additional duty, stemming from our responsibilities to stewardship, is a “Duty to Transparency and Openness to Public Input.” If we are to be changing the rules within the context of an ethic of an epidemic, the public deserves to know what we are doing and why. They have a right to enter the conversation.

Identifying The Goal

Besides challenging our traditional moral principles, the immediacy of the situation also clarified our purpose. Our multicultural society, during normal times, enjoys a multiplicity of goals. For some it is to accumulate wealth, for others to enjoy friends and family, many work to improve our community. But in the time of a pandemic, everyone’s goal becomes crystalized – staying alive. Therefore, we began our framework by clearly stating its goal as “saving the most lives possible during the declared period of the pandemic” and made sure that all subsequent recommendations remained consistent with this unitary purpose.

This goal may seem obvious, but there are a number of ways to allocate resources, including by social status, ability to pay, potential contribution to society, randomly, and even equally.

We chose an ethical distribution framework based on need and expectation of survival with treatment. The stated point was to avoid any implication of considering the “worth” of any individual patient. Thus age, as a specific variable, was rejected as a means for prioritization.

Simultaneously, separate groups developing policies for other states and regions settled on a slightly different goal – saving the most “life-years.” In short, this means accounting for the number of remaining years a patient could be expected to live if they survived. Saving a 20-year-old would save more life years than an 80-year-old, or a 30-year-old for that matter. When applying the reasoned calculus of utilitarianism, this makes WWW.SFMMS.ORG

sense. Some on the Task Force were concerned that we would be disrespecting the wholeness of each life as it exists and troubled by thinking of people somehow as “lesser persons” or not worth saving based on the number of years of life they had remaining.

The CMA Ethics Task Force eventually settled on the clear, clean, and easily identifiable criteria of lives saved, regardless of whose. One reason for this decision was because we did not feel the “life years” concept had received adequate public discussion and input. Of note, all the policies that came out advocating some type of prioritization by age, co-morbidities, long term prognosis etc. were immediately challenged by disability advocates. Many of these guidelines have had to be modified.

Methods

Armed with a clear vision and firm understanding of the ethical principles governing our conduct, we were ready to assess the methods necessary to accomplish the goal.

Triage teams Psychologically, as well as ethically, it would be hard for a physician to knowingly remove, or not provide, a requested medical intervention that could save a patient’s life. Thus, decisions to provide, refuse, or remove a respirator are to be made by an impartial group of hospital personnel who have only clinical parameters on which to make their recommendations. The triage team would not only decide who receives a respirator, but also, on routine scheduled review, who would be allowed to remain on one. The triage teams would be available 24/7 during the declared time of the pandemic and communicate with the clinical teams as needed. Hopefully the remote decision-making process would help shield the providers from the emotional turmoil and distress experienced by our colleagues in other centers.

Exclusions We decided that, in the interest of fair access, the only exclusion criteria that would immediately eliminate someone from consideration of ventilator support were refusal to accept the treatment, ability to survive without a respirator, and clear evidence that a patient would not survive even with a respirator. Within the group accepted for consideration, ability to survive the treatment was the sole consideration. If more than one person were in need, clinical parameters indicating their prognosis with treatment would be appropriate to determine the recipient. If there were two or more patients with similar prognoses and only one respirator, a lottery was determined to be the method of last resort.

Prognostication could also not be left to an amorphous assessment. Previous ventilator allocation guidelines developed in 2015, by the New York State Task Force on Life and the Law, relied on an assessment tool called the SOFA score. Originally developed for estimating ICU prognosis in sepsis, it was appropriated by the New York group to address ventilator allocation in an influenza epidemic, not bacterial sepsis. SOFA assessment was also considered for use in the Ebola crisis and now we are using it for a fourth disease, COVID-19. The advantage over earlier prognosticators is that it considers multiple organ systems to provide a more wholistic score. Validation is still an issue for some, but most intensivists agree that it is the best prognostic tool so far.

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Reassessment Clinical medicine is ever-changing and our plans to deal with it must reflect that change. Each patient on a ventilator is reassessed regularly to determine its continued appropriateness. Patients who do not show improvement along clinical parameters are considered for removal from the machine. As an example of learning on the run, the timeline for initial reassessment, set at 48 hours, was determined from experience with influenza. Our intensivists have found that COVID-19 needs longer to declare itself and thus the initial reassessment time should occur a bit later in the course.

Provider priority in access The military has an ethic of “no one left behind.” We reject the idea that the ethic of an epidemic is consistent with the military ethic in most ways, but there is a longstanding social tradition of supporting those who are most directly contributing to the goal of survival. The utilitarian purpose of this policy is evident if it gets health care providers, and other front-line responders, back into the fray faster. Whether health care workers deserve special privilege based on the risks they take was a concept too complex to ponder in five days, so the committee remained silent in this area while supporting provider and first responder access as a means of maintaining the workforce.

The Product

Thanks to the masterful work of the CMA staff and the collective wisdom of my fellow Task Force members, we were able to assemble a report defining the goal and the principles and methods necessary to achieve it. I am in regular communication with my colleagues in New York who were tasked with similar policy assignments. To date, none of them have needed to be enacted. Unfortunately, we are not just building castles in the sky. The threat remains, and we know it now that we have fallen deep into Alice’s world. What we need to take away from this assignment is that we are not finished. One striking need is for greater public input, but death is not something people are comfortable talking about.

William Andereck, MD, is an internist in longtime practice at CPMC, where he is also chairman of the ethics committee, founder of the Sutter Health Program in Medicine and Human Values, a former CMA trustee and chair of the CMA ethics committee, and onetime editor of this journal.

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ENVIRONMENTAL POLLUTANTS AND INADEQUATE POLICIES: The “pre-existing conditions” disproportionately impacting vulnerable populations and contributing to COVID-19 susceptibility

Veena Singla, PhD and Patricia Koman, MPP, PhD The ravages of COVID-19 have starkly exposed deep disparities that break down clearly on racial lines in the U.S., from the prevalence of pre-existing conditions like diabetes, to the social determinants of health like lacking access to health care. The pandemic is also highlighting another long-standing inequity disproportionately burdening African American and Latinx populations and contributing to COVID-19 susceptibility: toxic environmental exposures. Current research hypothesizes a direct connection between increased air pollutant exposures and COVID-19 mortality; and many decades of research link toxic environmental chemicals to increased risks of diabetes and metabolic disorders, cardiovascular disease, and respiratory diseases like asthma.

Over the last 20 years, robust scientific evidence has emerged finding that toxic environmental agents can have a profound and lasting impact on health over a person’s life, including exposures that occur prenatally and even to parents pre-conception. These exposures include industrial chemicals that we eat, breathe, drink and absorb from food, air, water and everyday products. Chemicals such as heavy metals, flame retardants, those used in plastics and food packaging, “Teflon” components (PFAS) and others are linked to increased risks of reduced immune response, hormone disruption, cancers, and neurodevelopmental disorders (IQ loss, ADHD, autism spectrum disorders).

Although these chemicals are ubiquitous in all patient populations, many environmental chemicals and exposures disproportionately affect vulnerable and underserved populations.

For example, minority populations are more likely to live near contaminated/ hazardous waste sites and have indoor exposures to lead. Women of reproductive age have higher levels of cosmetic and personal care product-related chemicals in their bodies and hair products for Black women contain mixtures of endocrine disrupting chemicals.

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The science on how industrial chemicals can especially harm susceptible groups is well established. To understand susceptibility related to an environmental pollutant, think about how a chemical like lead can hurt children in a more pronounced way than adults. Children’s brains and bodies are still developing; placing their health at higher risk, and children’s behaviors (e.g., putting things in their mouth, crawling on the floor) increases exposures to contaminant-laden dust. As shown in the Figure below, age, life stage, pre-existing disease, pregnancy status, genetic variation, and many other factors can contribute to increased susceptibility. Social vulnerabilities like poverty can prevent people from being able to reduce harms due to lack of access to nutrition or medical care.

Currently more than 40,000 chemical substances are listed by the U.S. Environmental Protection Agency (EPA) as “active” for manufacturing, processing, or importing under the Toxic Substances Control Act (TSCA), the federal law governing industrial, commercial and consumer product chemicals.

Because of regulatory deficiencies, unlike pharmaceuticals, most chemicals in commerce have entered the marketplace without comprehensive and standardized research into their reproductive or other long-term toxic effects.

In 2016 with bipartisan support, the Frank R. Lautenberg Chemical Safety for the 21st Century Act became law, updating TSCA after 40 years. Before the update, TSCA was widely seen as ineffective at protecting public health, especially for susceptible groups like pregnant women, infants, children, the elderly, and workers. Under the new Lautenberg amendments to TSCA, EPA has begun to assess health risks of 10 initial chemicals, but is EPA applying the best available science on susceptibility to safeguard the health of at-risk groups?

We recently published a peer-reviewed commentary highlighting that EPA’s plans for risk evaluation of the first ten chemicals do not incorporate established science on factors WWW.SFMMS.ORG

contributing to increased susceptibility or exposure and will underestimate the risks chemicals pose to health.

To protect susceptible groups as required by law, we make specific recommendations to improve the scientific basis of EPA’s risk evaluations and align them with evidence-based principles to protect public health. These principles are articulated in the National Research Council’s 2009 report, Science and Decisions: Advancing Risk Assessment, including: • Incorporate biological and sociodemographic factors that affect susceptibility (e.g., age, life stage, underlying disease),

• Add up chemical exposures to susceptible groups from all pathways such as air, water, food, skin contact (a.k.a., aggregate exposure), and

• Accurately detect highly exposed groups, including those with occupational exposures.

These common-sense, science-based guidelines are not new; what is new is EPA’s complete departure from this science despite the law mandating EPA to protect the health of susceptible and highly exposed groups. These protections are needed even more now with the pandemic adding another stressor to frontline communities and workers.

Under the new legal framework in the Lautenberg amendments, EPA has started to evaluate risk for an important set of 10 chemicals, which have an annual total production volume of over 1 billion pounds. How EPA assesses susceptible and highly exposed populations is critically important to public health—for these chemicals and for all those to come. EPA’s decisions on key details in the risk evaluations will influence its future evaluations and the level of toxic chemicals in our homes, communities and bodies for generations—with our most vulnerable populations disproportionately bearing the burden of health consequences.

This has been the case for decades, which is why Professor Carl Cranor of University of California, Riverside concluded the public was being “legally poisoned” under the old TSCA. Without correctly identifying and taking into account risks to susceptible groups, it’s unlikely that EPA’s actions under new Lautenberg TSCA will change this situation. However, with strong, timely, and evidence-based public health action, EPA has the opportunity – and we argue legal duty — to reverse this legacy, limit dangerous chemicals, and improve the health of our families and communities.

In the meantime, health care providers can act to identify and reduce harmful environmental exposures at the patient and policy levels. Doctors and nurses remain the most trusted source of health information; providers can take an exposure history and provide anticipatory guidance to patients. Health professionals do not need to be environmental health experts to provide useful information and appropriate referrals if they find an exposure of concern.

But individuals can do little about many toxic exposures, such as to air pollution and tainted drinking water. Health professionals can be strong, credible voices for evidence-based policy changes that focus on primary prevention through limWWW.SFMMS.ORG

iting dangerous chemicals and pollution, with priority on vulnerable populations. Such policies are key to removing the hazardous environmental exposures contributing to health disparities and thus COVID-19 susceptibility. Focusing on health as a core value and robustly implementing the environmental laws will ultimately create better health for all.

Resources on environmental health for health professionals: https://prhe.ucsf.edu/clinical-practice-resources https://prhe.ucsf.edu/info

Veena Singla, PhD is Associate Director, Science & Policy, Program on Reproductive Health and the Environment at UCSF. Obstetrics, Gynecology and Reproductive Sciences, Program on Reproductive Health and the Environment, University of California San Francisco School of Medicine, San Francisco, California.

Patricia Koman, MPP, PhD is President, Green Barn Research. Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, Michigan.

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Dr. Richard Pan Introduces SB 483 to Protect Health Officers from Personal Threats and Attacks July 1, 2020 Sacramento, CA – While an increasing number of public health officials receive threats to their safety and that of their family, and as eight public health officials in California have resigned or retired since mid-April, Dr. Richard Pan, pediatrician and State Senator, introduced SB 483 to keep the personal information of health officers confidential.

“We cannot allow this attack on public health to succeed,” said Dr. Richard Pan, State Senator. “Public safety demands that public health officials must make recommendations based on science and free from intimidation.”

Public health officers are trained medical professionals with the expertise to protect the public from preventable injury and death. During outbreaks, they have the authority to act to halt an outbreak from spreading. During the COVID-19 emergency, extremists who oppose almost every measure to halt the coronavirus pandemic, including stay-at-home orders, wearing masks, contact tracing, and vaccination have sought to intimidate health officials to change the orders.

At an Orange County Board of Supervisors meeting, a fringe extremist with ties to anti-vaccine groups threatened the health officer of Orange County and announced her home address, inciting protesters to visit her house. She resigned after that incident and extremists announced online they would be targeting other health officers. They protested at the home of the Contra Costa County Public Health Officer and other health officials throughout the state have been receiving threats, including the Director of the Los Angeles County Department of Public Health who released a statement about threats she has received during the COVID-19 health emergency.

Under current law, the home addresses of members of the legislature, city councils, board of supervisors and other officials are prohibited from appearing in Department of Motor Vehicle records that can be accessed by the public. SB 483 would extend that prohibition to the disclosure of the home addresses of public health officers.

SB 483 is sponsored by the California Medical Association. “We cannot continue to subject public health officers to the unfair, uninformed, personal attacks we have seen across the state in recent months. The nearly 50,000 members of the California Medical Association want to thank Dr. Pan for stepping up to protect the people who are working to protect public health. This bill is an important step to support our local health officials, who are providing the courage and leadership California needs to continue to navigate our current health crisis,” said California Medical Association President Peter N. Bretan, M.D. “These trained medical professionals work day in and day out to stop the spread of disease in their communities.

It is impossible to say how many lives have been saved over the years because of public health actions such as sanitation, food safety, vaccination, and quarantine. The health officers protect Californians; it’s time for California to take action to protect the health officers,” said Kat DeBurgh, MPH, Executive Director of the Health Officers Association of California.

“Public health officials shouldn’t have to choose between their own safety and livelihood and the public’s health. SB 483 will protect our health officers so they can focus on their job and protect the public,” added Dr. Pan.

Starts October 17 (full day), followed by five evening sessions.

For information see: https://learning.accma.org/leadership-program-part-1 Overview • Covers broad-based skills that strengthen physician leadership across specialties and modes of practice • Curriculum developed by experts from UC Berkeley Haas School of Business and the School of Public Health • Unique among leadership programs - affordable, accommodates busy physicians’ schedules, manageably sequenced • Exceptional educational experience featuring nationally recognized faculty and a dynamic, interactive format • Earn up to 19.5 CME credits

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COMMUNITY MEDICAL NEWS Kaiser Permanente

Chinese Hospital

Maria Ansari, MD

Sam Kao, MD

Organizations across the world are re-assessing and strengthening their commitment to diversity and inclusion as part of the national dialogue on race. At Kaiser Permanente, diversity and equality has been at the core of our mission since the very beginning.

Founded to serve shipyard workers during WWII, Kaiser Permanente employed men and women of all races, working together side by side. When other hospitals were segregated, ours actively built diverse teams of employees and physicians and had integrated wards. All our patients were treated equally, regardless of race.

Looking forward, we’re working to strengthen our inclusive culture for our employees and members and expand our work that addresses health disparities and their root causes. Among these are projects to close the gaps in health care outcomes for communities of color in the areas of hypertension, diabetes, and prostate cancer.

Nationwide, data shows that African Americans are 40 percent more likely to have hypertension, 60 percent more likely to have diabetes, and are 20 percent more likely to die of heart disease than their non-Hispanic white counterparts.

We are working to address these issues through increased outreach and awareness, systematic blood pressure checks, physician education, and using pharmacist knowledge and input to choose the right medications.

In our innovative Spanish-speaking module, Salud en Espanol, we offer a multidisciplinary team to allow our Spanish speaking members to receive medical care and support, all in one visit and in the patient’s preferred language.

And these efforts are proving successful. Both Kaiser Permanente San Francisco and the northern California region have achieved higher rates of well-controlled blood pressure in African Americans compared with national benchmark data.

We’re also addressing the disparity in prostate cancer for Black men, who have a higher likelihood of developing the disease at a younger age.

We know what we’re doing is working; we’re committed to doing more and are proud to be in the vanguard of fighting for health equity.

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Congratulations are in order for our entire San Francisco Medical Community, and the Community at large, for the impressive containment of the Covid-19 surge. The relatively small numbers of overall admissions here in San Francisco, and particularly low numbers of mortalities, was a relief, given what has played out in other cities throughout the world.

In addition to the Physician leadership from my entire Medical Executive Committee, Chinese Hospital is proud to highlight the leadership from our CEO Jian Zhang DNP, our Nursing Supervisor Nia Lendaris MSN,CNS,RN Chief Nursing /Operations Officer and Director of Operations Gina Yang PharmD. Ms. Lendaris comes to us with over 35 years experience in a variety of positions in clinical nursing and administration with a focus in expanding cardiac services, oncology services, orthopedics and improving patient outcomes. Those skills have proven invaluable throughout this crisis. Ms. Yang not only focused on COVID19 operations in the hospital, but also in the outpatient clinics and the community, including mobile testing in the Chinatown SROs. We are also pleased to report the resumption, in the coming months, of our Chinese Community Summer Program for medical students. Chinese Hospital, in cooperation with the physicians of the Chinese Community (CCHCA/CH Medical Staff ) are offering a unique experience for two medical students who have just completed their first year to immerse themselves in the delivery of care in both the inpatient and outpatient settings from the perspective of private practice doctors in the San Francisco Medical Community. Started over a decade ago, this program was conceived as a forum to introduce students to our culturally integrated community medicine, in hopes that some will be interested enough to come back to join all of us at the completion of their residency and fellowships. The Chinese Community Healthcare Association has generously stepped up to fund the Program for 2020, and we are especially indebted to the vigorous efforts of Dr. Joseph Woo, past Chief of Staff here at Chinese Hospital, to drive these efforts and keep us all on track, even despite the recent disruptions. We are looking forward to welcoming to our community the two impressive finalists drawn from the pool of superbly qualified candidates. It is quite reassuring to see the next generation of physicians, to see how bright and inspired each of them are, and to see their interest in potentially coming to join our Medical Community.

We wish all of you and your patients continued good health as we gradually work towards resuming normal operations.

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CMA COVID-19 TELEHEALTH TOOLKIT FOR PHYSICIAN PRACTICES AVAILABLE Telehealth allows physicians to stay connected and provide care to patients without an in-person visit through the utilization of telecommunications. As physicians around the state are ramping up telehealth services so care can continue to be provided to those who need it during the COVID-19 public health emergency, CMA is compiling telehealth information from CMS and the major payors in the state. This toolkit includes payor guidance for billing and coding telehealth services, privacy and security concerns and flexibilities, and key considerations when implementing telehealth into your practice. https://www.cmadocs.org/Portals/CMA/files/public/ CMA%20COVID-19%20Telehealth%20Overview.pdf

THANK YOU TO OUR NEW MEMBERS REGULAR ACTIVE MEMBERS Audrey May Mariko Arai, MD | Family Medicine Gurpreet Kaur Aujla, MD | Psychiatry Benjamin Bailey Barreras, MD | Psychiatry Isa Barth-Rogers, MD Rachael Haas Beckert, MD | Pediatrics Richard Bodony, MD | Emergency Medicine Kenneth Marcus Chin, DO | Psychiatry Angelo Asa Clemenzi-Allen, MD Elizabeth Ray Dei Rossi, MD | Emergency Medicine Eric David Gordon, MD | Family Medicine Susannah Graves, MD | Internal Medicine Nicole Marie Kaipust, MD | Internal Medicine Lara Kathryn Kulchycki, MD | Emergency Medicine Kira Liana Levy, MD Erin Ilana Lewis, MD | Obstetrics and Gynecology Tanya Majumder, MD Samantha Ann Mason, DO | Family Medicine Dzovag Minassian, MD | Internal Medicine Gene A Nakajima, MD | Psychiatry David R Pating, MD | Psychiatry Trudy Katrina Singzon, MD | Family Medicine Allanceson Jay Smith, MD Marjorie Alexander Smith, MD | Internal Medicine Kathryn Elyse Taylor, MD Yakira Heather Teitel, MD Stephan Paul Wyss, MD | Psychiatry

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