San Francisco Marin Medicine, Vol. 96, No. 4 Oct/Nov/Dec

SAN FRANCISCO MARIN MEDICINE J OU 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 IC A L S O C I E T Y

YEAR-END SUMMARIES: The SFMMS Annual Report, CMA/SFDPH Highlights plus…

New Discharge Navigator Tool, A Bridge Barrier at Last, Medical Student Reports, and more…

Volume 96, Number 4 | OCTOBER/NOVEMBER/DECEMBER 2023

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IN THIS ISSUE

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FEATURE ARTICLES

MONTHLY COLUMNS

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2 Membership Matters

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October/November/December 2023 Volume 96, Number 4

SFMMS Secures Legislative Wins in the State Legislature Adam Francis, CAE

SFMMS 2022/23 Annual Report

27 Message From the Director of Public Health Grant Colfax, MD

30 The Golden Gate Bridge Barrier is Completed Mel Blaustein, MD 32 Please Stay Kevin Hines

5 President's Message: Slow Advocacy on Big Issues Heyman Oo, MD, MPH 6 Executive Memo: Consolidation Remains a Force in Medical Practice Conrad Amenta

7 HOD Report Michael Schrader, MD, PhD

COMMUNITY NEWS

34 Discharge Navigator: An Innovative Provider-Facing Tool to Support Patients’ Social Needs Caroline Burke, MD; Alice Lu, MLS; Elisa Danthinne; Melissa King and Christopher Peabody, MD 36 Compassion in Action: Humanizing Harm Reduction and Addiction Care Patrick Low 37 UCSF Medical Students Reflect on the Start of the Haight-Ashbury Free Clinic Mallory Shingle

33 Kaiser Permanente Monica Kendrick, MD

OF INTEREST 28 CMA's Top Highlights for 2023 40 In Memoriam: Arthur Lyons, MD and Robert Dennis Collins, MD 44 Advertiser Index

39 A Life Transformed by a Volunteer Surgeon Dennise García León 42 Physician Wellness: Embrace Seasonality Jessie Mahoney, MD

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MARIN MEDICAL SOCIETY

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Editorial and Advertising Offices: San Francisco Marin Medical Society 312 Sutter, Suite 608 SF, CA 94108 Phone: (415) 561-0850 Web: www.sfmms.org

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MEMBERSHIP MATTERS SFMMS a Major Presence at CMA Annual Meeting The CMA House of Delegates (HOD) met virtually on November 5, after the in-person meeting was postponed due to a major hotel labor dispute in Los Angeles. The SFMMS featured heavily in the proceedings. SFMMS past-president Shannon Udovic-Constant was elected CMA President-Elect; SFMMS pastpresident George Fouras was elected Vice-Speaker of the CMA HOD; and the SFMMS delegation once again won honors as the highest contributors to the CMA Political Action Committee, CALPAC. And sadly but very movingly, there was a video tribute to our late great past-president Lawrence Cheung featuring deeply felt comments from colleagues and elected officials.

Details of the meeting appear in this edition of our journal.

President Tanya Spirtos, M.D. “Physicians are the backbone of the Medicare program, and we will continue to fight to ensure that our patients have access to high-quality physician care. CMA urges Congress to stop the cuts in the January 2024 must-pass appropriations legislation.”

CMA, AMA and more than 100 other physician groups recently sent a joint letter to Congressional leaders urging swift action to stop the cuts.

“America’s physicians and their patients deserve better. The flawed Medicare physician payment system is in desperate need of fixing,” the letter said. “We stand ready to work with House and Senate leadership on bipartisan solutions to stop these drastic payment reductions and provide stability in the Medicare program for our nation’s seniors and the physicians who care for them.”

Physician payment has already declined by 26% over the last two decades. With an expected 4.6% rise in health care inflation this year, the net impact on physician payments will be an 8% decrease in 2024, which will be devastating for physician practices and patient access to care in California.

Laguna Honda Hospital (LHH) Recertification Update

Thanks to the hard work at Laguna Honda Hospital and advocacy of many, including the SFMMS, The California Department of Health Services (CDPH) recertified the facility as a skilled nursing facility in 2023 as eligible to accept Medicaid patients.

LHH then submitted an application for Medicare recertification as a “change of information” application as directed by CMS. CMS then requested a different application be submitted, which was done September 15, 2023. LHH is now awaiting a full survey by CMS for the recertification to the Medicare program.

Hiroshima Medical Team Visit

CMA Continues to Aggressively Push Congress to Stop the Medicare Pay Cuts In an urgent appeal to safeguard the nation’s Medicare program, the California Medical Association (CMA) is calling on Congress to stop the looming Medicare physician payment cuts, which if allowed to take effect would devastate physician practices and make it even more difficult for the nation's seniors to get the care they need.

CMA, the American Medical Association and all of organized medicine are uniting to urge Congress to stop the 3.4% payment cut and provide an inflation update for 2024.

“While there is broad bipartisan support to address Medicare payment reform, the political dysfunction in Congress continues to make it extremely difficult to meaningfully address long-term solutions and protect Medicare patient access to care,” said CMA

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Hiroshima Prefectural Medical Association representatives at St. Mary’s Medical Center, hosted by Dr. John Umekubo (center) and hospital CEO Daryn Kumar, including SFMMS representatives Brian Grady, George Fouras, Michael Schrader, and Steve Heilig. The Japanese visitors were in San Francisco to do followup examinations of WWII atomic bomb survivors living here, as part of their long-ongoing project to research longterm effects of the bombing.

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SFMMS Annual General Meeting an Inspiring Evening A sold-out crowd attended the SFMMS annual general meeting on December 6 at the Golden Gate Yacht Club, with short and stirring presentations by outgoing President Heyman Oo, CMA President-Elect Shannon Udovic-Constant, Past-Presidents Kimberly Newell Green and Man-Kit Leung, CMA Speaker-Elect George Fouras, and CEO Conrad Amenta. Steve Heilig presented a special award to Gordon Fung, MD, for his long service to SFMMS as President, chair of the delegation to CMA, and Editor of our journal. San Francisco Supervisor Rafael Mandelman then addressed the group on various health issues facing our city.

October/November/December 2023 Volume 96, Number 4 Editor Gordon L. Fung, MD, PhD, FACC, FACP Managing Editor Steve Heilig, MPH Production Maureen Erwin SFMMS OFFICERS President Heyman Oo, MD, MPH President-elect Dennis Song , MD, DDS Secretary Sarita Satpathy, MD Treasurer Jason Nau, MD Immediate Past President Michael Schrader, MD SFMMS STAFF Executive Director Conrad Amenta Associate Executive Director, Public Health and Education Steve Heilig, MPH Director of Operations and Governance Ian Knox Director of Engagement Molly Baldridge, MPH Senior Director, Advocacy and Policy Adam Francis

Drs. Michael Schrader, Heyman Oo, Dennis Song, and Shannon Udovic-Constant with San Francisco Supervisor Rafael Mandelman (center).

2023 SFMMS BOARD OF DIRECTORS Edward Alfrey, MD Melinda Aquino, MD Ayanna Bennett, MD Julie Bokser, MD Kristina Casadei, MD Clifford Chew, MD Esme Cullen, MD Manal Elkarra, MD Mihal Emberton, MD Cindy Greenberg, MD Gordon L. Fung - MD, Editor Beth Griffiths, MD Ian McLachlan, MD Jason Nau, MD, Treasurer Heyman Oo, MD, President Sarita Satpathy, MD, Secretary Michael Schrader, MD, Immediate Past-President Yalda Shahram, MD Neeru Singh, MD Dennis Song, MD, DDS, President-Elect Kristen Swann, MD Kenneth Tai, MD Melanie Thompson, MD Matthew D. Willis, MD Kristen Wong, MD Andrea Yeung, MD Helen Yu, MD For questions regarding journal, including possible submissions, contact Steve Heilig: Heilig@sfmms.org

Outgoing SFMMS editor, Past President, and Delegation Chair Gordon Fung, MD receives special recognition from SFMMS president Heyman Oo, MD.

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COVER ART _____________________ WPA poster art of the peak of Mount Tamalpais in Marin County, California, done in works project administration style, c. 1934-43.

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PRESIDENT’S MESSAGE Heyman Oo, MD, MPH

SLOW ADVOCACY ON BIG ISSUES As this year winds down and we make our final sprints through the holidays, I am struck by how much we all do in our personal and professional lives just to keep the plates spinning. With all that’s going on and the endless list of things to do, it can be difficult to reflect on how far we’ve come. Moreover, with all the heaviness and heartbreak in the world, it can be easy to feel like our daily actions are ineffectual and unimportant.

I recently met with a group of dynamic, mission driven residents for a physician leadership workshop. Many of them were struggling with how to reconcile their desire to end the health inequities and injustices that their patients face with the often painfully slow pace of positive, systemic change. In the face of such monumental, urgent problems, it is only natural to feel like the only answer is equally monumental, urgent action.

I reminded them that only a little over a decade ago, few in medicine even considered social determinants of health. For our new generation of physicians though, understanding the social factors that impact health is as foundational, if not more so, as understanding biochemistry and pharmacology. We came to this point, not by sudden upheaval, but by the unseen, slow process of social science research leading to knowledge dissemination and eventual gradual shifts in GME and education requirements.

As I was sharing this perspective, one of the residents offered the idea of “slow advocacy:” Building relationships and using existing avenues to advance seemingly tiny changes to policies, procedures, legal codes, curricula, certification requirements— the unsexy stuff. It is “slow advocacy,” oftentimes working in the background, that solidifies and makes permanent the changes called for with flashier advocacy like protests, press conferences, and boycotts.

Slow advocacy is meeting with a local legislator when you do not know if they will support your solution to the physician workforce crisis. Slow advocacy is coming together with other physicians to craft a resolution to the CMA, not knowing if it will pass or what actions will be taken if it does. Slow advocacy is serving on a committee in a field like urban planning or an advisory board for the Chamber of Commerce or as a consultant for K-12 education, vital sectors where health experts are rarely at

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the table. Slow advocacy is presenting a physician’s perspective at a city council meeting when reviewing traffic ordinances, it is educating a patient or a colleague about climate change’s impact on health, one conversation at a time…it is all the actions we do that require patience, perseverance, and humility on this long road to improving the health and healthcare of our patients.

As you read through this year’s final edition of the journal, you will find a summary of our activities and accomplishments as a medical society this past year. While you will find impressive newsworthy moments, you will also find numerous examples of our regular, determined, daily progress, our “slow advocacy.” We should certainly celebrate the monumental wins, but let us not forget the importance and value of our slow advocacy actions.

Moreover, these actions could not have happened without you, our members. I invite each of you to pause and remember all the seemingly small, likely unseen ways you have made a difference this year, for your clinical practices, your patients, your communities, and yourself.

It has been such an honor to have been your medical society president this year. I have learned tremendously from all of you and am inspired by your dedication, passion, and, perhaps most importantly, persistence and patience.

Onwards, with Gratitude, Heyman Oo, MD, MPH SFMMS President

Heyman Oo, MD, MPH is a primary care pediatrician and Site Medical Director at Marin Community Clinics in Novato. She also serves as an Information & Guidance Clinical Lead for the San Francisco Department of Public Health under the COVID-19 Task Force. She is a graduate of the UCSF Pediatric Leaders Advancing Health Equity (PLUS) Residency Program and obtained her MPH in Healthcare Policy and Administration at the Harvard T.H. Chan School of Public Health. She has been involved in organized medicine since the beginning of her medical school years at UC San Diego and has been a member of SFMMS for almost a decade.

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EXECUTIVE MEMO Conrad Amenta, SFMMS Executive Director

CONSOLIDATION REMAINS A FORCE IN MEDICAL PRACTICE I joined SFMMS as its Executive Director in 2020, one month after COVID-19 lockdowns. At that time, the percentage of our membership that self-identified as practicing in a small or solo private medical practice was a little under 10 percent.

Almost four years later, that percentage has continued to shrink, and today sits at a little over six percent.

Consolidation occurs when a medical practice is acquired by, or the physicians therein join, a larger medical practice or integrated health system. San Francisco and Marin counties are among the most heavily consolidated physician labor forces in California, and California is among the most heavily consolidated states in the country.

There are positive aspects to consolidation. SFMMS members who practice in large groups and systems are more likely to report relative satisfaction with the availability of practice support tools, continuing medical education, and health information technology. Larger groups and systems, competing for in-demand medical specialties, sometimes offer higher salaries and signing bonuses than can be earned via public and private insurance reimbursement. Some physicians report that they are relieved to be free of the business management practices and rigorous regulatory compliance testing that can accompany private practice. And, in the aggregate, consolidated labor forces are less likely to produce unwarranted clinical practice variation.

However, physicians practicing in consolidated labor forces also sometimes report feeling a reduced sense of autonomy and prestige, a disconnect from emerging innovations, and from their professional community. Consolidation can reduce competition, and thus physician and patient choice. Distinct cultures that had taken root in our communities can be diluted as medical groups

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and institutions are absorbed by larger groups and systems.

And, in a consolidated market place, medical students and residents often miss opportunities to learn about private practice and to consider all of their options.

At SFMMS, we’re committed to supporting private medical practice, and to educating medical students and residents about the unique rewards and challenges of private practice. In 2023, we convened members in a Private Practice Forum (pictured here).

And we participated in San Francisco County’s assessment of its gross receipts tax, which disproportionately negatively affects medical groups. We’re advocating for reforms that will appear on the November 2024 ballot, and are designed to reduce your tax burdens.

The landscape of medical practice has changed quickly and drastically, and so must professional associations if we’re to continue to meet the needs of all of our members, wherever they practice. If you would like to help us design member engagement opportunities for every segment of physician membership, please apply to join the SFMMS Membership Engagement Committee using the following form, or by scanning the QR code with your phone’s camera: https://www.surveymonkey.com/r/P8RRGJT

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CMA HOUSE OF DELEGATES 2023 Michael Schrader, MD, PhD

CMA POLICYMAKING UNDER PRESSURE:

THE 2023 ANNUAL HOUSE OF DELEGATES MEETING The 155th CMA House of Delegates (HoD) was held on Sunday, November 5th. Despite an inauspicious delay and much abbreviated format, this was a very good day for your SFMMS District VIII Delegation.

The original HoD was scheduled to be held at LA Live from October 20-22. Three major issues were selected: Climate change, Artificial Intelligence, and the informational topic Office of Health Care Affordability. We were anticipating the election of Dr. Shannon Udovic-Constant, who was running unopposed, to CMA President-Elect. In addition, Dr. George Fouras was running against Dr. Jerry Abraham for Vice-Speaker of the House of Delegates.

Unfortunately a labor dispute with LA Live brought an abrupt end to months of planning. Hospitality workers at LA Live had been intermittently striking for better coverage for health benefits. They threatened to picket the CMA HoD and our members would have had to cross a picket line of workers striking for better health care access. CMA elected to cancel the event.

Despite the disappointment CMA was able to get a full refund from LA Live as well as refunds to the Delegations for meeting rooms and food they had purchased.

California law requires that member organizations have yearly in person meetings. The current officers could not be succeeded without convening the HoD. The in person meeting was held at the DoubleTree Sacramento with remote access. In addition to our candidates Drs. Udovic-Constant and Fouras, our Delegation members Drs. Brian Grady and Man-Kit Leung attended in person. The rest of our Delegation attended remotely with our community connected by GroupMe chat, email, a mid- meeting Zoom conference, and urgent phone messages to correct last minute discrepancies in our Delegate voter roll.

There were 322 delegates seated forming a quorum.

Dr. Tonya Spirtos was sworn in as CMA President, Dr. Shannon Udovic-Constant was sworn in as President-Elect, and Dr. Jack Chou was sworn in as Speaker of the HoD. One important issue for an early vote was scheduling the consideration of the Major Issues. A reconvening in early 2024 will consider the major issues.

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tion caucusing. Our Delegation convened via Zoom and included our members who were attending in Sacramento. We thanked Ian Knox for all his work on the canceled meeting and the virtual meeting and Steve Heilig for his commitment to the policy that SFMMS has formulated over the years. We asked Steve Heilig and Dr. John Maa to recall some of the highlights of our activism.

These included: needle exchange, banning of smoking in bars and restaurants, medical abortion, support to keep Laguna Honda open, firearm taxation, flavored-tobacco ban, the defeat of the JUUL initiative, and efforts to curtail sugary beverages. By no means an exhaustive list, but impressive for a small medical society. We are the mouse that roared.

The highlight of the afternoon was the contested race for Vice-Speaker. Dr. Jerry Abraham, family practice physician and current President of LACMA, was running against Dr. George Fouras, child psychiatrist and past President of SFMMS. Both are accomplished physicians, trained parliamentarians, and have extensive experience at CMA. They both shared their visions in statements and debate. Dr. Fouras prevailed and was elected Vice-Speaker.

Dr. Lawrence Cheung was remembered for his exemplary life and his dedication to the CMA. We have all lost a good friend and a leader who has inspired many of us to become leaders in his image. His legacy to CMA and SFMMS is to lead by encouraging others to lead.

Dr. John Maa worked tirelessly to raise contributions for CALPAC. Thanks to Dr. Maa and the generosity of our Delegation we were awarded the Victory Bell as the top donating Delegation. And SFMMS staffer Ian Knox saved the day at the last minute in getting all our attending delegates fully credentialed to vote!

Every year CALPAC has a raffle for donors. To top off our afternoon of triumphs, Dr. Gordon Fung won the best prize in the raffle. The only thing missing was in-person celebration for our superlative afternoon. But that will occur at our General Members Meeting in December.

Dr. Schrader, an internist at Dignity Health, is Chair of the SFMMS delegation to the CMA and a past-president of the SFMMS.

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SFMMS SECURES LEGISLATIVE WINS IN THE STATE LEGISLATURE Adam Francis, CAE The first year of the 2023-24 Legislative Session at the capitol in Sacramento is in the books, and SFMMS was able to secure some important wins for physicians and their patients. While the majority of state legislative work is handled by the incredible staff and physician leaders at CMA, SFMMS also advocates for a select number of bills on its own—particularly bills authored by our local legislators. SFMMS also dedicates resources to bolster CMA’s sponsored legislation, working hand-in-hand to fight for measures that will improve health care throughout the State. In addition to our extensive work with the San Francisco and Marin counties’ Board of Supervisors, this makes up the bulk of our advocacy efforts throughout the year.

With a flurry of action before the State Legislature deadline to pass and sign legislation, six SFMMS-supported bills were approved by Governor Newsom and will soon become law.

• AB 28 (Gabriel) will impose an 11 percent tax on firearms and ammunition to generate $160 million annually to fund school safety and violence prevention programs.

• AB 470 (Valencia) allows Continuing Medical Education (CME) requirements to include courses that improve the quality of physician-patient communication through culturally and linguistically competent education.

• AB 571 (Petrie-Norris) will ensure licensed medical providers have access to professional liability insurance coverage without discrimination for providing abortion care, contraception, and gender affirming care.

• AB 816 (Haney) will allow a minor who is 16 years of age or older to consent to replacement narcotic abuse treatments that use buprenorphine, while maintaining the requirement that the clinician providing the treatment shall include the parent in the treatment plan, unless the professional determines it would be inappropriate.

New Law of Note—SB 525—Health Care Facility Minimum Wage Law A major compromise was reached at the end of the year on legislation, SB 525, that would increase the minimum wage of “health care employees” to $25 in California over a period of years (definitions of which facilities and employees are covered is included later in this article). While supportive of employees receiving fair compensation, CMA and other health care advocacy organizations ensured legislators understood the potential harm that rushing into large minimum wage increases would have on patient access to care at a time when providers are already strained. When it became clear that some form of the bill was very likely to pass and be signed by the Governor, CMA secured amendments to limit the impact on our members, including a phased in multi-tiered implementation schedule and exemptions for IPAs and small practices (i.e., those with less than 25 physicians). The new implementation schedule more closely aligns with wage trajectories that are anticipated to naturally occur due to economic pressures outside of SB 525, including existing law that requires an annual assessment and adjustment of the minimum wage to reflect inflation. The bill also includes a 10-year moratorium on wage ordinances, regulations, or administrative actions for health care employees.

Without this freeze, it was likely that local ballot measures or a statewide proposition would be filed to establish an immediate wage increase to $25 per hour.

The following graph shows when SB 525 wage increases would go into effect:

• AB 935 (Connolly) makes selling flavored tobacco punishable by civil penalties.

• SB 487 (Atkins) protects providers from automatic Medi-Cal suspension and health insurance discrimination when suspended in another state due to providing health care services legal in CA.

To learn more about the great work CMA did this year at the state level, read CMA’s 2023 Legislative Wrap Up. 8

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A “health care employee” includes but is not limited to nurses, physicians, caregivers, medical residents, interns or fellows, patient care technicians, janitors, housekeeping staff persons, groundskeepers, guards, clerical workers, non manage-

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rial administrative staff, food service staff, gift shop staff, technical and ancillary services workers, medical coding and billing personnel, schedulers, call center and warehouse workers, and laundry workers, regardless of formal job title. It also includes contracted or subcontracted health care employees where the heath care facility employer directly or indirectly exercises control over the employee’s wages, hours, or working conditions.

A “health care employee” does NOT include outside salespeople; public sector employees whose primary duties are not health care services; or delivery/waste collection workers and medical transportation workers, provided that the worker is not an employee of any person that owns, controls, or operates a covered health care facility.

The “health care facility” that must adhere to this requirement includes essentially any location where health care services are delivered (e.g., clinics, hospitals, home health care, county correctional facility, dialysis clinic, psychiatric facilities, SNFs, residential care facility, any work site that is part of an integrated health care delivery system, a nonprofit clinic that conducts medical research/health education with 40 or more independently contracted physicians representing at least 10 board-certified specialties and not less than two-thirds of whom practice on a full-time basis at the clinic).

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A “health care facility” does NOT include a hospital owned, controlled, or operated by the Department of State Hospitals, or a tribal clinic or outpatient setting conducted, maintained, or operated by a federally recognized Indian Tribe, tribal organization, or urban Indian organization.

CMA will be closely monitoring how the new law impacts physician practices and patient care, especially small rural practices, hospitals, and clinics.

If you would like to learn more about legislative advocacy and policy, we encourage interested members to join our new Advocacy and Policy Committee. Visit our webpage to learn more: https://tinyurl.com/SFMMS-APC.

Adam Francis is Senior Director of Policy and Advocacy for the SFMMS.

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MESSAGE FROM THE DIRECTOR OF PUBLIC HEALTH Grant Colfax, MD, Director of Health

I am pleased to present the San Francisco Department of Public Health’s (SFDPH) Annual Report for Fiscal Year 2021 – 2022, describing the accomplishments of our programs and services throughout the City. Below are some highlights of the tremendous body of work SFDPH accomplished.

The COVID-19 pandemic has continued to test our strength and resilience, yet our City has come together repeatedly to protect our health and well-being. This fiscal year marked our one-year anniversary of an equitable and strategic vaccine rollout.

Between December 2021 and when the first doses were administered, nearly 1.4 million COVID-19 vaccine doses had been delivered, inoculating about 750,000 San Franciscans with the best defense against the virus. The City also entered a new stage of the pandemic and embarked on a full reopening.

With COVID, San Francisco came together to address this public health crisis. We expect no less for our drug overdose epidemic. Building on DPH's longstanding expertise and innovation, we launched the Street Overdose Response Team (SORT).

SORT is a collaboration between DPH and the Fire Department that reaches people after they experience a nonfatal overdose and offers them risk reduction services. In addition to SORT, other overdose prevention efforts undertaken this year included expanding access to buprenorphine, increasing distribution of naloxone, and improving access to SUD treatment programs. As a Department and a City, we are stepping up to protect our community, to save lives, and to be a national model for overdose response and drug use disorder treatment.

To that end, the department also continued its implementation of Mental Health San Francisco—an initiative that increases support and care for people experiencing mental health and substance use disorders. Through the initiative, SFDPH plans to increase overnight residential treatment capacity by 400 new beds. In 2022, DPH opened two new facilities: SoMA Rise, one of the nation’s first drug sobering centers, and the Minna Project, which supports people with mental health and substance use

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disorders who are transitioning from the justice system to independent living.

DPH has also prioritized increasing staffing to support new services under MHSF and hired over 250 behavioral health workers in 2022.

SFDPH cannot fulfill its mission to protect and promote the health of all San Franciscans without unequivocal support for racial equity and concrete actions to be an antiracist institution.

DPH continued to prioritize racial equity through the implementation of the department-wide Racial Equity Action Plan (REAP). This fiscal year, SFDPH sought to improve human resources staffing and policies in hiring and employee experience, including creating a new Office of Experience & Culture to build clear and accessible systems of employee support. SFDPH also saw progress in its infrastructure and accountability by staffing up the Office of Health Equity.

Finally, in April 2022, the federal Centers for Medicare & Medicaid Services (CMS) terminated its Medicare and Medicaid payments to Laguna Honda Hospital. Participation in this program is how we fund the majority of Laguna Honda patient care. Strengthening and sustaining Laguna Honda is the top priority, and every effort is being made to recertify the hospital and ensure long-term stability. For more than 150 years, Laguna Honda Hospital has been a pillar of our healthcare system and a pride of San Francisco. It is an indispensable institution where patients with complex medical conditions receive world class healthcare from our dedicated staff.

Everyone at the DPH is essential to our success. I thank all our dedicated staff, our community and city partners, and the Health Commission for their contributions, partnership, and service to the health of San Francisco.

The full report can be accessed at https://sf.gov/sites/default/ files/2023-05/FY21-22%20DPH%20Annual%20Report_1.pdf

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THE GOLDEN GATE BRIDGE BARRIER IS COMPLETED Mel Blaustein, MD The Golden Gate Bridge will finally erect a barrier at the end of this year.

The death toll since its completion in 1937 is about 2,000. Two a month still jump to their deaths. The bridge is tragically known as the number one suicide site in the world.

As the medical director for 25 years of a psychiatric unit less than five miles from the bridge, I interviewed many potential jumpers. I was instrumental in launching the final drive for a suicide barrier, which began in 2004.

At the time, I was president of the Northern California Psychiatric Society's foundation. From this vantage point, I turned our attention to a suicide barrier.

I assembled a task force of experts.

The late Jerome Motto, MD, past president of the American Society of Suicidology, and Eve Meyer, executive director of San Francisco Suicide Prevention had both worked on the previous 1990 effort.

Psychiatrist Anne Fleming, who had lost a colleague to the bridge, joined us. Assemblyman Tom Ammiano sent Esther Marks from his staff. Kevin Hines, who survived a jump in 2000, was also a member. Our consultant was Paul Muller, who with Dave Hull founded the Bridge Rail Foundation. Janice Tagart was our executive director.

The common belief is that jumpers come to the Bridge for its iconic beauty. Actually, nearly two-thirds come to the site because it is accessible with its four-foot railing, parking lot, and bus access.

Some of the comments I heard from jump survivors included: "It's the fastest way to do it… A sure way to die... close to my house." Only a quarter chose the Bridge for its romantic allure, but those who did told me, "It looks so majestic... It seems a lot more dignified." "You're in a community with those who jump before." A smaller number had no specific reason for their choice, saying only: "I'm tired of living."

Erecting a suicide barrier was not popular. Seventy-five percent of polled San Franciscans in 2005 opposed the project.

This opposition was the reason that seven prior campaigns had failed.

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The 19-member Bridge board of directors was the body to decide on a barrier. They represented San Francisco County and five northern counties.

Our task force attempted to meet with board members and legislators. We set up a speaker’s bureau and gave presentations at hospitals, Rotary Clubs, neighborhood organizations, and schools. We wrote op-eds and lobbied the media. It was an uphill fight. One board member in a northern county told me that the solution would be to build a diving board on the Bridge.

We wanted the public to appreciate that the jumpers were their neighbors. Coroner Ken Holmes, surveying jumpers between 1995 and 2005, found that 87 percent were from the six adjacent counties. Only five percent were out of state. The median jumper from the Bridge was a 40-year-old single white male.

We always stressed that suicides are often impulsive but preventable and treatable. We cited successful barriers at the Eiffel Tower, Sydney Harbour Bridge, and the Empire State Building.

The most frequent argument against the barrier was that individuals who were prevented from jumping would go elsewhere. Psychologist Richard Seiden followed 515 people taken

by California Highway Patrol from the bridge over 25 years. At the end of his study, 94 percent were still alive or died of natural causes. They did not go on to kill themselves.

Many barrier opponents were concerned that the Bridge would lose its beauty. At the time when we were lobbying, we did not know whether the final design would satisfy critics.

Our aesthetic model at the beginning of the campaign was the Prince Edward Viaduct in Toronto. It was dubbed the Bridge of Death and second only to the Golden Gate Bridge in suicides in North America.

When the Schizophrenia Society lobbied the city for a deterrent, the Canadian government staged an architectural competition. The winner was Professor Derek Revington, whose "luminous veil” was awarded Ontario's top engineering prize in 2002.

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Some believed jumpers were exercising free will. But suicidal people are generally in great psychic pain, despondent and feeling hopeless. These are impulsive, desperate individuals for whom the Bridge offers an escape from their misery.

Another objection was that jumpers are all mental patients and that the answer to the problem is to shore up the mental health system. No one would disagree with that goal. But the 2005 coroner’s study found that nearly two-thirds of jumpers had no psychiatric history. Indeed, they come from all walks of life.

Finally, we could reassure the public that their bridge tolls were not paying for the barrier. Money was raised from the transportation agencies and the government. The final cost was estimated at $215 million.

Jumpers themselves have some misconceptions. The survivors of the jumps told us they believed theirs would be a painless exit. But hitting the water in four seconds at speeds up to 75 mph, from the equivalent of a 20-story building shreds vessels and organs, ribs, and the nervous system. There have reportedly been only 30 to 35 survivors in the past 86 years. The fatality rate is 98 percent.

It was beneficial that the story was covered by the local newspapers, USA TODAY, the New York Times and the Washington Post. The San Francisco Chronicle ran a seven-day series titled "Lethal Beauty" after meeting with our taskforce.

Two movies also moved the debate forward. Jenni Olson's Joy of Life appeared at the Sundance Festival. Eric Steel's controversial 2005 movie, The Bridge, filmed 19 suicides and featured Kevin Hines. Kevin also appeared on Good Morning America, CNN and the Oprah Winfrey Show.

The support of chief engineer Denis Mulligan, who went on to become CEO, was invaluable.

The most important deciding factor in the success of the campaign was the appearance at the board meetings of the family members. They held up posters of their children which could not fail to move the directors.

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The final design of the barrier is a metal net 20 feet below and 20 feet out from the bridge. Drivers crossing the bridge cannot see it.

Ken Baldwin, who survived the jump, sent me this statement: "I suicided in August 1985. I jumped off the Golden Gate Bridge…. I just looked over the water to the city, and it was beautiful. I felt that this was the right time and place to kill myself. I vaulted over the railing. The last thing I saw leave the Bridge was my hands. It was at that time that I realized what a stupid thing I was doing. It's incredible how quickly I decided I wanted to live when I realized that I was going to lose my wife, my daughter, the rest of my family. " He added, "There are two parts to my life. Before the jump and after the jump. I'm the luckiest guy in the world."

Like other survivors that I have interviewed, he told me that had there been a barrier he never would have jumped.

Some people reproached the barrier campaign since “only” 2,000 lives have been lost since 1937. To these people, I quote from the Talmud: "To save one life is to save the entire world."

Mel Blaustein, MD was chief of inpatient psychiatry for 25 years at St. Francis Hospital.

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PLEASE STAY Kevin Hines Our new (currently in production) feature length documentary film THE NET is about the harrowing, 87-year effort to stop suicides at the elusive Golden Gate Bridge.

While it is a beautiful monument, with a rich history, a dramatic allure, and the ninth wonder of the world, tragically, it is also a place where thousands have died by their hands due to unrelenting and seemingly inescapable lethal emotional pain.

Our film is about the people who fought for decades to change a harbinger of death into a beacon of hope. The film is also about the people who fought against raising the net and stifled our efforts, pushing us down, berating us, and saying so often that looks matter over lives.

This film shares with all who see it that a small group of like-minded people, who believe in a just cause can come together and do a great deal of good, if they never give in, never give up, and never waver.

My father, Patrick K. Hines, founded the Bridgerail Foundation along with Dave Hull and Paul Muller. Our founding funds came from Alexis De Raadt St. James; without her, without the Bridgerail Foundation and this goal of stopping suicide on the Golden Gate Bridge, forever, would never have been achieved.

When the film is released, it will inspire millions to make the change they wish to see in the world by making real efforts to make a difference and always taking action to do great amounts of good.

What are the aesthetics of a bridge compared to one human life, someone you love, someone you love unconditionally, someone you need in your life every day?

I survived my leap from the GGB to do this work; it has been a nearly-30 years purpose. Finally, the Golden Gate Bridge will become the largest, brightest, and most powerful beacon for suicide prevention around the world.

More about Kevin Hines: https://bio.site/kevinhinesstory

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COMMUNITY MEDICAL NEWS Kaiser Permanente Monica Kendrick, MD Patients are increasingly seeking an integrated approach to their health, complementing a doctor’s appointment with an ongoing focus on a healthy lifestyle. This whole-body approach is effective for achieving positive results for both patients and health care providers.

This emphasis on prevention and wellness is not new to Kaiser Permanente; it’s been a primary focus since our inception almost 80 years ago. Today, we offer these services to our patients through a robust program of Lifestyle Medicine. Using evidence-based therapeutic approaches to prevent, treat, and even reverse chronic disease, Lifestyle Medicine addresses the root causes of many conditions and empowers patients to have more control over their health.

Lifestyle Medicine is organized according to six pillars: nutrition; physical activity; stress reduction; restorative sleep; social connection; and avoidance of risky substances.

First-line targets are typically nutrition and physical activity, along with guiding patients towards avoiding or decreasing their use of tobacco, drugs, and alcohol. We offer an extensive menu of classes and provide guidance on the value of eating a pre-

dominantly plant-based diet. Our Thrive Kitchen hosts a monthly virtual cooking class which is free to members and available for a nominal charge to non-members. Our virtual 12-session Plant Strong Program helps patients improve their health through lifestyle medicine to gain energy, stabilize—or even reverse chronic conditions such as diabetes, high cholesterol, and hypertension.

Instead of focusing solely on formal exercise, many practitioners emphasize movement to help patients understand that walking, housework, gardening, and other daily activities count as physical activity. We also offer free handouts and streaming videos teaching strength training, yoga poses, stretches, and fitness routines.

We help patients manage stress and improve sleep through coaching, handouts and classes on breathwork, mindfulness, sleep hygiene, and more. Kaiser Permanente members can also take advantage of free access to the popular apps Calm and myStrength.

Kaiser Permanente also offers a wide range of counseling services, classes, support groups, and other programs for tobacco cessation, alcohol overuse and abuse, and addiction. We aim to remove barriers when our members are ready to improve lifestyle and they may self-refer to our Patient Health Education department to get started.

For details see CMADOCS.ORG

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DISCHARGE NAVIGATOR: AN INNOVATIVE PROVIDER-FACING TOOL TO SUPPORT PATIENTS’ SOCIAL NEEDS Caroline Burke, MD; Alice Lu, MLS; Elisa Danthinne; Melissa King and Christopher Peabody, MD Background The Zuckerberg San Francisco General Emergency Department (ZSFG ED), like many hospitals in the City, serves a diverse patient population with a range of complex social needs that impact their health and care. Approximately 25% of ZSFG ED patients are unhoused, 24% have documented substance use disorder, and over 50% of the ZSFG population is food insecure.

In addition to their immediate medical concerns, many patients present to the ED primarily seeking help with these social needs.

This poses a challenge for emergency clinicians who are often unfamiliar with the specific San Francisco resource landscape and have competing demands on their time while on shift.

ShelterTech is a San Francisco non-profit that develops technology-based solutions for vulnerable populations and the community organizations that serve them. ShelterTech has particular expertise in resource management and referrals, maintaining an accessible online database for people experiencing homelessness called the San Francisco Service Guide (SFSG). A novel, collaborative partnership between ZSFG and ShelterTech has enabled a creative approach to addressing the social resource gap for patients in the ED.

Discharge Navigator: A Clinician-Focused Resource Database

The Discharge Navigator is a new digital tool that supports clinician, nursing, and social work staff’s ability to nimbly identify targeted social resources and share them with patients at the time of discharge. It reflects an up-to-date database of community organizations across five high-need content areas: mental health, housing, substance use, food insecurity, and immigration.

Clinicians on shift are able to select content areas of interest and filter based on individual demographics (i.e. age, gender identity) to create a targeted list of resources to be shared with patients.

This dynamic, efficient interface is of particular value during busy shifts or outside of office hours, when other hospital social support services may not be readily available.

This project was initially developed under UCSF’s Acute Care Innovation Center, and has been bolstered, expanded, and maintained through the unique partnership with ShelterTech, a volunteer-driven non-profit with expertise in building socially-minded digital solutions. This collaboration has enabled improved website functionality, a robust database and resource management system, and expanded module content area expertise.

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Incorporating Discharge Navigator On-Shift The Discharge Navigator can be accessed and utilized onshift from any ED or clinical setting and can support patient care across San Francisco. After navigating to the website (dcnav. sfserviceguide.org), providers select their patients’ social needs and share demographics that may impact program eligibility to tailor referrals.

This generates a list of targeted resources across San Francisco and reflects updated contact information, program offerings, and participant requirements. This information can be shared with patients in several ways: through printed PDFs, by a list texted to the patient, or via QR code. Crucially, these resources are able to be automatically translated into six high-frequency non-English languages (Spanish, Tagalog, Chinese, Vietnamese, Russian, and Arabic).

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These resource lists are the product of collaborations with community and healthcare organizations across the city, built with the support of content experts familiar with the referenced programs. The database is refreshed quarterly to reflect new resources and current hours, requirements, and contact information. This empowers ED teams to support their patients with accurate, up-to-date information at the time of discharge.

Ongoing Expansion and Next Steps

The Discharge Navigator continues to evolve and expand, with a goal of helping to support discharge planning and social resource needs in EDs across San Francisco. The tool will soon launch a novel intimate partner violence (IPV) module that utilizes a survivor-centered approach to provide patients with discreet information about safety planning and self-referrals to resources, including emergency shelter, case management, legal aid, and psychosocial support. The module was created in concert with community-based organizations that work with survivors and other experts in IPV and trauma-informed care.

In addition, the collaborative teams at ShelterTech and UCSF/ ZSFG continue to work to improve interface design and website functionality. There are ample opportunities for partnership and innovation, and the Discharge Navigator team welcomes ideas or suggestions for how to continue developing this tool to better support patient care in San Francisco.

For questions, comments, or potential collaborations, please reach out to the UCSF Acute Care Innovation Center team: christopher.peabody@ucsf.edu.

This Tool is Accessible to all San Francisco clinicians at dcnav. sfserviceguide.org Caroline Burke, MD is a Chief Resident at the UCSF/ZSFG Emergency Medicine Residency.

The underlying resource listings were developed in partnership between the UCSF Acute Care Innovation Team and ShelterTech, which maintains a regularly vetted online directory of human services in San Francisco for individuals and families (SF Service Guide). Discharge Navigator augments this database with a tailored interface for ED providers as end-users, emphasizing discharge planning and required clinician actions that help enable smoother access to services.

To date, the project has focused on five content areas of particular importance for patients’ physical and emotional wellbeing: • Mental Health: Urgent stabilization, overnight care, outpatient clinics • Shelter: Emergency shelter, long-term housing navigation, at-home support • Substance Use: Support groups, medication assisted treatment, sobering centers, residential programs, safe use and harm reduction resources • Food Insecurity: Food pantries, daily free meals, home food delivery, food benefits • Immigration: Legal services, citizenship classes WWW.SFMMS.ORG

Alice Lu, MSL, is a fourth-year medical student at UCSF applying into Emergency Medicine.

Elisa Danthinne is the Co-Lead of ShelterTech’s Research team.

Melissa King is the Co-Executive Director at ShelterTech.

Christopher Peabody, MD, is the Director of the UCSF Acute Care Innovation Center and an Associate Professor of Emergency Medicine, practicing at ZSFG.

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UCSF Medical Student Perspectives

COMPASSION IN ACTION: HUMANIZING HARM REDUCTION AND ADDICTION CARE Patrick Low One of the most impactful stories I’ve heard as a student was from a mentor conducting post-overdose outreach. This individual spent a significant portion of their earlier years on the streets of the Tenderloin before turning his life around. After running into an old companion decades later, he opted to touch elbows instead of shaking hands. “Your hands used to be dirty, too” the friend chuckled in response. Although it was meant to be lighthearted, my mentor took the comment to heart. Moving forward, he made it a point to always prioritize the humanity of the individuals we served, whether it be through something as little as a handshake or the potentially life-saving harm reduction resources we are able to offer.

Despite the progress we’ve made in substance use policy, the effects of the opioid epidemic continue to be felt across the country with over 81,000 opioid overdoses occurring in 2022.

This number only increases each passing year. What started as a pharmaceutical industry push to increase opioid prescribing in the 90’s has since spiraled out of control, costing the U.S. nearly $1 trillion in 2017 alone.1 The recent Walgreen’s opioid settlement and SFMMS’s letter to Mayor Breed and San Francisco’s leaders provide a unique opportunity in addressing the crisis. With further settlement payments (i.e., Janssen and distributors) expected to trickle in over the coming years, there are several key areas of spending and policy that I would like to highlight to further humanize and care for individuals who use drugs.

First, continuing investment in naloxone distribution should be a priority. The recent approval of over-the-counter naloxone was monumental in increasing access, but it has missed the mark in many ways. The out-of-pocket cost of over-the-counter naloxone is $45, which poses a significant financial barrier in a population that already faces significant systemic barriers. Although Medicaid and private insurance may cover the medication, this will vary by state, and the confusion will likely pose further obstacles. Free distribution should be prioritized in the community setting. In addition to pharmacies, public access points including vending machines, community health centers, and outreach teams are essential for distributing the life saving medication.

Additionally, drug checking supplies such as fentanyl test strips are invaluable in the context of frequent adulteration and contamination. By informing individuals about the content of substances, we can reduce unintentional exposure to fentanyl which may lead to overdose and empower individuals to make informed decisions in regard to their substance use. In more recent times, xylazine test strips are becoming essential in achieving this as well. Unfortunately, test strips and other drug testing technologies such as spectrometry are commonly classified as “drug paraphernalia” and remain illegal in many states. State laws must decriminalize all forms of drug testing 36

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equipment, and expanding access should also be a top priority.

Furthermore, expanding access to medications for opioid use disorder (mOUD) treatment is essential. Methadone and buprenorphine are among the most effective treatments for opioid use disorder, yet many barriers to access remain prevalent. One individual I met reported driving over two hours from Sacramento every day just to find treatment in San Francisco.

Initiatives including mobile care vans and outreach teams providing mOUD are becoming popular and could potentially help bridge this much needed gap in care. At the same time, there are very few areas of medicine as regulated on a state and federal level as addiction treatment where medications such as methadone can only be given at designated clinics and with a dosage cap. These strict regulations, although intended to protect patients, frequently strip them of their autonomy and dignity. Such policies require substantial updating.

Finally and perhaps most importantly, urgent effort should be placed into addressing the disparity in overdose rates. Black individuals are disproportionately experiencing overdose deaths at alarming rates nationwide—in San Francisco, the rate is five times higher than the citywide rate.2 Preliminary evidence suggests that Black individuals may face increased barriers to accessing harm reduction care.3 All of the recommendations above and in SFMMS’s letter to Mayor Breed should be conducted with intentions of rectifying these disparities.

Healthcare providers and community members must remember the humanity of those facing substance use disorders first and foremost. This can be achieved both in the words and actions we choose as well as the policies which shape the systemic barriers our patients must overcome. In the wake of unprecedented funding and resources in the coming years, bridging access to lifesaving resources and overcoming racial disparities in overdose deaths is not just a policy issue. It's an ethical obligation that requires dedication and resolve in order to honor the inherent dignity of every individual in our community.

Patrick Low is a fourth year medical student at UCSF from Castro Valley, CA. He is the current SFMMS Student Liaison.

1 Luo F. State-Level Economic Costs of Opioid Use Disorder and Fatal Opioid Overdose — United States, 2017.

MMWR Morb Mortal Wkly Rep. 2021;70. doi:10.15585/mmwr.mm7015a1

ACCIDENTAL OVERDOSE DEATHS DECLINE IN SAN FRANCISCO FOR THE SECOND CONSECUTIVE YEAR AS FENTANYL/OPIOID EPIDEMIC RAGES NATIONWIDE | San Francisco. Accessed March 13, 2023. https://sf.gov/ news/accidental-overdose-deaths-decline-san-francisco-second-consecutive-year-fentanylopioid

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3 Khan MR, Hoff L, Elliott L, et al. Racial/ethnic disparities in opioid overdose prevention: comparison of the naloxone care cascade in White, Latinx, and Black people who use opioids in New York City. Harm Reduction Journal. 2023;20(1):24. doi:10.1186/s12954-023-00736-7

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UCSF Medical Student Perspectives

UCSF MEDICAL STUDENTS REFLECT ON THE START OF THE HAIGHT-ASHBURY FREE CLINIC Mallory Shingle As a first year medical student, faculty frequently remind me that I am in a unique position.

Medical students are unhindered by the restraints associated with paid institutional roles but empowered by our growing body of clinical knowledge and structural failures making our voices apt for advocacy.

Yet, utilizing this unique position in effective service to others can feel like too nebulous a task to tackle this early in our career.

On Friday, December 1st, 2023, Dr. David Smith, founder of the Haight-Ashbury Clinic, and some of his current “co-conspirators” would relieve that pressure, as they emphasized a simple message of maintaining non-judgmental curiosity in our community until they steer us towards the need.

Steve Heilig, of the San Francisco Marin Medical Society and legendary activist for individuals living with HIV, women’s reproductive health, the addicted, terminally ill patients, and more, would be our tour guide for the day. After a morning of lectures on pulmonary physiology, his tour would transport us medical students through the Great Depression, the Beatnik Movement, and land us in the Summer of Love and the start of the Haight-Ashbury Free Clinic in 1967, when tens of thousands of “hippies” arrived in the unprepared neighborhood.

With Steve were six other experts, Drs. David Smith, Keith Loring, Sophia Vero, and three dogs. “We get together every Tuesday morning, walk our dogs, and discuss addiction medicine and psychedelics as medicine,” Keith quipped in an unassuming way that didn’t let on the powerhouse group with whom we’d be spending the day.

Dr. Smith started us off by showing us his office tucked behind a nondescript door on Stanyan Street, just blocks from where he lived during his time as a UCSF medical student. Behind him were walls serving as a sort of photo book memorializing the WWW.SFMMS.ORG

different stages of the Haight-Ashbury Clinic, which we would later see has hardly changed in appearance since its opening. Pictures featured the likes of the Grateful Dead’s Jerry Garcia, The Beatles’ George Harrison, and Janis Joplin, all of whom had either stopped by to visit the clinic for treatment or to raise money for it through a concert.

As hippies flooded San Francisco in 1967, Dr. Smith contemplated what to do with his career following his internship at San Francisco General Hospital. He opened the clinic at an abandoned dental office with money earned from a single lecture matched with a church donation. Steve led us there through the upper Haight.

He showed us former comedy clubs that have now been turned into breakfast bistros and called careful attention to clues of the neighborhood’s history hidden in plain sight, like a tile peace sign in a driveway or fragments of a rock and roll mural.

Acknowledging this history gave me a greater appreciation for how far we have come as a medical culture, in particular towards our treatment of addiction as a chronic disease. But it gave me a sense of direction as to where it can still go, including the use of psychoactives for the treatment of PTSD and other forms of therapy.

When we arrived at the original site of Haight-Ashbury Free Clinic now run by Healthright 360, we bumped into organizers visiting from France, who were eager to take a photo with the legendary Dr. Smith. Jeffrey Schindler, Director of Philanthropy of Healthright360, took the opportunity to sit and talk with us about his personal experience being seen in Dr. Smith’s clinic.

Discussing the ways in which Dr. Smith could look beyond the scope of the world view in which he grew up in, Jeffrey said “Here is David who was raised in the Eisenhower era where if you were continued on page 38

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UCSF Medical Student Perspectives drinking too much or using drugs, it was a moral failing, and then there was the hippies,” he said gesturing towards himself.

He went on to say: “The reason my generation was not really thrilled with medical people was because it was mostly white men. They were very arrogant and very judgmental. The absolute opposite of what the Haight-Ashbury Free Clinic was. There was David with his short hair. He could have gone anywhere with his degree, but he thought this was a healthcare emergency and knew how to solve it. He was determined, wise, inventive, flexible, funny…and always getting into hot water over something, including the needle exchange.”

At the start of the needle exchange movement during the AIDS epidemic, Dr. Smith came forward describing the practice as enabling individuals with substance use disorders. But when Steve Heilig challenged Dr. Smith on the topic and showed him how healing it could be in building trust with the community, Dr. Smith looked at the evidence before him and became one of the strongest advocates for needle exchange programs.

In reflecting on this history of needle exchange programs, Steve said, “We learned that Dave and I had something in common; we liked to break bad laws!” Dr. Smith’s humility in listening to the community, admitting error in his views, and joining other advocates in solidarity shows true leadership to me. I looked around the room at my peers, eager to think that I may have identified a few of my own “co-conspirators.” More than ever, the medical community can use a reminder from Dr. Smith’s remarks about the clinic 55 years ago: “Health care is a right, not a privilege. No matter how you look, dress, or act.”

Mallory Shingle is a first-year medical student at UCSF and a graduate of Columbia University.

Editorial Note: The SFMMS played a big role in supporting the Haight Clinic through many years, including saving its existence from nearly the start by securing liability insurance, and by helping recruit volunteer physicians. It is very rewarding now to be able to take new UCSF medical students on a tour of the original clinic and neighborhood, as part of the UCSF alumni program. They seem to enjoy it each year, and some even get inspired, as we think is evidenced here!

– David Smith and Steve Heilig

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A LIFE TRANSFORMED BY A VOLUNTEER SURGEON Dennise García León For as long as he could rememfinally able to go out with friends again and participate in the outdoor ber, Yusuf suffered from painful activities he previously enjoyed swe l l i n g o f h i s to n s i l s . H i s without concern of getting another swollen tonsils often prevented tonsil infection. him from engaging in activities he loves such as playing sports, “It is an honor to give back to my hiking, and being outdoors with community and to help improve his friends. “I got sick all the access to health care.” time,” he said. ”It felt like I was – Dr. Jacob Johnson catching a cold every other month, For 30 years, Operation Access and at least three times a year, I has enabled healthcare providers to would be on bed rest for a week donate surgical and specialty care or more.” Yusuf regularly turned to people in need. Specialist physidown invitations from his friends cians volunteer to provide elective Yusuf, Dr. Johnson, and Dennise from our Cheers to a n d avo i d e d b e i n g o u td o o r s outpatient procedures at no cost to 30 Years of Volunteers Celebratiaon, sponsored by SFMMS. because he feared getting severely the patient in partnership with hosPhoto curtesty of Coyotl Cuatlacuatl Photography ill again which would require pitals and ambulatory care centers him to be on bed rest again. He was often exhausted because

throughout Northern California. breathing difficulties caused by his swollen tonsils often disrupted his sleep.

“Access to healthcare can make a world of difference in a Yusuf tried various remedies, including painkillers and nasal person's life, especially when faced with chronic health sprays, but nothing provided lasting relief. While in school, a issues. Organizations like Operation Access play a crucial nurse recommended he have his tonsils removed. However, even role in ensuring that everyone, regardless of their financial with the temporary insurance provided through his student visa, situation, can access the healthcare they need. My story is a the surgery was deemed non-essential. The cost of a bilateral testament to the importance of such programs in improving tonsillectomy would cost about $16,000. Yusuf, unable to afford the well-being of individuals who might otherwise go this cost, continued to endure the discomfort. After graduating without essential medical treatment. Dr. Johnson and his from school, Yusuf lost his health insurance and could not afford team's dedication to their work and their compassion for to pay the monthly premium to maintain coverage. Fortunately, patients like me are truly remarkable. I am living proof that he found the San Francisco Free Clinic, where he was able to donated medical care can change lives for the better.” receive care for his recurring tonsillitis and illness. San Francisco

– Yusuf, patient Free Clinic referred Yusuf to Operation Access, a local nonprofit If you are interested in learning more about how you can organization that coordinates donated surgical and specialty volunteer with Operation Access to provide donated specialty care for people in need. care to uninsured people in your community, please reach out Yusuf shared, “I was skeptical about the idea of receiving to Dennise García León at dennise@operationaccess.org or by donated care, but I was desperate for relief, so I tried it. My hopes phone at (415) 733-0085. were not high, and I did not expect to be treated like a regular patient.” To his surprise, he qualified for Operation Access, which The name of the patient has been changed to protect their privacy. matched him with Dr. Jacob Johnson, an otolaryngologist at San Francisco Surgery Center and California Pacific Medical Center.

Dennise García León is a Program Manager Upon meeting Dr. Johnson, Yusuf immediately felt reassured with Operation Access. that he was in good hands. Dr. Johnson was professional, kind, and very knowledgeable. Yusuf was hopeful that he would finally get the care he needed.

Dr. Johnson and his team donated their time and expertise and performed a tonsillectomy. After surgery, Yusuf shared that his life has immensely improved. Yusuf can sleep through the night again and no longer has difficulty breathing. He is WWW.SFMMS.ORG

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IN MEMORIAM: Arthur Lyons, MD SFMMS Past-President April 23, 1931 - November 7, 2023 Arthur Lyons, M.D. died peacefully in San Francisco on November 7 of cancer. A seven-decade San Franciscan, he was a prominent neurosurgeon, a father of two, and actively involved in the professional, cultural, civic, and outdoor life of the city he loved. He was 92.

Arthur Edward Lyons grew up in Queens, NY, the son of Alfred Lyons, a general practice doctor, and Evelyn Lyons (Joseph), a successful portrait artist. As an Eagle Scout, he developed a lifelong love of the outdoors. On April 28, 1945, his father, a Navy surgeon, was killed in action, a tragedy that reverberated throughout his life.

Following in his father's footsteps, he attended Columbia University, and Vanderbilt Medical School. He moved to San Francisco in 1956 to complete surgical training at UCSF. He married Linda Seligman soon after and raised two sons. Except for two years as an officer in the Navy, he has lived in San Francisco ever since.

In 1966, Arthur started his successful neurosurgical practice in San Francisco. Known as an excellent and cautious surgeon, he was esteemed by his colleagues and beloved by his patients, who appreciated his caring and candor. He was on the staff of Mount

Zion Hospital for over 40 years, serving as Chief of Neurosurgery from 1985 to 1992. As an Associate Clinical Professor at UCSF for many years, he was able to share his love and knowledge of medicine with innumerable aspiring doctors. Very active in medical policy making, his strong advocacy for private practice helped reform malpractice litigation in California, leading to lower costs and more affordable health care. Tirelessly working to improve medical care, he was very involved with many local organizations, including the San Francisco Medical Society where he was elected President in 1988. In addition, he served on the Medical Board of California from 2001 to 2002.

He is predeceased by his partner, Susan Scott, and sister, Edith Mendel. He is survived by his son Michael Lyons; son, Alan Lyons, daughter-in-law Jessica Lutes, and their children, Marshall, Sarah, and Ru Lyons, all of San Francisco; brotherin-law Jules Mendel and niece, Amy Mendel of New York; and many friends. Plans for a memorial gathering are underway.

All are invited to make a donation in his honor to the Biden Victory Fund.

Published by San Francisco Chronicle on Nov. 17, 2023.

) Robert Dennis Collins, MD SFMMS Past-President October 13, 1937 – November 19, 2023 Robert (Dennis) Collins, died in Modesto on November 19, at the home of his son, Ryan after a long bout with Parkinson’s.

Dennis grew up in Walnut Grove on a pear ranch. He graduated from the University of San Francisco in 1959, and St. Louis Medical School in 1963.

After his internship at Presbyterian Hospital in San Francisco, he went to Cali, Colombia for 2 years where he was the physician for the Peace Corps volunteers.

He returned to San Francisco, did a residency at Presbyterian and then a fellowship in Endocrinology at Stanford. Afterward, he entered private practice and headed up the Diabetes Clinic at SF General.

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In the mid-90’s he was a pioneer in the emerging field of managed care. His last employment was as the Medical Director of the Santa Clara County Health Plan.

After retirement, he volunteered at Samaritan House in San Mateo.

His beloved wife, Judy, predeceased him. He is survived by his three siblings, his two children, his four grandchildren, and many extended family members.

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WELLNESS

EMBRACE SEASONALITY Jessie Mahoney, MD Seasonal eating, seasonal nature, seasonal yoga, and seasonal coaching. That is how I approach my work and my life.

Embracing the season you are in is commiting to living in alignment and a choice to not resist reality or swim against the current.There are also seasons of life, careers, and relationships. Seasons of babies and toddlers, and seasons of parenting teens and young adults.There are seasons where your parents help you and seasons where you help them.

There are seasons of growth and action and seasons of rest and recovery. There are seasons of peace and harmony and seasons of discord and disharmony. There are many different seasons in a career as well. Medical school, residency, and fellowship are a season of training.They are followed by a season of early attending-hood.

Different stresses present here than present in mid career and later career. None are without ups and downs. And they

Mindful Yoga for Healers in Old Mill Park Sponsored

by SFMMS a Success!

SFMMS members attended yoga and community building at the Old Mill Park Amphitheatre in Mill Valley on Sunday, October 15th. Special thanks to Dr. Jessie Mahoney for hosting this beautiful event. This event was so successful that SFMMS plans on hosting it annually. Stay tuned for dates and more information.

Want to practice Mindful Yoga for Healers with Jessie before this event?

Join Dr. Mahoney on Zoom most Saturdays at 9am or anytime on YouTube.

For more information visit: https://mindfulyoga.jessiemahoneymd.com/ or https://youtube.com/c/JessieMahoney.

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are all impacted by the weather in that season. Some seasons are filled with atmospheric rivers and rains. Others are colored by superblooms, abundant crops, and vibrant sunsets.

The concept of seasons and embracing the season you are in is a huge help for many in mindful coaching.

Winter, Spring, Summer or Fall. None of them lasts forever.

When things feel hard, remembering that a new season will come soon helps. Each season is also good and bad. 50/50.

All seasons have delights and disappointments. We all have a favorite and least favorite season. And we can choose to embrace and attend to the parts we love about each season and not focus as much on the parts we don’t love. There is also always a transition between seasons. When we choose to transition well and embrace the season we are in, life is much more tasty, easeful and fun.

Listen to the Mindful Healers Podcast: Letting Go of Negative Feedback and What Other People Think with Dr. Jessie Mahoney and Dr. Ni-Cheng Liangi

It’s normal to be uncomfortable, sad, angry, and frustrated when you receive negative feedback and reviews.

It’s normal to want to defend yourself, explain why they’re wrong, and try to convince them otherwise. If you struggle with negative feedback and reviews and find it hard to let go of what others think about you, you are not alone. To listen to the podcast, scan the QR code with your smartphone or visit: https:// podcasts.apple.com/us/podcast/167letting-go-of-negative-feedback-andwhat/id1542538851?i=1000637334368

Jessie Mahoney is a pediatrician, a certified life coach for physicians, and a yoga instructor. She is the Chair of the SFMMS Physician Wellness Task Force. She practiced pediatrics and was a Physician Wellness leader at Kaiser Permanente for 17 years. She is the founder of Pause and Presence Coaching where she supports and empowers her physician colleagues using mindfulness tools and mindset coaching.

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Upcoming Wellness Opportunities & Resources Join the Membership Engagement Committee!

The SFMMS Membership Engagement Committee (MEC) was established by the SFMMS Board of Directors. Delegated to and directed by the SFMMS Board of Directors, the MEC plans, facilitates, and reviews proposed SFMMS membership engagement opportunities, including but not limited to: in-person, virtual, or hybrid convenings of members and non-member physicians; communications campaigns; educational and practice support opportunities; wellness activities; the Annual Gala; Annual General Meeting; socials and mixers; networking opportunities; and raffles and other promotional initiatives.

This opportunity is right for you if you want to foster a sense of community among physicians in San Francisco and Marin Counties and believe that physician engagement is key to improving the conditions of medical practice and outcomes for patients.

To learn more and apply, visit https://www.surveymonkey.com/r/P8RRGJT or scan the QR code with your smartphone

Upcoming LOCAL Physician Wellness CME Retreat Opportunities!

Mindful Coaching, Yoga and Culinary Medicine CME Wellness Retreats for Women Physicians: 4-5 night intimate physician wellness retreat opportunity for women physicians in Santa Margarita CA. March 17-22nd, April 14-18th, and May 5-9th, 2024.

Find out more and sign up here: https://www.jessiemahoneymd.com/retreats.

SFMMS Physicians at Honoring Diastole at Pie Ranch in Pescadero in June 2023

Read our Monthly SFMMS Wellness Blog Each month, as part of the Physician Wellness leaders' work, they curate wellness resources around a common theme for our monthly wellness blog. Read, listen, and attend the monthly resources the committee has curated for SFMMS members by visiting: https://www.sfmms.org/news-events/sfmms-blog.aspx? Category=physician-wellness.

Have you missed a recent Wellness Event?

You can learn more about upcoming wellness events or view recordings of past events on the SFMMS Wellness Page at www. sfmms.org/get-help/physician-wellness

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Improvements to California End of Life Option Act Note: The SFMMS was instrumental in the long effort to legalize careful medically-assisted dying in California, after surveys of both physicians and the public showed strong majority support for this option for patients with terminal conditions. For the professional medical association, the American Clinicians Academy on Medical Aid In Dying, see https://www.acamaid.org/

Enhanced Law Working as Lawmakers Intended: to Increase Access for Dying Californians Aug, 2023

A new report on California’s End of Life Option Act that allows mentally capable, terminally ill adults to use medical aid in dying to gently end their suffering shows 47% more Californians used the law in 2022, increasing access to the law exactly as intended.

The new report by the California Department of Public Health shows this increase is largely due to a reduction in the law’s waiting period between the mandatory two oral requests for aid-in-dying medication from 15 days to 48 hours thanks to the passage of Senate Bill 380, which took effect on Jan. 1, 2022. A 2018 study by Kaiser Permanente Southern California showed more than one out of five terminally ill adults (21%) who requested to use the End of Life Option Act died during the 15-day waiting period, suffering needlessly because they ran out of time to obtain the aid-in-dying medication.

The Department of Public Health report shows 1,270 terminally ill Californians received prescriptions for medical aid in dying and 853 patients (65%) took the medication in 2022 (0.28% of the state’s 308,015 annual deaths). More than 95% (814) of these terminally ill Californians “were receiving hospice and/or palliative care” and nearly four of out five, “947 individuals, or 78.7%, waited less than 15 days between the two verbal requests,” the report states.

“This report shows the improved law shortening the waiting period is working exactly as lawmakers intended: allowing hundreds of terminally ill Californians to die peacefully last year who otherwise would have died needlessly suffering,” said Kim Callinan, president and CEO of Compassion & Choices and Compassion & Choices Action Network, which led the campaigns to pass both the 2015 End of Life Option Act and Senate Bill 380 to reduce the waiting period. “We are grateful for Sen. Susan Talamantes Eggman and Rep. Jim Wood for championing this crucial improvement in the law.”

Three in four Californians (75%) support the End of Life Option Act according to a 2019 survey by the California Health Care Foundation, including a majority of every demographic group surveyed: Hispanic Californians (68%), Black Californians (70%), Asian Californians (76%) and white Californians (82%).

Despite this widespread support, a far higher proportion of whites (89%) utilized the law in 2022 than other ethnic/racial groups combined (11%), even though whites represent only 36.5 percent of the state’s population. In contrast, just four American Indian/Alaska Native Californians (0.5%), four Black Californians (0.5%), 54 Asian Californians (6.3%) and 24 Hispanic Californians (2.8%) utilized the law in 2022, even though these communities collectively represent a higher percentage of the state’s population (American Indian/Alaska Native: 1.7%, Black Californians: 6.5%, Asian Californians: 15.5%, Hispanic Californians: 39.4%).

“Our leadership councils for the African American community, the Latino community, and the Asian American, Native Hawaiian and Pacific Islander community are designed to inform these communities about the full range of end-of-life options to ensure that all communities are able to access care consistent with their values and priorities,” said Callinan.

California is one of 10 states — including Colorado, Hawaii, Maine, Montana, New Jersey, New Mexico, Oregon, Vermont and Washington — as well as Washington, D.C., that have authorized medical aid in dying. Collectively these 11 jurisdictions represent more than one out of five U.S. residents (22%) and have decades of combined experience using this end-of-life care option, starting with Oregon in 1997.

Link to report: https://www.cdph.ca.gov/Programs/CHSI/CDPH%20 Document%20Library/CDPH_End_of_Life%20_Option_Act_ Report_2022_FINAL.pdf

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CLASSIFIED ADS FOR LEASE Modern Medical/Surgical Office Nob Hill San Francisco.

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Walking distance to CPMC Van Ness. Non-medical building with street level entrance. Valet parking in building. Perfect for surgical, aesthetic or medi-spa practice. Price negotiable.

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San Francisco Marin Medical Society 312 Sutter, Suite 608 San Francisco, CA 94108

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